Differentials
Spinal epidural abscess
SIGNS / SYMPTOMS
Fever is often present.
Potential risk factors include a history of intravenous drug use, diabetes mellitus, history of recent spinal surgery or trauma, indwelling spinal catheter, contiguous local infection, concomitant bacteraemia or endocarditis, chronic renal disease, and immunosuppression (e.g., HIV infection, malignancy).
INVESTIGATIONS
Gadolinium-enhanced MRI spine shows epidural space and bone involvement of abscess.
Blood or cerebrospinal fluid culture will be positive for causative organism - most commonly Staphylococcus aureus, although many other bacteria have been implicated. FBC, CRP, and ESR are usually elevated.
Osteoporotic spinal compression fracture
SIGNS / SYMPTOMS
Characterised by kyphosis and loss of height. Back pain is typical, and there may be acute onset with relatively atraumatic activities (e.g., standing up from a seated position or bending forwards). Neurological deficit is uncommon.
INVESTIGATIONS
Anteroposterior and lateral spine x-rays often reveal the classic wedge fracture, with loss of anterior vertebral height and relative preservation of posterior body height.
MRI spine is useful in distinguishing between osteoporotic compression fractures and those caused by underlying tumour or infection.
Transverse myelitis
SIGNS / SYMPTOMS
More than half of patients have a systemic viral illness 1 to 4 weeks before onset of neurological symptoms. Most have leg weakness of varying degrees of severity. The arms are involved in a minority of cases.
INVESTIGATIONS
MRI shows focal demyelination with possible enhancement at the appropriate level, and excludes compressive lesion. Serum autoantibodies to serum aquaporin-4, or myelin oligodendrocyte glycoprotein, are present in over 80% of cases.
CSF analysis shows pleocytosis with a modest number of lymphocytes and increase in total protein.
Guillain-Barre syndrome (GBS)
SIGNS / SYMPTOMS
Two-thirds of patients have a gastroenteritis- or flu-like illness weeks before onset of neurological symptoms. Also associated with other viral and bacterial infections, as well as with some cancers and with checkpoint inhibitor cancer therapies. It is frequently severe and presents an ascending paralysis initially, with weakness in the legs that spreads to the upper limbs and the face, along with complete loss of deep tendon reflexes. Autonomic signs may be present in some variations. Up to 30% of patients develop progressive respiratory muscle weakness requiring ventilation.
INVESTIGATIONS
Typical CSF findings include albuminocytological dissociation; that is, an elevated protein level (100-1000 mg/dL) without an accompanying increased cell count.
Electrodiagnostics (i.e., electromyogram and nerve conduction studies) may show prolonged distal and F-wave latencies, reduced conduction velocities, and prolonged or absent H reflex. Evidence of demyelination is present in 85% of patients with early testing.
Traumatic conus medullaris (CMS)
SIGNS / SYMPTOMS
Patients with axial compression injury (e.g., fall, motor vehicle accident) or flexion injury can experience a vertebral body fracture with retropulsion of a fragment of bone or disc, and spinal shock. This usually resolves in a few days. Penetrating injuries (e.g., projectile, knife) often cause loss of function, and with entry forces conus medullaris syndrome or CES-like symptoms.
INVESTIGATIONS
A history of the injury and some description of the force vectors (if known) leads to the diagnosis. Imaging includes MRI without contrast and/or CT scanning. CMS may result from injury of vertebrae T12 to L2, and involves damage to neural structures from spinal cord segment T12 to nerve root S5; CES may result from an injury of vertebrae L3 to L5, and involves damage to nerve roots L3 to S5.[37]
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