Antecedent Minor Trauma and Hyperacute Presentations in Childhood Transverse Myelitis

Fibrocartilaginous embolism and spinal cord infarction may resemble transverse myelitis with antecedent minor trauma (sporting activity or minor falls) or with hyperacute (<12-hour) presentation.

Diagnostic criteria for fibrocartilaginous embolism and spinal cord infarction were applied to a 10-year (2007-2016) cohort of children aged 1 month to 16 years with transverse myelitis and clinical, laboratory, neuroimaging, and outcome data compared between those with and without antecedent minor trauma.

Thirty-two children of median age 8.9 (range 2.7-15.8) years were included; 19 (59%) were female. Falls at home, school, or play (6 children, 60%), swimming (2, 20%), physical education (1, 10%), and caning (1, 10%) were antecedent events in 10 (31%) children. Six (19%) had hyperacute presentations. One patient met spinal cord infarction criteria; none had fibrocartilaginous embolism. Children with transverse myelitis and antecedent minor trauma had single, short spinal cord lesions (median 3 vertebral bodies) but without a specific neuroimaging lesion pattern. None had intervertebral disc abnormalities or brain involvement and were negative for myelin oligodendrocyte and aquaporin 4 antibodies. Twenty-five (86%) of 29 had cerebrospinal fluid inflammation, and 30 (94%) received immunotherapy. Thirty (97%) were followed for a median of 3.6 (0.1-10.2) years, with good outcome (modified Rankin Scale score 0-1) in the majority (80%). Four (75%) with hyperacute presentation had a good outcome (modified Rankin Scale score 0-1), but the patient with spinal cord infarction was the most disabled (modified Rankin Scale score 4).

Minor trauma or hyperacute presentations does not always indicate fibrocartilaginous embolism or spinal cord infarction. Children with minor trauma preceding transverse myelitis have a distinct clinicoradiologic syndrome, with good outcome following immunotherapy.