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 bacteremia 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, as have fungal and parasitic pathogens.
CBC, CRP, and ESR are usually elevated.
Osteoporotic spinal compression fracture
SIGNS / SYMPTOMS
Characterized 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). Neurologic deficit is uncommon.
INVESTIGATIONS
Diffusion-weighted MRI can distinguish between hypointense osteoporotic fractures and hyperintense metastatic tumors.
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.
Intervertebral disk herniation/compression
SIGNS / SYMPTOMS
Patients typically present with back pain. May have radicular symptoms into an arm or leg depending on the region of the spine involved. Neurologic deficit may be present in distribution of the compressed nerve/nerves.
INVESTIGATIONS
MRI shows disk compression or herniation, with or without nerve root compression.
Transverse myelitis
SIGNS / SYMPTOMS
More than half of patients have a systemic viral illness 1 to 4 weeks before onset of neurologic 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.
Cerebrospinal fluid analysis shows pleocytosis with a modest number of lymphocytes and increase in total protein.
Guillain-Barre syndrome
SIGNS / SYMPTOMS
Two-thirds of patients have a gastroenteritis- or flu-like illness weeks before onset of neurologic 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 with features similar to those of MSCC, as 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 cerebrospinal fluid findings include albuminocytologic dissociation; that is, an elevated protein level (100-1000 mg/dL) without an accompanying increased cell count.
Electrodiagnostics (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.
Vascular or dural malformation of the spinal cord
SIGNS / SYMPTOMS
Pain, especially with activity. Local root dysfunction.
INVESTIGATIONS
Initially suspected on MRI; confirmed with vessel imaging study (magnetic resonance angiography or angiography).
Sacral joint instability
SIGNS / SYMPTOMS
Low back pain, coupled with dysfunction (climbing stairs, arising from seated).
INVESTIGATIONS
Dynamic imaging of the sacrum or MRI helps to make the diagnosis.
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