What is the most likely diagnosis for a man presenting with lower limb weakness, difficulty walking, a T10 sensory level, and recent urinary retention, without pain?

Spinal Cord Compression (Compressive Myelopathy)

The most likely diagnosis is spinal cord compression (Option A), and this patient requires emergency MRI of the entire spine followed by urgent neurosurgical consultation within hours to prevent permanent neurological deficit. 1

Why Spinal Cord Compression is the Answer

The clinical presentation is pathognomonic for spinal cord pathology:

• A defined sensory level at T10 is the critical diagnostic feature that localizes pathology directly to the spinal cord itself, not to peripheral nerves or nerve roots 1
• The combination of motor (bilateral lower limb weakness), sensory (T10 level), and autonomic dysfunction (urinary retention) at a specific spinal level is diagnostic for spinal cord compression 1
• Acute onset over 3 days with bilateral symptoms and urinary retention indicates an evolving myelopathy requiring emergency imaging 1
• The absence of pain does not rule out compression—many compressive lesions can present without significant pain, particularly when compression develops gradually or involves certain pathologies 1

Why the Other Options Are Incorrect

Guillain-Barré Syndrome (Option B) - Wrong Pattern

• GBS presents with ascending weakness starting distally in the legs, progressing upward over days to weeks 1
• GBS causes areflexia due to peripheral nerve involvement, not a defined sensory level 1
• GBS does not produce a discrete sensory level like T10—sensory changes are typically in a stocking-glove distribution 1
• The presence of a clear spinal sensory level excludes peripheral nerve pathology 1

Transverse Myelitis (Option C) - Possible but Less Likely

• Transverse myelitis typically follows a viral infection or immune-mediated process 1, 2
• The absence of infectious prodrome makes structural compression more likely in this acute presentation 1
• While transverse myelitis can present similarly, you must first rule out compressive lesions with emergency MRI before making this diagnosis 2
• Transverse myelitis is a diagnosis of exclusion after imaging rules out compression 2

Cauda Equina Syndrome (Option D) - Wrong Anatomical Level

• Cauda equina affects lumbosacral nerve roots below L1-L2, causing lower motor neuron signs with areflexia 1, 3
• A T10 sensory level is anatomically too high for cauda equina syndrome, which would produce saddle anesthesia and lower lumbar/sacral deficits 1, 3
• Cauda equina typically presents with bilateral radiculopathy, not an upper thoracic sensory level 3

Immediate Management Algorithm

1. Do not delay—obtain emergency MRI of the entire spine without and with contrast immediately to differentiate between compressive lesions (tumor, abscess, hematoma, disc herniation) and non-compressive myelopathy 1

2. Contact neurosurgery urgently upon clinical suspicion—do not wait for MRI results if there will be any delay 1

3. Early surgical decompression within 24 hours is associated with better functional outcomes in compressive myelopathy 1

4. The timing of decompression is critical for neurological recovery—hours matter in preventing permanent deficit 1

Critical Pitfall to Avoid

The single most dangerous error is assuming this is a lumbar pathology based on lower limb symptoms and delaying cervical/thoracic imaging. Several case reports document patients with cervical or thoracic cord compression presenting solely with lower limb symptoms who were initially misdiagnosed and treated for lumbar pathology, resulting in delayed appropriate treatment 4, 5, 6. The T10 sensory level in this case clearly localizes to the thoracic cord, but the principle remains: always image the entire spine when myelopathy is suspected, as the level of symptoms may not match the level of compression 1.