What is the most likely diagnosis for a patient presenting with acute onset of lower limb weakness, urine incontinence, difficulty walking, and a T10 sensory level, without a history of previous infection?

Spinal Cord Compression

The most likely diagnosis is A - Compression of Spinal Cord. The acute presentation of bilateral lower limb weakness, urinary incontinence, difficulty walking, and a clearly defined T10 sensory level over 3 days strongly indicates a compressive myelopathy requiring emergency imaging and neurosurgical evaluation 1.

Key Diagnostic Features Supporting Spinal Cord Compression

A defined sensory level at T10 is pathognomonic for spinal cord pathology and localizes the lesion to that specific spinal level 1. This critical finding, combined with the acute onset over 3 days with bilateral motor, sensory, and autonomic dysfunction, indicates an evolving myelopathy 1.

The combination of:

• Bilateral lower limb weakness (motor dysfunction)
• Urinary incontinence (autonomic dysfunction)
• T10 sensory level (sensory dysfunction)
• Acute onset over 3 days

creates a clinical picture most consistent with structural compression of the spinal cord 1, 2.

Why Other Diagnoses Are Less Likely

Guillain-Barré Syndrome (Option B) - Unlikely

Guillain-Barré syndrome presents with ascending weakness starting distally in the legs and progressing upward over days to weeks, causing areflexia due to peripheral nerve involvement 1, 3. The key distinguishing features that argue against GBS include:

• GBS does not produce a defined sensory level - it causes a glove-and-stocking pattern of sensory loss 3
• GBS causes areflexia (lower motor neuron signs), whereas spinal cord compression typically causes hyperreflexia below the lesion 4
• Urinary retention is uncommon in early GBS 3

Transverse Myelitis (Option C) - Less Likely

While transverse myelitis can present with similar symptoms (bilateral lower limb weakness, sensory level, urinary retention), the absence of a preceding infection makes structural compression more likely in this acute presentation 1, 3.

The critical distinguishing feature is that transverse myelitis characteristically presents without significant back pain, whereas spinal cord compression typically presents with back pain as a prominent early symptom 3. The question does not mention whether back pain is present or absent, but the lack of infectious prodrome weighs against transverse myelitis 3.

Cauda Equina Syndrome (Option D) - Anatomically Incorrect

Cauda equina syndrome affects lumbosacral nerve roots below L1-L2, causing lower motor neuron signs with areflexia 1, 4. A T10 sensory level is too high for cauda equina syndrome - this indicates spinal cord involvement, not nerve root involvement 1, 3, 4.

Immediate Management Algorithm

1. Do not delay imaging - obtain MRI of the entire spine without and with contrast immediately to differentiate between compressive lesions and non-compressive myelopathy 1

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

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

Clinical Pitfall

The absence of back pain does not rule out spinal cord compression 2, 5. Some patients, particularly those with gradual onset or certain pathologies (such as multiple myeloma presenting as a solid tumor), may not report significant back pain initially 2.