A rare clinical presentation of acute ischaemic myelopathy of the conus medullaris: a case report

Background: Conus medullaris infarction is a rare cause of acute spinal cord injury that can mimic Guillain-Barré syndrome (GBS) or cauda equina syndrome. Early diagnosis is important for management and prognosis. We report a case in a patient without major vascular risk factors. Case presentation: A 68-year-old man with a history of Pott's disease and smoking presented with sudden left foot numbness that progressed within hours to bilateral leg weakness, back pain, urinary retention, and a T10 sensory level. Examination showed complete flaccid paraplegia (American Spinal Injury Association Impairment Scale, AIS, Grade A) with normal upper limb function. MRI revealed T12–L1 conus medullaris oedema without evidence of compression. Cerebrospinal fluid analysis and autoimmune/infectious workup were unremarkable. High-dose methylprednisolone was administered for suspected Guillain–Barré syndrome, with minimal clinical improvement. CT angiography showed only mild aortoiliac atherosclerosis. Acute ischaemic myelopathy of the conus medullaris was diagnosed. Rehabilitation started at 7 weeks led to partial recovery of strength in the hip flexors and quadriceps, as well as independent wheelchair mobility at 12 weeks. Conclusions: This case demonstrates the diagnostic challenges of conus medullaris infarction. Clinicians should consider spinal cord ischaemia in acute paraplegia with early urinary retention and normal CSF, even in individuals without significant vascular risk factors. Rehabilitation can produce significant recovery despite poor initial presentation.