Disclosures: Sudeep K. Mehta, MD: Nothing to disclose

Case Description: A 32-year-old African American male was treated with a right L5-S1 transforaminal epidural injection, as prior non-contrast lumbosacral magnetic resonance imaging (MRI) revealed a disc protrusion with S1 nerve root compression. The patient subsequently presented with severe neurological deficits, requiring emergent decompressive laminotomy and intravenous antibiotics to treat an underlying epidural abscess.

Setting: Interventional Pain Outpatient Clinic

Patient: A 32-year-old African American male, recently treated for an L4-L5 radiculopathy with methylprednisolone dosepack and hydrocodone, presented with acute back pain and right thigh stiffness. Non-contrast lumbosacral MRI revealed a right paracentral disc protrusion at the L5/S1 level abutting against the right S1 nerve root, with L4/L5 neuroforaminal narrowing. He subsequently underwent a right L5-S1 transforaminal epidural injection. He soon presented to the emergency department unable to ambulate.

Assessment/Results: MRI with contrast imaging revealed an epidural abscess at L4-L5 and L5-S1 levels, requiring emergent decompressive laminotomy. Intra-operative cultures revealed methicillin resistant Staphylococcus aureus (MRSA). His hospital course was also complicated with MRSA prepatellar bursitis, requiring intravenous Daptomycin treatment.

Discussion: Literature discusses the risk of infection after lumbar epidural steroid injections due to contaminated steroid solutions or immunocompromised states. We present a case of a young adult who presented with atypical radiculopathy secondary to epidural abscess, who later developed worsening of symptoms after a transforaminal epidural steroid injection. This case emphasizes the need for thorough patient screening to screen for infectious etiologies prior to steroid therapy.

Conclusion: This case report presents a case of epidural abscess with an atypical presentation mimicking a lumbar radiculopathy secondary to disc herniation. Symptoms of epidural abscesses can vary at initial stages of disease, and neurological deficits may not appear until progression of infection. Contrasted MRI scans should be performed to clear ambiguity in diagnosis. The classical triad of symptoms may not appear early, making the pain symptoms mimic radiculopathy.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/atypical-presentation-of-epidural-abscess-in-interventional-practice-a-case-report/