Residual bladder dysfunction 2 to 10 years after acute transverse myelitis

Bladder management in children with transverse myelitis

BACKGROUND

Patients with transverse myelitis (TM) often present with urinary retention. While many recover their bladder function, some have persistent voiding dysfunction, and both intermediate and long-term outcomes are variable.

OBJECTIVE

In patients who develop urinary retention requiring clean intermittent catheterization (CIC) at onset of TM, we sought to assess factors associated with improved voiding function and the risk of requiring persistent CIC over time.

STUDY DESIGN

We reviewed children evaluated at our institution for TM from April 1998 to October 2018. Patients were included if they required CIC at initial presentation of TM. Demographics, initial and follow up neurologic exams were evaluated for their association with a return to baseline volitional voiding after requiring catheterization upon diagnosis of TM, with or without medical therapy.

RESULTS

Among the 78 patients who presented with TM during the study period, 43 patients required CIC, with median follow up of 2.7 years. When evaluating for demographic or sensorimotor features associated with improvement to baseline voiding function in patients who initially required CIC, preserved lower extremity reflexes at presentation was the only significant prognostic factor (p < 0.05). Additionally, having complete lower motor neurologic recovery was associated with volitional voiding (p < 0.05). Among the 43 patients who were initially catheterizing, 27/43 (62%) were volitionally voiding at median follow up of 7 months from initial presentation, while the remaining 16/43 remained on CIC for a median follow up of 3.6 years. The cumulative risk of remaining on CIC was 60%, 47%, and 42% at 1, 5, and 10 year follow up, respectively, though there was not a significant difference in the rate of bladder recovery if patients had preserved reflexes.

DISCUSSION

In children with TM who initially developed urinary retention, intact reflexes at presentation were associated with urologic recovery. Additionally, complete neurologic recovery was associated with volitional voiding. While 62% were volitionally voiding at most recent follow-up, the cumulative incidence of dependence on CIC within the first year of diagnosis was 60%, with a relatively few patients regaining volitional voiding by 10 years of follow-up.

CONCLUSION

Among those initially evaluated for urinary retention in the setting of transverse myelitis, intact lower extremity reflexes on physical exam was associated with improved voiding function at most recent follow-up. However, more than half the patients on CIC at initial presentation required CIC at one year of follow-up. Careful, long-term monitoring of voiding status in patients with TM is recommended, even with improvement of neurological status.

The demographic, clinical, and magnetic resonance imaging (MRI) features of transverse myelitis in children

The authors collected demographic, clinical, and neuroimaging data prospectively on 38 children with transverse myelitis. One child died during the illness. The female:male ratio was 1.2:1 for children under age 10 years and 2.6:1 over age 10 years. Twenty-eight (74%) reported a prodromal event. Twenty-two patients (58%) had longitudinally extensive transverse myelitis, 9 (24%) had focal lesions, and 5 (13%) had both. Twenty of 33 with brain imaging (61%) had brain lesions; 7 fulfilled McDonald criteria for dissemination in space. Seven of 22 (36%) tested had cerebrospinal fluid oligoclonal banding, 6 of whom had brain lesions. Serum neuromyelitis optica IgG antibodies were absent in all 20 of the children for whom this test was available. At follow-up (mean 3.2 ± 2.0 years), 16% are wheelchair-dependent, 22% have persisting bladder dysfunction, and 13% have been diagnosed with multiple sclerosis.

Acquired transverse myelopathy in children in the United Kingdom--a 2 year prospective study

AIMS

To define the incidence, describe presentation, management and outcome and identify prognostic factors in Acquired Transverse Myelopathy (ATM) in children under 16 years.

METHODS

A prospective population-based surveillance study, involving all consultant paediatric neurologists in the United Kingdom from 1 July 2002 to 30 June 2004.

RESULTS AND DISCUSSION

Response rate was 91%, and 60 children were reported, of whom 41 were included. Median age was 9 years. The incidence of ATM in children under 16 years in confirmed cases is at least 1.72 per million children per year. There was a previously unrecognised male predominance (M:F 25:16). Early evaluation of bladder function is sometimes omitted. MR imaging should include whole spine and brain to maximise diagnostic information. Despite the use of high dose steroids, 25% of cases were left with significant sequelae. Outcome data was available for 36 children in whom recovery was defined as 'complete' in 19, 'good' in 8, 'fair' in 3 and 'poor' in 6. Significant positive prognostic factors were preceding infection, start of recovery within a week of onset, age less than 10 years, and lumbosacral spinal level on clinical assessment. Significant negative predictors were flaccid legs at presentation, sphincter involvement and rapid progression from onset to nadir within 24h.

