Download

Download Full Text (284 KB)

Description

Spinal epidural abscess (SEA) is a rare but potentially devastating spinal infection in which delayed diagnosis can lead to permanent neurologic injury or death. Back pain is common and often nonspecific, while fever and focal neurologic deficits may be absent early, making SEA easy to miss in emergency department (ED) patients with seemingly benign presentations. Intravenous drug use (IVDU) is a major risk factor, yet reliance on "red flag" symptoms and reassuring examinations can contribute to diagnostic anchoring and delay.

A 38-year-old unhoused woman with prior intravenous heroin use and chronic low back pain presented four times over 10 days to three EDs for worsening back pain. Initial visits showed normal vitals, intact neurologic exams, no spinal tenderness, and unremarkable labs; she was repeatedly diagnosed with musculoskeletal pain, and inflammatory markers were not obtained. On the fourth visit, she arrived in septic shock with leukocytosis, lactic acidosis, pulmonary nodules concerning for septic emboli, and positive blood cultures for Staphylococcus aureus; MRI revealed an extensive cervical to lumbar dorsal spinal epidural abscess.

This case illustrates how SEA in a patient with IVDU can be repeatedly overlooked when clinicians rely on normal neurologic examinations and the absence of classic red flags to exclude serious spinal infection. It underscores the importance of recognizing IVDU as a persistent high-risk feature, obtaining inflammatory markers, and maintaining a low threshold for contrast-enhanced MRI in high-risk patients with recurrent back pain, even when early findings are reassuring. Earlier consideration of SEA might have limited disease extent and preserved neurosurgical options.

Publication Date

5-8-2026

Disciplines

Emergency Medicine

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 1897

When Back Pain Isn't Just Back Pain: Spinal Epidural Abscess in an Unhoused Woman with IV Drug Use History

Share

COinS