Case Diagnosis: A 32-year-old African American male, recently diagnosed and treated for an acute L4-L5 radiculopathy with methylprednisolone dosepack and hydrocodone, presented with acute back pain, joint pain and stiffness in his right thigh. Non-contrast lumbosacral MRI revealed a right paracentral disc protrusion at the L5/S1 level abutting against the right S1 nerve root without definite compression, with L4/L5 neuroforaminal narrowing. The patient was treated with a right L5-S1 transforaminal epidural injection. He soon presented to the emergency department unable to ambulate, and was diagnosed with an epidural mass at L4-L5 and L5-S1 levels.
Case Description: MRI with contrast imaging revealed the epidural abscess at L4-L5 and L5-S1 levels, requiring an emergent decompressive laminotomy. Intra-operative cultures revealed methicillin resistant Staphylococcus aureus (MRSA), and hospital course was also complicated with a prepatellar bursitis, revealing MRSA also. He was subsequently treated with intravenous Daptomycin.
Discussions: Until recent times, epidural abscesses were considered rare phenomena induced by compromised immunities or through sources of infections in spinal column treatment. Epidural abscesses have the potential to spread into the anterior aspect of the spinal canal from the epidural space, causing excruciating pain from nerve root compression. A classic triad of back pain, fever, and variable neurological deficits is not always present. It is essential to recognize them early and treat appropriately
Conclusions: This is a case of epidural abscess with an atypical presentation mimicking lumbar radiculopathy secondary to disc herniation. It is imperative to learn that symptoms of epidural abscesses can vary at initial stages of disease, and neurological deficits may not appear until progression of infection is evident. Contrasted MRI scans should be performed to clear ambiguity in diagnosis, and Infectious Disease should be consulted to screen for possible infectious etiology. The classical triad of symptoms may not appear in every patient, making the pain symptoms comparable to typical radiculopathy.