Transverse myelitis

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RustedFox

RustedFox

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I kinda feel like this is the one back pain related diagnosis that I haven't yet made.

Granted, it's not common.

For those who have seen it; how did it present? How did you make the dx?
What made you think about it?
What else...
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they usually have bilateral leg neurologic deficits, sometimes bladder/bowel problems.
Interesting diagnosis but kind of boring from an ER perspective. You call neuro, they want an MRI and you admit
 
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RustedFox said:
I kinda feel like this is the one back pain related diagnosis that I haven't yet made.

Granted, it's not common.

For those who have seen it; how did it present? How did you make the dx?
What made you think about it?
What else...
Click to expand...

I had one. it's like guillain barre with a lot of pain with weakness, bilateral. i thought it was guillain barre at first but MRI showed transverse myelitis.
 
It’s pretty profound neuro symptoms. I gotta call you later and tell you a story about this actually. It’s hilarious.
 
You've probably already seen one and admitted them as a stroke rule out. I've found that most of these pt's only get diagnosed after their MRI Brain comes back normal and neuro decides to MRI their entire spine. Neuro deficits can be all over the place. I once had a cervical transverse myelitis present very much like a central cord syndrome. Most of us aren't holding these pt's in the ED until all their MRIs are completed so I've found that it typically gets picked up later in their hospital course.
 
I've had a few. The presentations were variable and ranged from classic low back pain with paralyzed lower extremities and sensory level to "my legs feel funny" in a patient that was ambulatory but with unsteady gait.

My general takeaway is that if symptoms are in a non-dermatomal distribution and bilateral I'll at least think about it.
 
RustedFox said:
What made you guys *not* blow it off as generally poor patient behavior NOS?
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I haven't found a case myself yet. But I have a pretty cool video of someone with new onset gait changes / lower extremity weakness. She DID NOT have back / neck pain (or risk factors), but wound up having a critical stenosis in the lower c-spine that presented with lower extremity weakness only. Not fair.

My approach is real deficits get a MRI.
neurology mri.jpg
 
MechEDoc said:
I haven't found a case myself yet. But I have a pretty cool video of someone with new onset gait changes / lower extremity weakness. She DID NOT have back / neck pain (or risk factors), but wound up having a critical stenosis in the lower c-spine that presented with lower extremity weakness only. Not fair.

My approach is real deficits get a MRI. View attachment 345959
Click to expand...

Yea any acute neuro deficit that is worth a salt I admit for further care. Sometimes I wish I could summon a Neurologist to the ED for an evaluation, much like Emergency Medical Hologram Mark I from Star Trek Voyager. But alas, that technology doesn't exist yet so I'm stuck admitting for a consult at a cost of thousands of dollars.
 
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thegenius said:
Yea any acute neuro deficit that is worth a salt I admit for further care. Sometimes I wish I could summon a Neurologist to the ED for an evaluation, much like Emergency Medical Hologram Mark I from Star Trek Voyager. But alas, that technology doesn't exist yet so I'm stuck admitting for a consult at a cost of thousands of dollars.
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Yeah, like if only there was some sort of thing like a real time video conferencing from a cell phone? Can't wait for life to catch up to the Jetsons.
 
RustedFox said:
I kinda feel like this is the one back pain related diagnosis that I haven't yet made.

Granted, it's not common.

For those who have seen it; how did it present? How did you make the dx?
What made you think about it?
What else...
Click to expand...

I’ve made the dx twice. Both in residency.

In both cases I thought it was conversion disorder because it was diffuse weakness with a distribution that only made sense from c spine with no med hx.

I wish I could tell you I nailed it but I thought both were fos and found it on mri I got to call bs.

That dx and ms are now my first thought whenever I think “this sounds like bs” because they’re the two things that my spidy sense completely fails me on.
 
MechEDoc said:
Yeah, like if only there was some sort of thing like a real time video conferencing from a cell phone? Can't wait for life to catch up to the Jetsons.
Click to expand...

We actually have teleneuro with a local academic hospital who helps us with stroke. But I can't use them for any random neuro complaint.

Neuro complaints and Neurology is interesting. it's one of those fields where doctors who are not neurologists have no clue about the field. If there is a neuro deficit they don't think, they just call Neurology. Ophtho, Rheum, Dermatology are others.
 
As @dadaddabatman pointed out, it's one of those presentations that's either complete BS or transverse myelitis without much else in the ddx. I would say that a commonality between cases that I've seen/discussed is that as subtle as it can be sometimes, none of them were able to walk without assistance.The presentation was always fairly acute as well, so I don't really consider it in the "back pain for 6 months" presentations.

In general though I give patients the benefit of the doubt unless they're coming to the ED q48hrs with chronic pain complaints.
 
Jabbed said:
As @dadaddabatman pointed out, it's one of those presentations that's either complete BS or transverse myelitis without much else in the ddx. I would say that a commonality between cases that I've seen/discussed is that as subtle as it can be sometimes, none of them were able to walk without assistance.The presentation was always fairly acute as well, so I don't really consider it in the "back pain for 6 months" presentations.

