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Transient paralysis of bilateral lower limbs: case report An 87-year-old man developed transient paralysis of bilateral lower limbs during treatment with betamethasone sodium phosphate and dexamethasone. The man, who had well-controlled hypertension and prostate cancer, presented with chronic low back pain radiating to the legs. His symptoms deteriorated in last 3 months. Additionally, he had intermittent loss of sensation in the legs, multiple episodes of unexplained new-onset fecal incontinence and buckling of his legs with falls. Following investigations, degenerative changes at the lower lumbar levels with severe bilateral foraminal narrowing at L5-S1 and moderate bilateral foraminal narrowing at L4-L5 with no central canal stenosis at any level were noted. He chose to undergo an elective epidural steroid injection for pain control. He received an L4-L5 interlaminar epidural steroid injection (ESI) of betamethasone sodium phosphate 2mL (6 mg/mL) diluted with 1% lidocaine 2mL (a total injectate volume of 4mL). He also received iohexol [Omnipaque] as a contrast media for confirmation of appropriate needle placement and epidural injectate flow. He had no procedural complications and was discharged home. Within hours following the ESI, he developed severe low back pain radiating to bilateral legs. At this time, he did not seek immediate medical attention. He took unspecified opioid medication for the pain and went to sleep. On the subsequent morning, he woke up with urinary incontinence and bilateral lower limb paresis. The man presented to a local emergency department. Initial evaluation in the emergency department revealed 2000mL of urinary retention leading to overflow incontinence. He had complete loss of sensory and motor function in the bilateral lower limbs. Spine MRI revealed spinal cord oedema from the midthoracic region to the conus medullaris. He then received IV dexamethasone 10mg empirically due to concern for transverse myelitis and was shifted to a tertiary spinal cord injury care center. His sensation and motor function in the bilateral lower limbs found to be improved partially by the time of transfer the next day. At tertiary spinal cord injury care center, physical examination revealed intact sensation with subjective paresthesia along with decreased strength throughout the lower limbs. He only had with trace movement in the proximal muscles and up to 4/5 motor power in the distal muscles. Based on atypical clinical presentation, MRI of the thoracolumbar spine showed an underlying spinal dural arteriovenous fistula (SDAVF) originating at the right L2 level. Thereafter, an endovascular embolisation with coiling of the feeder vessel was attempted; however, it failed secondary to difficulty accessing the feeding vessel. Following the attempted coiling and angiogram, he again experienced transient complete paralysis of the bilateral lower limbs, thought to be linked to vascular congestion after the procedure. Contribution of dexamethasone in the second episode of transient paralysis could not be