Monday, June 29, 2009

Inflammation. . . . damaging the sheath

She was 37 years old, with complaints of progressive weaking in her lower extremeties over a couple of weeks. It really started with slight neck pain, then to the lower back. Then all of the sudden her left leg was really weak, then the right. By the end of the two weeks, her husband was calling 911 because she could not move any part of her body from her belly button down. She was unable to urinate, unable to have a bowel movement, unable to wiggle her toes, unable to lift her feet or legs off the bed. She could feel them if you touched them but she could not move anything! She kept complaining that her legs were tingling like they were asleep, and that they were so heavy she couldn't lift them. She really wasn't having alot of pain other than a headache and some "muscle pain" in her shoulders.

After several tests including x-rays, MRI's, a lumbar puncture, and blood work up they diagnosed her with Transverse Myelitis. What is Transverse Myelitis you ask? I am going to give you the short version since I have also left you with a very informative website. The website is where I am getting all my information for this post as well.

This is an MRI of the thoracic spine (the part between your neck and your lower back). The grey solid area in the middle is your spinal cord. The white area where there is an arrow (very difficult to see) in the spinal cord is the area of inflammation. The really white areas that kinda outline the solid grey spinal cord is CSF (cereberal spinal fluid).

Transverse Myelitis is not limited to age, sex or race. There does not have to be any family history of this for you to have it. Most cases occur however, at the ages of 10-19 and 30-39.

It is a neurological disorder that is caused by inflammation across the spinal cord. Inflammation can actually damage or destroy myelin, which is the fatty substance that insulates and covers nerve cell fibers. This ends up causing scaring on the nervous system that interrupt communication betweent he nerves it the spinal cord and other parts of the body.

There are many things that can cause Transverse Myelitis, such as viral infections, insufficient blood flow in the spinal cord, complications from syphilis, measles, lyme disease, certain vaccinations (ex: chickenpox and rabies). It often developes following viral infections such as varicella zoster, herpes simples, cytomegalovirs, Epstein-Barr, influenza, echovirus, HIV, Hep A, and rubella.

Because some affected individuals also have autoimmune diseases such as systemic lupus erythematosus, Sjogren’s syndrome, and sarcoidosis, some scientists suggest that transverse myelitis may also be an autoimmune disorder. In addition, some cancers may trigger an abnormal immune response that may lead to transverse myelitis.

An acute, rapidly progressing form of transverse myelitis sometimes signals the first attack of multiple sclerosis (MS), however, studies indicate that most people who develop transverse myelitis do not go on to develop MS. Patients with transverse myelitis should nonetheless be screened for MS because patients with this diagnosis will require different treatments.

Symptoms may develope over several hours to several days/weeks. Usually starting with lower back pain and/or sudden burning, tickling, prickling or tingling in the legs, as well as partial paralysis of the legs. This paralysis usually progressed from the legs to the lower part of the trunk. Bladder and bowel dysfunction is very common. The patient will likely feel general discomfort, headache, maybe a fever, loss of appetite and muscle spasms. Depending on the area of the inflammation on the spinal cord, some may even experience respiratory problems.

There is currently no effective cure for Transverse Myelitis. Treatment is meant for managing the symptoms and really depends on the severity. Steroids to degrease the inflammation, they also reduce the immune system activity since there is also suspected autoimmune involvement. Then there is pain control. The goal is early treatment and keeping the boy functioning, while waiting and hoping for some kind of spontaneous recovery of the nervous system. Physical therapy place a huge role in this, with range of motion and keeping those muscles moving.

Recovery typically begins within 2 to 12 weeks of the onset of symptoms and may continue for up to 2 years. However, if there is no improvement within the first 3 to 6 months, significant recovery is unlikely. About one-third of people affected with transverse myelitis experience good or full recovery from their symptoms; they regain the ability to walk normally and experience minimal urinary or bowel effects and paresthesias. Research shows that a rapid onset of symptoms generally results in poorer recovery outcomes.

Many people with Transverse Myelitis only have one episode, however there is always a chance it can rare it's ugly head again. When/if it does return there will likely be more workups for underlying causes such as MS or systemic lupus erythematosus. Most people who have more than one episode have some kind of underlying disorder.

Now that you have had some education, let me tell you that I have seen this many times in my years of nursing. It is very scary for the patient and family. One day you have control over your own body and the next day, you can't move! People think they are just tired, been doing too much, and pretty much let it go. Thinking they just need some much needed rest.

This particular patient I cared for after she had already spent over a week inpatient. She was scheduled to go to an inpatient rehab hospital for intensive Physical and Occupational Therapies. She was diabetic, had been on 1000mg of Solumedrol for 5 days. That is ALOT!!! Her blood sugars had been hard to control because of all the steroids, so she was having to deal with that aspect as well. They also had her on Baclofen to help with the muscle spasms, as well as low doses of Vicodin for pain. While in the hospital she was also receiving therapies. She had a foley catheter, because she was unable to urinate, and she was having trouble with her bowels. They just didn't want to work.

Her husband was amazing! He never left her side. He was right there caring for her and doing whatever it was she needed at that moment. Her spirits were good. When she was admitted to the hospital, as I stated before, she could not move ANYTHING from her belly button down. The day I had her, the day prior to her discharge, she was able to lift her left leg (the first leg to be affected) off the bed. Now, she was not able to lift it far, but she did get it off the bed. She also couldn't hold it for long and was unable to hold it against pressure. But she was making progress.

Her attitude was amazing. He kept me in stitches all night. She and her husband both should have been stand up comedians. Most patients of this age would have found themselves in a heap of tears and doom. Looking only at the possibility of never being able to move again. Not this young lady. She knew she was going to recover fully and have a full normal life.

I have not heard of her or seen her back at my hospital since that night. My prayer is that she did recover. That she is home with her husband, living life to the fullest!



  1. Word Up!! That is one wild situation. I am always so in awe at your skills, as the awesome nurse whom you are.

  2. PB&J - I'm glad you stuck it out reading this long long post. I did not mean for it to get so lengthy. I remember I said I was going to give the short version... opps!
    I am glad you hung in there and liked it.

  3. What an interesting diagnosis. So glad for the wonderful outcome!!!