In general though I give patients the benefit of the doubt unless they're coming to the ED q48hrs with chronic pain complaints.
Click to expand...

Neither of mine could walk. However, I would point out that if they could I would probably not have tested them. I have probably missed less severe acute cases.
 
MechEDoc said:
I haven't found a case myself yet. But I have a pretty cool video of someone with new onset gait changes / lower extremity weakness. She DID NOT have back / neck pain (or risk factors), but wound up having a critical stenosis in the lower c-spine that presented with lower extremity weakness only. Not fair.

My approach is real deficits get a MRI. View attachment 345959
Click to expand...
Wait, which Neurologists are you working with? Since about 2012 I hear "if it's not a stroke alert I wont see the patient until the MRI is back"
 
Jabbed said:
As @dadaddabatman pointed out, it's one of those presentations that's either complete BS or transverse myelitis without much else in the ddx. I would say that a commonality between cases that I've seen/discussed is that as subtle as it can be sometimes, none of them were able to walk without assistance.The presentation was always fairly acute as well, so I don't really consider it in the "back pain for 6 months" presentations.

In general though I give patients the benefit of the doubt unless they're coming to the ED q48hrs with chronic pain complaints.
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With the caveat that you need to avoid anchoring on the "6 months" too early. Make sure it's not 6 months of right sided SI pain, but now I've got a new lumbar pain + deficits.

That said, I've probably missed this diagnosis several times.
 
Jabbed said:
As @dadaddabatman pointed out, it's one of those presentations that's either complete BS or transverse myelitis without much else in the ddx. I would say that a commonality between cases that I've seen/discussed is that as subtle as it can be sometimes, none of them were able to walk without assistance.The presentation was always fairly acute as well, so I don't really consider it in the "back pain for 6 months" presentations.

In general though I give patients the benefit of the doubt unless they're coming to the ED q48hrs with chronic pain complaints.
Click to expand...

It's a shame that this is America, and "complete BS" outnumbers actual pathology by a ratio of 100,000:1.
 
RustedFox said:
I kinda feel like this is the one back pain related diagnosis that I haven't yet made.

Granted, it's not common.

For those who have seen it; how did it present? How did you make the dx?
What made you think about it?
What else...
Click to expand...
Neuro here. It has a subacute onset usually over a few days with weakness and/or numbness, bowel/bladder involvement, typically younger patients, often post-infectious. Exam usually has objective weakness, a sensory level, hyperreflexia (vs. hyporeflexia/areflexia in GBS/AIDP), positive Babinski/Hoffman (long tract signs) with normal cranial nerve exam. DDx includes neoplasm, infection, other demyelinating disease (e.g., NMO) which typically can't be ruled out except after MRI and lumbar puncture.
 
elanmorin said:
Neuro here. It has a subacute onset usually over a few days with weakness and/or numbness, bowel/bladder involvement, typically younger patients, often post-infectious. Exam usually has objective weakness, a sensory level, hyperreflexia (vs. hyporeflexia/areflexia in GBS/AIDP), positive Babinski/Hoffman (long tract signs) with normal cranial nerve exam. DDx includes neoplasm, infection, other demyelinating disease (e.g., NMO) which typically can't be ruled out except after MRI and lumbar puncture.
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Thanks for the input.

Forgive me... what does NMO abbreviate?
What specifically do you mean by "a sensory level"?
 
RustedFox said:
Thanks for the input.

Forgive me... what does NMO abbreviate?
What specifically do you mean by "a sensory level"?
Click to expand...
NMO = Neuromyelitis Optica, an aggressive demyelinating disease with autoantibodies against aquaporin-4 channels; longitudinally extensive (3+ spinal segments) transverse myelitis is one of the diagnostic criteria

Sensory level means there is a drop off in sensation at a specific dermatomal level, typically elicited by pinprick along the back; e.g., if the patient reports loss of sensation below T10 level, that suggests a lesion anywhere above that point.
 
elanmorin said:
NMO = Neuromyelitis Optica, an aggressive demyelinating disease with autoantibodies against aquaporin-4 channels; longitudinally extensive (3+ spinal segments) transverse myelitis is one of the diagnostic criteria

Sensory level means there is a drop off in sensation at a specific dermatomal level, typically elicited by pinprick along the back; e.g., if the patient reports loss of sensation below T10 level, that suggests a lesion anywhere above that point.
Click to expand...

Okay, thanks.

I figured the "sensory level" would refer to a dermatome, but I've learned that when discussing matters such as this where I am the inquisitor and there is an authority figure (say, neurology - you, in this example), it is best to not presume - especially when dealing with certain lingo-type expressions.
 
RustedFox said:
Okay, thanks.

I figured the "sensory level" would refer to a dermatome, but I've learned that when discussing matters such as this where I am the inquisitor and there is an authority figure (say, neurology - you, in this example), it is best to not presume - especially when dealing with certain lingo-type expressions.
Click to expand...
I think the word you need here is "jargon".

/pedantic
 
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