Progressive paraparesis is a neurosurgical and neurological emergency. The patient's neurological outcome relies on the course of the diagnostics and treatment. Physicians having experience in emergency medicine are familiar with the typical etiologies of paraparesis. Uncommon causes of paraparesis may, however, elicit diagnostic challenges. Intraspinal bleeding causes a rapid progression of the symptoms. Intraspinal epidural hematoma is a rare complication of spinal anaesthesia and may be diffcult to diagnose if the blood is located in the subarachnoidal space. Spinal arteriovenous malformations and arachnoideal cysts causing medullary compression, and myelitis may present with slowly proceeding paraparesis. The diagnostics of the conditions described above is often difficult and typically requires facilities that are available only in larger centers.