Transverse myelitis physical examination
Jump to navigation
Jump to search
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Julinka Auta Fernandes
|
Transverse myelitis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Transverse myelitis physical examination On the Web |
|
American Roentgen Ray Society Images of Transverse myelitis physical examination |
|
Risk calculators and risk factors for Transverse myelitis physical examination |
Overview
- Patients with suspected transverse myelitis require a complete general and neurological examination, with particular attention to objective motor, sensory, respiratory, and sacral/autonomic findings. The Transverse Myelitis Consortium Working Group defines the core clinical syndrome by dysfunction attributable to the spinal cord; findings should be bilateral, although they need not be symmetric, and a clearly defined sensory level should be sought.[1]
- The 2023 Neuromyelitis Optica Study Group consensus recommends an extended physical and neurological examination in suspected myelitis. Examination should cover sensory, motor (including respiratory), bladder, bowel, and sexual dysfunction; pain; and findings suggesting associated optic-nerve or brainstem involvement.[2]
- No single physical-examination finding confirms transverse myelitis. The examination localizes the neurological deficit, defines its severity, and establishes a baseline for serial assessment.[1]
Clinical examination priorities
- Motor function: Determine the distribution, severity, and symmetry of weakness in all four limbs.
- Sensory function: Identify a reproducible sensory level and compare sensory modalities bilaterally.[1]
- Respiratory function: Look for respiratory-muscle involvement in cervical or extensive myelitis.[2]
- Reflexes and tone: Document reduced or increased tone, deep tendon reflexes, plantar responses, and clonus.
- Sacral/autonomic function: Document objective bladder and sacral findings, including sacral sparing when clinically indicated.[2]
- Associated central nervous system involvement: Examine both optic nerves and look for cranial-nerve, brainstem, or cerebellar signs when an acquired demyelinating disorder is possible.[2]
Physical Examination
General and respiratory examination
- Vital signs and general status: Record general appearance, level of alertness, temperature, blood pressure, pulse, respiratory rate, and oxygen saturation.
- Functional observation: Observe the patient's posture and ability to sit, stand, transfer, and walk. Provide assistance and fall precautions when weakness or sensory loss makes testing unsafe.
- Respiratory assessment: In suspected cervical or extensive myelitis, assess respiratory rate, work of breathing, speech, chest expansion, diaphragmatic movement, and cough strength. Severe myelitis may produce tetraparesis or tetraplegia and respiratory insufficiency.[2][3]
Targeted general and systemic examination
- Spine and musculoskeletal examination: Inspect the spine and assess for focal vertebral tenderness, deformity, or restricted movement when clinically indicated. Examine limb joints and range of motion when pain or systemic inflammatory disease is suspected.
- Skin, mucosa, and joints: Look for objective features of systemic inflammatory, autoimmune, infectious, or vascular disease—such as rash, oral or genital ulceration, synovitis, or vasculitic lesions—when suggested by the clinical context. These findings may indicate an underlying disorder rather than idiopathic transverse myelitis.[1]
Neurological examination
Mental status and cranial nerves
- Assess: Perform a standard mental-status and cranial-nerve examination as part of the complete neurological examination.
- Document: Record abnormalities that are not explained by an isolated spinal-cord syndrome.[2]
Optic-nerve, brainstem, and cerebellar examination
- Optic nerves: Because neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease may present with myelitis, examine both eyes. Assess habitually corrected visual acuity, color vision, visual fields by confrontation, pupillary responses for a relative afferent pupillary defect, and the optic discs by fundoscopy.[2][3]
- Brainstem and cerebellar function: Assess ocular alignment and movements, nystagmus, facial sensation and movement, hearing, palatal movement, swallowing, speech, tongue movement, and limb or truncal ataxia. Findings outside the spinal cord should be documented because they may indicate a broader inflammatory central nervous system disorder.[2]
Motor system
- Inspection: Examine the upper and lower limbs for muscle bulk, involuntary movements, and resting posture.
- Strength: Test and record strength in all four limbs using a consistent 0-to-5 muscle-strength scale. Document proximal versus distal, upper- versus lower-limb, and right-versus-left involvement. When standardized spinal-cord documentation is required, test the paired key muscle functions in a rostral-to-caudal sequence.[4]
- Pattern and severity: Motor findings may range from subtle paresis to paraparesis, paraplegia, or tetraparesis/tetraplegia; bilateral deficits may be asymmetric.[1][2][3]
- Tone: Assess passive muscle tone and record whether it is reduced, normal, or increased, including flaccidity or spasticity when present.
