title: Distant skip level discitis and vertebral osteomyelitis after caudal epidural injection: a case report of a rare complication of epidural injections.
abstract: METHODS
  A case report of distant discitis and vertebral osteomyelitis involving skip levels after caudal epidural steroid injection.
  
  
  OBJECTIVE
  To report and investigate the occurrence of distant infective discitis and vertebral osteomyelitis involving skip levels after epidural injection.
  
  
  BACKGROUND
  Distant discitis and vertebral osteomyelitis is a serious but rare complication after epidural injection. A case involving skip levels and without the occurrence of epidural abscess formation has apparently not been previously reported in the literature.
  
  
  METHODS
  An elderly woman presenting with clinical, radiologic, and magnetic resonance imaging evidence of spinal canal stenosis involving L3/4 and L4/5 levels and degenerative spondylolisthesis of the L4/5 level was given an epidural injection of steroids and lignocaine via the caudal route. A month later, she presented with worsened low back pain, elevated serum acute phase reactants, and plain radiographic evidence of L4/5 infective discitis. Magnetic resonance imaging and microbiologic examination of computed tomographically guided biopsy specimens confirmed infective discitis involving L2/3 and L4/5 intervertebral levels, together with adjacent vertebral osteomyelitis.
  
  
  RESULTS
  The patient was successfully treated with antibiotics targeted at Pseudomonas aeruginosa, which was isolated in the culture of the biopsy specimens. Follow-up improvements in the clinical condition, serum acute phase reactants levels, radiographs, and magnetic resonance imaging were noted.
  
  
  CONCLUSIONS
  Distant discitis and vertebral osteomyelitis involving skip levels and without the occurrence of epidural abscess formation is a serious but rare complication after epidural injection.
authors.affiliation: Department of Orthopaedic Surgery, Singapore General Hospital, Singapore. yuewm@singnet.com.sg
authors.forename: Wai-Mun
authors.initials: WM
authors.lastname: Yue
authors.forename: Seang-Beng
authors.initials: SB
authors.lastname: Tan
mesh_terms: D000368:Aged; D000763:Anesthesia, Caudal / Q000009:adverse effects*; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects; D015299:Discitis / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000209:etiology*; D005260:Female; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects*; D007403:Intervertebral Disc / Q000000981:diagnostic imaging / Q000382:microbiology; D008012:Lidocaine / Q000008:administration & dosage / Q000009:adverse effects; D017116:Low Back Pain / Q000150:complications / Q000188:drug therapy; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000187:drug effects; D008161:Lumbosacral Region; D010019:Osteomyelitis / Q000175:diagnosis / Q000209:etiology* / Q000473:pathology; D011552:Pseudomonas Infections / Q000175:diagnosis / Q000188:drug therapy; D011859:Radiography; D013130:Spinal Stenosis / Q000150:complications / Q000188:drug therapy; D013168:Spondylolisthesis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy; D013256:Steroids / Q000008:administration & dosage / Q000009:adverse effects; D014221:Triamcinolone / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000779:Anesthetics, Local; D013256:Steroids; D014221:Triamcinolone; D008012:Lidocaine