Misdiagnosis of Surgical Conditions in ALS Patients: Analysis of a Single‐Center Experience and Review of Literature

Background/Objectives: In amyotrophic lateral sclerosis (ALS) late or incorrect diagnosis significantly reduces the therapeutic window, while also increasing the risk of inappropriate interventions, with a negative impact on disease progression rate. We aim to identify and characterize the clinical profile of ALS patients followed in our center who underwent surgeries due to initial clinical presentation, and to review the literature. Methods: We conducted a prospective observational study of patients newly diagnosed with ALS at our center between 2021 and 2024. Patients were categorized into two groups: those who underwent surgical intervention (Surgery Group, n=17) and those who did not (non-Surgery Group, n=284). Variables analyzed included demographic characteristics, onset region, diagnostic delay, baseline disease progression rate (ΔFS), the first specialist consulted, upper motor neuron (UMN)/lower motor neuron (LMN) predominance, and presence of fasciculations at onset. English medical literature was reviewed. Results: Of 301 ALS patients, 17 (5.6%) underwent surgery due to initial symptoms. These patients had a significantly longer diagnostic delay (median 14.95 vs. 8.99 months, p=0.010) and all had spinal-onset ALS (p=0.014). No significant differences were found in sex (p=0.354), progression rate (p=0.453), UMN/LMN predominance (p=0.708), or fasciculations at onset (p=0.129). Conclusions: Surgical interventions in ALS, particularly in spinal-onset cases, remains a clinical concern. Surgeries may delay diagnosis and bypass early neurological assessment. We advocate for increased ALS awareness among non-neurologists and emphasize the necessity of neurological evaluation prior to elective spinal surgery in patients exhibiting progressive motor symptoms.