What is the most likely diagnosis for a patient presenting with lower limb weakness, urine incontinence, difficulty walking, and a T10 sensory level over 3 days, with no history of previous infection?

Spinal Cord Compression

The most likely diagnosis is A - Compression of Spinal cord. The combination of bilateral lower limb weakness, urinary incontinence, difficulty walking, and a clearly defined T10 sensory level over 3 days represents an acute myelopathy requiring emergency imaging to rule out structural compression 1.

Why Spinal Cord Compression is Most Likely

A defined sensory level at T10 is pathognomonic for spinal cord pathology, not peripheral nerve or nerve root involvement 1. This critical diagnostic feature localizes the lesion to the spinal cord itself at the T10 level 1.

• Acute onset over 3 days with bilateral motor, sensory, and autonomic dysfunction (urinary incontinence) at a specific spinal level indicates an evolving compressive myelopathy 1.
• The clinical presentation demands immediate MRI of the entire spine without and with contrast to differentiate between compressive lesions and non-compressive myelopathy 1.
• Do not delay imaging—spinal cord compression requires urgent surgical decompression within hours to prevent permanent neurological deficit 1.
• Early surgical decompression within 24 hours is associated with better functional outcomes in compressive myelopathy 1.

Why Other Diagnoses Are Less Likely

Guillain-Barré Syndrome (Option B)

• GBS typically presents with ascending weakness starting distally in the legs and progressing upward over days to weeks, not a defined sensory level 1, 2.
• GBS causes areflexia due to peripheral nerve involvement, whereas spinal cord compression typically causes hyperreflexia below the lesion 1.
• A clear T10 sensory level and urinary retention are uncommon in early GBS 2.
• While one case report describes GBS with bladder incontinence following COVID-19, this patient had muted reflexes and required exclusion of cauda equina syndrome first 3.

Transverse Myelitis (Option C)

• The absence of back pain is a critical distinguishing feature—transverse myelitis characteristically presents without significant back pain, whereas spinal cord compression typically presents with prominent early back pain 2.
• Transverse myelitis typically follows a viral infection or immune-mediated process 1.
• The absence of infectious prodrome in this patient makes structural compression more likely 1.
• However, transverse myelitis remains in the differential and can only be definitively excluded after MRI rules out compression 2.

Cauda Equina Syndrome (Option D - assuming "Spina cuda symptom" refers to this)

• Cauda equina syndrome affects lumbosacral nerve roots below L1-L2, causing lower motor neuron signs with areflexia 1.
• A T10 sensory level is too high for cauda equina syndrome 1, 2.
• Cauda equina typically presents with severe back pain, saddle anesthesia, and asymmetric lower limb weakness 2, 4.
• The T10 sensory level indicates spinal cord involvement, not nerve root pathology 2.

Immediate Management Algorithm

1. Obtain emergency MRI of entire spine (without and with contrast) immediately 1.
2. Urgent neurosurgical consultation upon clinical suspicion—timing of decompression is critical for neurological recovery 1.
3. Do not wait for imaging results to consult neurosurgery if clinical suspicion is high 1.
4. Bladder catheterization for urinary retention management 5, 6.

Critical Pitfall to Avoid

The single most important pitfall is delaying imaging or neurosurgical consultation while pursuing other diagnoses. The presence of a defined sensory level with acute bilateral weakness and urinary incontinence is spinal cord pathology until proven otherwise 1. Even if transverse myelitis is ultimately diagnosed, structural compression must be excluded first as it requires immediate surgical intervention 1, 2.