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 defined T10 sensory level over 3 days is pathognomonic for spinal cord pathology requiring emergency imaging and potential surgical decompression 1.
Why Spinal Cord Compression is the Answer
A 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. This combination of:
- Bilateral motor weakness in lower limbs
- Urinary incontinence (autonomic dysfunction)
- Specific sensory level at T10
- Acute onset over 3 days
represents the classic triad of motor, sensory, and autonomic dysfunction at a specific spinal level, which is diagnostic for spinal cord compression 1, 2, 3.
Why the Other Options Are Incorrect
Guillain-Barré Syndrome (Option B) - Wrong
- GBS presents with ascending weakness starting distally in the legs, progressing upward over days to weeks 4
- GBS causes areflexia due to peripheral nerve involvement, not a defined sensory level 4
- The site of lesion in GBS is peripheral nerves and nerve roots (polyradiculoneuropathy), which cannot produce a T10 sensory level 4
- GBS does not typically cause urinary incontinence in the acute phase 4
Transverse Myelitis (Option C) - Less Likely
- 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
- While transverse myelitis can present with similar symptoms, it commonly shows bladder dysfunction patterns different from acute compression 5
- The 3-day acute presentation without preceding infection favors compression over inflammatory myelitis 1
Cauda Equina Syndrome (Option D) - Anatomically Impossible
- A T10 sensory level is too high for cauda equina syndrome 1, 6
- Cauda equina affects lumbosacral nerve roots below L1-L2, causing lower motor neuron signs with areflexia 1, 6
- The cauda equina cannot produce a thoracic sensory level 6
- Cauda equina presents with bilateral radicular pain and perianal anesthesia, not a defined thoracic sensory level 6
Immediate Management Algorithm
Do not delay imaging - obtain MRI of the entire spine without and with contrast immediately 1:
- This differentiates between compressive lesions (disc herniation, tumor, abscess, hematoma) and non-compressive myelopathy 1
- Spinal cord compression requires urgent surgical decompression within hours to prevent permanent neurological deficit 1
Urgent neurosurgical consultation upon clinical suspicion 1:
- Early surgical decompression within 24 hours is associated with better functional outcomes 1
- Timing of decompression is critical for neurological recovery 1
Critical Pitfall to Avoid
Never wait for complete paralysis or complete urinary retention before imaging - the acute onset over 3 days with bilateral weakness and urinary incontinence indicates an evolving myelopathy that requires emergency intervention 1, 2. Delayed decompression results in permanent neurological deficit and irreversible bladder/bowel dysfunction 1.