A 26-year-old man with a history of opiate abuse presented with quadriparesis and numbness.  He reported an 8 day period of abstinence to heroin prior to the day of presentation.  However, he continued his daily use of a quarter of a 100 mcg fentanyl patch.  The day of presentation, he instead used one half of a 100 mcg fentanyl patch sublingually and fell asleep on a couch.  When he awoke 3 hours later, he was barely able to move any of his limbs.

Examination demonstrated flaccid quadriparesis and a sensory level at C3.  MRI showed a T2 hyperintense intramedullary lesion at C4-7 and signal abnormality in adjacent paraspinal muscles.  He received pulse steroids for treatment.  On the second day of hospitalization, patient developed respiratory weakness and required intubation.  His condition gradually improved subsequently.  At time of discharge to rehab, he was regaining strength but was not yet ambulatory. 

Myelopathy in the setting of fentanyl use after a period of abstinence likely represents a similar entity to the well described heroin myelopathy.  Fentanyl myelopathy has not been previously reported.