What is the most likely diagnosis for a 43-year-old man presenting with lower limb weakness, urine incontinence, difficulty walking, and a T10 sensory level?

Most Likely Diagnosis: Spinal Cord Compression

The most likely diagnosis is spinal cord compression (Option A), given the acute presentation of lower limb weakness, urinary incontinence, difficulty walking, and a defined T10 sensory level in a 43-year-old man. This clinical picture represents an incomplete spinal cord injury requiring urgent MRI and potential surgical intervention 1.

Clinical Reasoning

Why Spinal Cord Compression is Most Likely

• Defined sensory level at T10 is the critical diagnostic feature that localizes pathology to the spinal cord itself, not peripheral nerves or nerve roots 1, 2
• Acute onset over 3 days with bilateral lower limb weakness and urinary incontinence indicates an evolving myelopathy requiring emergency imaging 1
• Urinary incontinence with bilateral motor weakness suggests upper motor neuron dysfunction from cord compression, not isolated nerve root pathology 3, 2
• The combination of motor, sensory, and autonomic (bladder) dysfunction at a specific spinal level is pathognomonic for spinal cord pathology 2, 4

Why Other Options Are Less Likely

Guillain-Barré Syndrome (Option B) is excluded because:

• GBS typically presents with ascending weakness starting distally in the legs, progressing upward over days to weeks 1
• GBS causes areflexia (absent reflexes) due to peripheral nerve involvement, whereas spinal cord compression typically causes hyperreflexia below the lesion 1
• A defined sensory level does not occur in GBS; instead, patients have distal sensory changes in a stocking-glove distribution 1
• GBS affects peripheral nerves and nerve roots (polyradiculoneuropathy), not the spinal cord itself 1

Transverse Myelitis (Option C) is possible but less likely because:

• Transverse myelitis typically follows a viral infection or immune-mediated process, and this patient has no history of preceding infection 1
• While transverse myelitis can present with similar symptoms, the absence of infectious prodrome makes structural compression more likely in this acute presentation 1
• Both conditions require urgent MRI, but compression is more common and must be excluded first as it requires surgical intervention 1

Cauda Equina Syndrome (Option D - assuming "Spina cuda symptom" refers to this) is less likely because:

• Cauda equina syndrome affects lumbosacral nerve roots below L1-L2, causing lower motor neuron signs with areflexia 5, 1
• A T10 sensory level is too high for cauda equina syndrome, which typically presents with saddle anesthesia and perianal sensory loss 5
• The cauda equina consists of nerve roots, not spinal cord, so a defined thoracic sensory level indicates cord pathology above the conus medullaris 5, 1

Immediate Management Algorithm

Step 1: Emergency MRI Spine

• Obtain MRI of entire spine (cervical, thoracic, lumbar) without and with contrast immediately 1
• Do not delay imaging—spinal cord compression requires urgent surgical decompression within hours to prevent permanent neurological deficit 1
• MRI will differentiate between compressive lesions (disc herniation, tumor, epidural abscess, hematoma) and non-compressive myelopathy (transverse myelitis) 1, 2

Step 2: Neurological Examination Details

While awaiting MRI, document:

• Motor strength in all muscle groups bilaterally (hip flexors, knee extensors/flexors, ankle dorsiflexors/plantarflexors) 1
• Sensory level precisely—confirm T10 dermatome with pinprick and light touch 1
• Reflexes: Check for hyperreflexia below the lesion (upper motor neuron sign) versus areflexia (lower motor neuron or spinal shock) 1, 4
• Rectal examination: Assess anal tone and perianal sensation to evaluate sacral sparing, which indicates incomplete cord injury with better prognosis 5, 4
• Bladder function: Determine if retention (palpable bladder) or true incontinence (overflow versus detrusor dysfunction) 3

Step 3: Urgent Neurosurgical Consultation

• Contact neurosurgery immediately upon clinical suspicion—do not wait for MRI results if there is high clinical suspicion 1
• Timing of decompression is critical: surgery within 24 hours of symptom onset provides the best chance for neurological recovery 1, 4

Critical Pitfalls to Avoid

• Do not assume lumbar pathology based solely on lower limb symptoms—cervical or thoracic cord compression can present with isolated lower extremity findings without upper extremity signs 6, 2
• Do not delay MRI to obtain CSF analysis or electrodiagnostic studies first—structural compression must be excluded emergently 1
• Do not miss spinal shock: Early acute spinal cord injury may present with areflexia before reflexes become hyperactive, mimicking lower motor neuron pathology 1, 4
• Do not overlook bladder retention: What appears as "incontinence" may actually be overflow incontinence from a distended bladder requiring catheterization 3

Prognosis Considerations

• Incomplete spinal cord injuries (those with any preserved sensation or motor function below the lesion) have significantly better recovery potential than complete injuries 4
• The majority of neurological recovery occurs within 9-12 months, with relative plateau by 12-18 months post-injury 4
• Early surgical decompression (within 24 hours) is associated with better functional outcomes in compressive myelopathy 1, 4