Review Question - QID 103642

This patient is presenting with paresthesias, pain, weakness, and urinary/bowel dysfunction suggesting a diagnosis of transverse myelitis (though multiple sclerosis and cauda equina syndrome are in the differential). The best next step in management is an MRI.

Transverse myelitis is a neurological disorder caused by inflammation of the spinal cord. Spinal cord dysfunction can occur over hours to weeks with this condition. Although there can be a wide spectrum of findings depending on the affected cord levels, there are 4 classic features:

(1) Weakness of the legs and arms
(2) Pain (usually in the back)
(3) Sensory alterations
(4) Bowel and bladder dysfunction

The management of transverse myelitis involves an MRI and often steroids and plasma exchange. A STAT MRI is important as it can rule out other life-threatening diagnoses such as cauda equina/conus medullaris syndrome (though keep in mind these diagnoses are a syndrome and are thus diagnosed clinically).

Incorrect Answers:
Answer 1: CT would be indicated to rule out a fracture if the patient had point tenderness over his spine after blunt trauma. It would not offer sufficient detail to confirm the diagnosis of transverse myelitis.

Answer 2: Emergency surgery would be indicated in cauda equina syndrome which presents with saddle anesthesia, urinary retention, and a loss of rectal tone; however, this would typically occur after a STAT MRI was performed.

Answer 3: Lumbar puncture is indicated once neuroimaging has excluded a compressive etiology. It is used to determine if there are signs of inflammation within the cerebrospinal fluid.

Answer 5: Pulmonary function tests are often the best initial step in management in Guillain-Barre syndrome which presents with an ascending flaccid paralysis with absent reflexes. They are indicated to determine if intubation is needed prior to beginning other treatments.

Bullet Summary:
The best initial step in management in transverse myelitis is an MRI.