Differentials
Epidural haematoma
SIGNS / SYMPTOMS
Spontaneous spinal haematoma is rare, with an annual incidence of about 1 person per 1 million population. Rarely presents with fever, but pain and neurological signs are common. Related to the fragility of the epidural venous plexus, spinal epidural haematoma is seen more often after minor trauma and in men.
INVESTIGATIONS
MRI shows low signal on T1 and bright on T2, with a few areas of T1 hyperintensity mixed within the early phase. The lesion can be isointense to the adjacent cord immediately after onset.
Multiple sclerosis
SIGNS / SYMPTOMS
Variable presentation with multiple episodes. Can present with sudden neurological deficit, but rarely with fever or back pain. Common symptoms include progressive limb weakness, gait difficulty, ataxia, loss of balance, and paroxysmal vertigo.
In the setting of acute paraparesis, visual symptoms (visual loss) may be present (neuromyelitis optica [NMO]). Patients may have optic disc atrophy.
INVESTIGATIONS
Brain MRI typically shows areas of demyelination.
Cerebrospinal fluid examination may show raised IgG and oligoclonal banding.
Visual evoked potentials are most commonly abnormal, with somatosensory and auditory evoked potentials less so.
Malignant spinal cord compression
SIGNS / SYMPTOMS
Clinical presentations may be similar.
Patients may have a history of cancer or show signs of malignant disease (e.g., weight loss).
INVESTIGATIONS
MRI shows spinal neoplasm.
Intervertebral disc herniation/compression
SIGNS / SYMPTOMS
Patients typically present with chronic back pain and sometimes only leg pain. Neurological deficit is absent.
INVESTIGATIONS
Erythrocyte sedimentation rate, CRP, and FBC are typically normal.
MRI shows disc compression or herniation.
Meningitis
SIGNS / SYMPTOMS
Clinical presentation may be similar (with meningismus, malaise, and fever) but with less focal pain or spasm, and few radicular signs. Patients typically have moderate encephalopathy.
INVESTIGATIONS
Imaging is negative for focal collections; may show diffuse dural enhancement.[40]
Transverse myelitis
SIGNS / SYMPTOMS
Interval from pain onset to paralysis is often 1 day or less. Most patients are afebrile.
INVESTIGATIONS
Cerebrospinal fluid analysis shows pleocytosis with a few lymphocytes and increased total protein.
Imaging is often negative in early stage or may show focal cord T2 signal change without enhancement at the appropriate level.
Patients with NMO may show NMO-IgG seropositivity.
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