Both general neurologists and neurologists with a broad spectrum of subspecialty interests are often asked to evaluate patients with disorders of the spinal cord [1]. Over the past decade, there have been significant advances in our understanding of a wide spectrum of immune-mediated, infectious, metabolic, hereditary, paraneoplastic, and compressive myelopathies. Advances have been made in the classification and management of spinal vascular malformations [1]. Even with all the technical and scientific advances, some doctors still make justifiable errors, especially in low-income countries, who seek them without imaging tests and incomplete medical history.

Typically, spina bifida presents with myelomeningocele is diagnosed before or right after birth, when medical care is available [2]. Children diagnosed with this condition should be followed by a specialized team of health care providers throughout their lives. Families should be educated on the different complications to watch for [2]. The diagnosis of acute anterior poliomyelitis was also common months or years after birth, especially in children without vaccination coverage or incomplete. One of the great functions of the physician is to provide a correct diagnosis, in order to establish the prognosis and clinical and rehabilitation treatment; in addition to requesting, for example, specific tests, such as molecular ones [3].

The aim of the present study is to differentiate, mainly through physical and neurological examination, the diagnosis between acute anterior poliomyelitis, post-spina bifida poliomyelitis syndrome [4] and myelomeningocele.

A 49-year-old man, retired due to disability at age 18, seeks a neurology service to update a medical report on post-poliomyelitis syndrome, offered to him about 10 years ago. When asked about birth, childhood, possible vaccines and birth history, little was remembered. He claimed that he always had delays in motor development, in addition to surgery performed on his back to remove a possible “tumor.” He added that his history of financial precariousness hampered the search for a correct diagnosis; this one that was possibly acute anterior poliomyelitis, given that he had received an overlapping diagnosis of post-poliomyelitis syndrome. Physical examination showed dislocation of the hip, muscle contractures, scoliosis, pes cavus, genu varus, and marked amyotrophy of the lower limbs (Figure 1 and Figure 2), in addition to changes in superficial sensitivity and scar from a surgical incision in the lumbar region (Figure 3). Neurological examination revealed difficulties in locomotion, associated with amyotrophy, bilaterally abolished Achilles reflex. Tactile and painful hypoesthesia, in addition to hypopalesthesia in nonsymmetrically distributed dermatomes, was also marked. The patient complained of urinary and fecal incontinence. Magnetic resonance imaging of the lumbar spine showed an anchored pattern. On electroneuromyography mixed involvement of peripheral nerves and lesions in the cone and spinal cord neurons were shown. The patient fulfilled only one criterion established for the diagnosis of post-poliomyelitis syndrome, which is a new condition of fatigue and muscle weakness, also possible in other diseases. Therefore, although physical and permanent disability was identified, as well as the patient’s rights to retirement, the diagnosis was changed to spina bifida (myelomeningocele).

The PPS is now a well-recognized entity encompassing the late manifestations that occur because of previous acute anterior poliomyelitis, which was not provided during the childhood of our case. Common signs and symptoms include fatigue, cold intolerance, joint deteriorations with pain, and prominent neurologic problems that include new weakness, muscle pain, atrophy, respiratory insufficiency, dysphagia, and sleep apnea [5]. Many of the above findings are also found in other genetic or acquired myelopathies and neuropathies [1].

Post-polio syndrome is a clinical diagnosis of exclusion. Your diagnosis requires careful exclusion of other known diseases neurological, orthopedic, or psychiatric disorders that could develop these same symptoms [6], including spina bifida findings. The first criterion of post-poliomyelitis syndrome, not fulfilled by our case, is the confirmation of paralytic poliomyelitis through the history of an acute, febrile illness that resulted in a motor loss without sensory deficit. In addition, our case had sensory impairment and bladder dysfunction. The occurrence of a similar disease in the family or contacts in the neighborhood was also not reported by him, due to the difficulties mentioned above. The only score was the presence of asymmetric muscle atrophy on physical examination. Electroneuromyography with a pattern of chronic denervation with reinnervation compatible with disease of the anterior horn of the spinal cord was not only identified by needle, as root involvement was also recorded. Medical records proving acute illness were also absent [7].

On the other hand, several signs and symptoms, in addition to physical examination findings, led us to make the diagnosis of spina bifida, especially the large “mark” of a surgical incision in the lumbar region and a slight memory of a history of a “tumor in the spine,” possibly spina bifida. Walking and mobility problems, specific orthopedic complications (pes cavus, abnormal growth, scoliosis, pelvic girdle dysfunction, compensatory genu varus, bowel, and bladder problems (urinary and fecal incontinence) were present. The accumulation of liquor in the brain (hydrocephalus) findings cannot be described for us, by the financial difficulty of the present case. The patient had no intellectual impairment [8].

Clinicians must be aware about several acquired or inherited clinical conditions, which can mimic features present in post-polio syndrome, such as lower limb amyotrophy, weakness, fatigue, and hypotonia. Structural neurological diseases must be ruled out during diagnostic work-up of patients to allow a diagnosis of post-polio syndrome. Spina bifida should be considered as a potential etiology of slowly progressive incomplete myelopathy, even with predominant anterior horn cell signs and symptoms. Typical surgical scars involving the lumbar region may give clues to consider neural tube defects as a differential diagnosis.

Therefore, the findings of the family history, previous pathological, physical, and neurological exams, in addition to classic imaging findings from magnetic resonance imaging of the lumbar spine and mixed findings on electroneuromyography, seem to support our diagnosis. An extensive scar due to a surgical incision in the lumbar region, very classically seen in patients with spina bifida/myelomeningocele, gave clues to differential diagnosis.