What is the most likely diagnosis for a patient 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 bilateral lower limb weakness, urinary incontinence, difficulty walking, and a clearly defined T10 sensory level over 3 days. 1

Why Spinal Cord Compression is the Primary Diagnosis

• A defined sensory level at T10 is pathognomonic for spinal cord pathology, localizing the lesion to the thoracic spinal cord itself rather than peripheral nerves or nerve roots. 1

• The combination of motor dysfunction (lower limb weakness), sensory dysfunction (T10 level), and autonomic dysfunction (urinary incontinence) occurring together at a specific spinal level is diagnostic of myelopathy requiring emergency imaging. 1

• The acute onset over 3 days with bilateral symptoms indicates an evolving compressive myelopathy that requires urgent MRI of the entire spine without and with contrast to differentiate between compressive lesions and non-compressive causes. 1

• Spinal cord compression is a surgical emergency requiring decompression within 24 hours to prevent permanent neurological deficit, and early surgical intervention is associated with better functional outcomes. 1

Why Other Diagnoses Are Less Likely

Guillain-Barré Syndrome (Option B) - Unlikely

• GBS typically presents with ascending weakness starting distally in the legs and progressing upward over days to weeks, with areflexia due to peripheral nerve involvement. 2, 3

• The site of lesion in GBS is peripheral nerves and nerve roots (polyradiculoneuropathy), not the spinal cord, which cannot explain a discrete T10 sensory level. 3

• GBS does not produce a defined sensory level; sensory changes are typically distal, symmetric, and in a stocking-glove distribution. 2

• While bladder dysfunction can occur in GBS due to dysautonomia, it is uncommon early in the disease course and would not present with a clear spinal sensory level. 2

Transverse Myelitis (Option C) - Possible but Less Likely

• Transverse myelitis typically follows a viral infection or immune-mediated process, and the absence of any mentioned infectious prodrome makes structural compression more likely in this acute presentation. 1

• While transverse myelitis can present with similar symptoms (bilateral weakness, sensory level, bladder dysfunction), the lack of preceding infection history and the 3-day time course favor a compressive etiology that requires immediate surgical evaluation. 1

Cauda Equina Syndrome (Option D) - Anatomically Incorrect

• Cauda equina syndrome affects lumbosacral nerve roots below the L1-L2 level, causing lower motor neuron signs with areflexia. 1, 4

• A T10 sensory level is anatomically too high for cauda equina syndrome, which would produce saddle anesthesia and lower lumbar/sacral dermatomal sensory loss, not a thoracic sensory level. 1, 4

• The site of lesion in cauda equina is lumbosacral nerve roots, not the thoracic spinal cord. 3

Immediate Management Algorithm

1. Do not delay MRI of the entire spine (cervical, thoracic, lumbar) without and with contrast to identify the compressive lesion and rule out non-compressive myelopathy. 1, 3

2. Obtain urgent neurosurgical consultation immediately upon clinical suspicion, as timing of decompression is critical for neurological recovery. 1

3. Monitor for progression of neurological deficits including worsening motor function, ascending sensory level, or respiratory compromise if cervical cord involvement develops. 3

4. Avoid administering steroids empirically until imaging excludes structural compression, as this may delay definitive surgical treatment. 5

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, 7, 8

• Do not wait for additional diagnostic tests (CSF analysis, EMG) before obtaining spinal imaging when a sensory level is present, as this indicates cord pathology requiring immediate visualization. 3

• Do not misinterpret early spinal shock - acute spinal cord injury may initially present with areflexia before reflexes become hyperactive, which could be confused with peripheral nerve pathology. 3

• Recognize that lower limb sensory disturbance in a non-radicular pattern should always raise suspicion of cord compression at a higher level, especially when concurrent with bladder dysfunction. 8