BACKGROUND A 61-year-old female with cervical stenosis underwent an elective cervical laminectomy with post-op worsening upper extremity weakness. Over the first 3 weeks post-op, she received two separate courses of intravenous steroids. Two days after cessation of steroids, she presented with non-specific symptoms of adrenal insufficiency (AI). Initial formal diagnostic tests of random cortisol level and 250 µg cosyntropin challenge were non-diagnostic; however, symptoms resolved with the initiation of empiric treatment with hydrocortisone. Ten days later, repeat cosyntropin (adrenocortocotropic hormone stimulation) test confirmed the diagnosis of AI. RESULTS AI is a potentially life-threatening complication of acute spinal cord injury (ASCI), especially in those receiving steroids acutely. Only three cases have been reported to date of AI occurring in ASCI after steroid treatment. The presenting symptoms can be non-specific (as in this patient) and easily confused with other common sequelae of ASCI such as orthostasis and diffuse weakness. The 250 µg cosyntropin simulation test may not the most sensitive test to diagnose AI in ASCI. CONCLUSIONS The non-specific presentations and variability of diagnosis criteria make diagnosis more difficult. One microgram cosyntropin simulation test may be more sensitive than higher dose. Clinicians should be aware that AI can be a potential life-threatening complication of ASCI post-steroid treatment. Prompt diagnosis and treatment can reverse symptoms and minimize mortality.