Transverse Myelitis in Children: Long-Term Urological Outcomes

PURPOSE

Urological complications are well documented in patients with traumatic spinal cord injury. We examined the long-term urological outcomes in a large population of children affected by transverse myelitis.

MATERIALS AND METHODS

We retrospectively reviewed the medical history, imaging studies and urodynamic findings in 22 children with transverse myelitis. Age at disease onset ranged from 3 months to 18 years (average 8.8 years).

RESULTS

At a mean followup of 7.1 years 19 patients (86%) had persistent bladder dysfunction and 17 (77%) had persistent bowel dysfunction. Initial evaluation at least 1 month after disease onset revealed detrusor overactivity in 59% of patients, detrusor external sphincter dyssynergia in 41%, low compliance in 47% and detrusor leak point pressure greater than 40 cm water in 12%. Functional motor recovery and absence of lower extremity spasticity did not reflect normal urodynamic findings. Of the 19 patients with imaging available for review 5 (26%) had upper tract changes. One patient had development of chronic renal insufficiency. Low compliance (p = 0.02) and upper tract changes (p = 0.1) were more frequent in patients who started clean intermittent catheterization more than 2 years after disease onset.

CONCLUSIONS

Persistent bowel and bladder dysfunction is common in transverse myelitis. Urodynamic abnormalities may be present despite normal neurological examination and absence of urinary symptoms. All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation to guide treatment. Early institution of clean intermittent catheterization appears to preserve bladder compliance and decrease upper tract disease, and should be instituted at disease onset.

Childhood autoimmune neurologic diseases of the central nervous system

An autoimmune mechanism for ADEM and MS can be supported by the similar patterns of pathologic changes seen in both diseases with the animal model EAE induced by inoculating animals with nervous tissue and the occurrence of ADEM in patients exposed to nervous tissue during vaccination. Whereas there are no universally agreed-upon criteria for the diagnosis of ADEM, a combination of prodromal illness or preceding vaccination, MRI signs of demyelination, and an acute presentation of neurologic symptoms are the triad most commonly looked for in making the diagnosis of ADEM. An ever-increasing number of infections and vaccinations (nonspecific URIs being most common) has been associated with ADEM. Fever and encephalopathy are seen frequently at presentation. Seizures also are common, as are cranial nerve abnormalities and motor symptoms. A mild pleocytosis or protein elevation is found in the majority of patients with ADEM. Intrathecal IgG synthesis and oligoclonal bands are relatively infrequent but should not be considered inconsistent with the diagnosis of ADEM. White matter changes on T2 in a bilateral although asymmetric distribution with relative sparing of the periventricular region with or without deep gray matter involvement is consistent and to some a requirement for the diagnosis. Low-dose steroids have no beneficial effect in the treatment of ADEM and may be contraindicated. High-dose steroids may have a beneficial effect, particularly in more prolonged illnesses, although the evidence is primarily anecdotal. If steroids are used to improve morbidity, 30 mg/kg/d of methylprednisolone for three to five days is the dose with a six-week taper to reduce the risk of recurrence. The prodromal infection may be a major factor in the ultimate mortality and morbidity of the disease. The current mortality of ADEM is quite low. Whether or not this is an effect of different triggering agents or changes in medical care cannot be determined. In larger series of patients with ADEM, 10% to 20% of children experience some sort of recurrence with the majority occurring in the initial one to two months after the first event. This is sometimes associated with steroid withdrawal. A second group of children have a late second recurrence that clinically may not be MS but a recurrence of ADEM, although longer follow-up may change that assessment. Two months should be allowed before a second relapse is considered a manifestation of MS, whereas a second attack also may occur years after an initial attack of ADEM and still be consistent with ADEM recurrence. MS does occur during childhood, with the youngest children at the least risk, and risk increasing with age. The criteria of Poser et al can be used to diagnose MS in childhood [40]. The presentation of MS in childhood is most often sensory, motor, and brainstem signs and symptoms. A relapsing-remitting course is most common with a first relapse occurring in the year after presentation. MRI findings in MS typically show periventricular changes. Oligoclonal bands and CSF IgG synthesis are found in the majority. Treatments of childhood MS have not been studied adequately, but, when treatments studied in adults are used in children, they are well tolerated. Efficacy has not been shown. The long-term outcome of MS in childhood can be either severe or benign with no clear consensus that childhood MS is either a less or more severe disease than the adult form. ATM and ON treatments and outcomes are particularly difficult to evaluate because of the heterogeneity of populations included in case series and the small numbers reported. Steroids are used with anecdotal reports of their superiority to nontreatment. Outcome in ATM often can be poor, whereas in ON it rarely is. A multinational collaborative effort to study and collect the large numbers necessary to address the important questions in these childhood autoimmune disorders would be of great benefit and the only way likely to demonstrate good evidenced-based medicine practiced in this field.