Reflexes
- Deep tendon reflexes: Test and compare bilateral biceps, triceps, brachioradialis, patellar, and Achilles deep tendon reflexes.
- Grading: Record whether reflexes are absent, reduced, normal, or brisk, and document asymmetry.
- Additional findings: Test plantar responses and assess for clonus.
- Serial interpretation: Record reflexes and tone at each examination; an acute cord syndrome may initially be flaccid or hyporeflexic, whereas upper-motor-neuron findings may become more apparent later.[1]
Sensory system
- Primary assessment: Test light touch and pinprick bilaterally over the trunk and limbs. Map abnormalities carefully to identify and document a reproducible sensory level.[1]
- Additional modalities: Assess temperature sensation, vibration, and joint-position sense (proprioception) when feasible.
- Pain-related sensory findings: Assess for allodynia, hyperalgesia, dysesthesia, neuropathic pain, and painful tonic spasms when present.[2]
- Distribution: Record whether findings are complete or partial, symmetric or asymmetric, and whether sensory modalities are affected to different degrees. Formal International Standards for Neurological Classification of Spinal Cord Injury assessment uses light touch and pinprick at 28 key dermatomes on each side.[4]
- Sacral sensation: When clinically indicated, assess sacral light touch, pinprick, and deep anal pressure to determine sacral sparing and completeness of spinal-cord impairment.[4]
Coordination, stance, and gait
- Coordination: Assess finger-to-nose and heel-to-shin performance when weakness permits reliable testing.
- Stance and gait: When safe, observe standing balance, ordinary gait, heel walking, toe walking, and tandem gait, and perform the Romberg test.
- Documentation: Record required assistance or walking aids, and interpret apparent incoordination in the context of weakness, sensory loss, and impaired proprioception.
Autonomic and sacral examination
- Bladder examination: Inspect, palpate, and percuss the lower abdomen for objective evidence of bladder distension when urinary retention is suspected.
- Sacral examination: When clinically indicated, and with informed consent and an appropriate chaperone, assess light touch and pinprick at sacral segments 4–5, deep anal pressure, resting anal sphincter tone, and voluntary anal contraction.[4]
- Documentation: Record objective sacral findings and whether sacral sparing is present.
Standardized and serial documentation
- Serial examination: Repeat the focused neurological examination when deficits evolve or new neurological findings appear. Document strength, sensory level, tone, reflexes, respiratory function, gait or mobility, and sacral findings.[2]
- Standardized documentation: When standardized documentation of spinal-cord impairment is needed, the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), maintained by the American Spinal Injury Association (ASIA) with the International Spinal Cord Society (ISCoS), may be used to record sensory levels, motor levels, sacral sparing, neurological level, and completeness. The ninth edition was released in 2026. ISNCSCI standardizes the description of impairment; it is not, by itself, a diagnostic criterion for transverse myelitis.[4][5]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology. 2002;59(4):499–505. doi:10.1212/WNL.59.4.499.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Jarius S, Aktas O, Ayzenberg I, et al. Update on the diagnosis and treatment of neuromyelitis optica spectrum disorders—revised recommendations of the Neuromyelitis Optica Study Group. Part I: Diagnosis and differential diagnosis. Journal of Neurology. 2023;270(7):3341–3368. doi:10.1007/s00415-023-11634-0.
- ↑ 3.0 3.1 3.2 Giorgi L, Marignier R, Pique J, et al.; MIRCEM Network. French guidelines for the diagnosis and management of neuromyelitis optica spectrum disorder. Revue Neurologique. 2026; online ahead of print. doi:10.1016/j.neurol.2026.06.004.
- ↑ 4.0 4.1 4.2 4.3 4.4 Rupp R, Biering-Sørensen F, Burns SP, et al. International Standards for Neurological Classification of Spinal Cord Injury: Revised 2019. Topics in Spinal Cord Injury Rehabilitation. 2021;27(2):1–22. doi:10.46292/sci2702-1.
- ↑ American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury. 9th ed. 2026. Accessed September 27, 2026.