59-year-old male with controlled diabetes mellitus, who developed sudden onset of bilateral paresthesias in his hands, and feet. Cervical spine MRI showed severe spinal stenosis at C5-C6 with cord impingement. Examination showed decreased sensation, with spared motor function, and global areflexia. Underwent to emergent ACDF for acute cervical myelopathy. Two days later had severe quadriparesis with new dysphagia, respiratory insufficiency, and orthostatic hypotension, without improvement after a decompressive laminectomy. 

Personal assessment, laboratory data analysis, neuroimaging and electrodiagnostic tests were performed. 

Repeat Neuroimaging did not reveal any fluid collection, hematoma or cord signal abnormality. NCS/EMG revealed a predominantly axonal, subacute mixed polyneuropathy suggestive of immune mediated axonal neuropathy considering the non-length dependent pattern and acute/subacute course. Neuropathy work up was unremarkable, including paraneoplastic and antiganglioside antibodies. Treatment with IVIG infusion showed significant response within the first 24 hours and gradual improvement in the following weeks, including ambulation, diet tolerance but orthostatism persisted. CSF studies were deferred after marked results with IVIG.  The absence of upper motor neuron signs including abnormal increased reflexes and spasticity were masked by the acute peripheral nerve process.