Pediatric spinal epidural abscess is a major suppurative infection of the central nervous system. It is an extremely rare pathology carrying serious risk of permanent neurological sequelae if is not properly treated. All the pertinent literature was analyzed, focused on pediatric cases of spinal epidural abscess and its peculiar features. Two illustrative cases are also presented. The first case is that of a 9-year old girl who took medical attention, when she was already paraplegic. Despite prompt surgical evacuation and good neuroradiological outcome and intensive rehabilitation, motor deficits did not recover after surgery. The second case was that of a 14-year old girl who presented with fever, neck pain, and torticollis. Prompt diagnosis, decompressive surgery, and 6 weeks of antibiotics allowed good neurological outcome. The management of spinal epidural abscess includes evacuation of the abscess with decompression of the spinal cord and prolonged antibiotic treatment. The presence of neurological deficit and the delay in the initiation of proper treatment are the two factors that more worsen prognosis.

Spinal epidural abscess in children: a case-based review.

Extensive spinal epidural abscesses (SEA) in pediatric patients are unusual bacterial infections that require early diagnosis and management to avoid potential complications of the spinal cord such as paralysis. Frequency of SEA is between 0.2 to 1.2 patients per 10,000 hospital admissions. Of pediatric patients who have SEA, 35% to 67% have predisposing factors such as previous trauma, infection, intravenous drug use, and immunodeficiency. SEA in a pediatric patient with immunocompetence without risk factors is an extremely rare condition and has not been described often in the literature. Bacteria gain access to the epidural space through contiguous spread (primary SEA) or by hematogenous dissemination (secondary SEA). In patients who have SEA, 20% to 40% have no source of infection. The most common causative agent is Staphylococcus aureus (50% to 90%), followed by Streptococci (8% to 17%) and Gram-negative bacteria (10% to 17%). SEA presents as a triad of back pain, fever, and neurologic deficits, although it is rare to find all three together. The most appropriate mode of management of pediatric SEA remains unresolved in the literature. While some authors recommend a conservative approach, others advocate surgical intervention in all patients, citing high failure rates for nonsurgical management. The management of choice for patients with neurological involvement or deficit is coupling spinal decompression of the abscess with antimicrobial therapy. Laminectomy and debridement can be catastrophic in a skeletally immature child as laminectomies may lead to complications related to prolonged surgery, instability, and progressive kyphotic deformity. Until neurological symptoms develop, diagnosis is frequently delayed because of the uncommon nature of the disease, lack of risk factors, and nonspecific clinical features in the pediatric age group. We report an 11-year-old child with extensive SEA without any risk factors who was treated by minimally invasive surgical drainage. Written informed consent was obtained from the patient’s parents for publication of this case report and any accompanying images.

Extensive spinal epidural abscess in an immunocompetent child: a case report of minimally invasive treatment and review of literature

Methicillin-susceptible Staphylococcus aureus (MSSA) occurs more frequently in the neonatal intensive care unit (NICU) than methicillin-resistant S. aureus (MRSA) and can result in comparable morbidity and mortality in the neonatal population. MSSA infection may present as pustulosis or cellulitis and evolve into bacteremia, pneumonia, endocarditis, brain abscesses, and osteomyelitis. There is a paucity of literature regarding the treatment and long-term outcomes in the premature infant.A 32-week twin developed MSSA sepsis with presentation of pain, decreased movement of upper extremities, and global hypotonia. Blood cultures remained positive despite antibiotic coverage.The infant was admitted to the level IV NICU with the diagnosis of MSSA bacteremia, with concern for dissemination and osteomyelitis.Diagnostic studies included laboratory testing for sepsis evaluation, radiologic studies to evaluate for dissemination, immunologic testing to rule out complement deficiency, and hematology testing to rule out hypercoagulable conditions.Diagnostic testing showed extensive cellulitis, osteomyelitis, multiple liver abscesses, and epidural abscesses suggestive of spinal epidural abscess (SEA). Abscess debridement and irrigation on the left distal femur, left elbow, and right tibia were performed. The infant completed 8 weeks of IV antibiotic therapy. Immunologic and hematology testing was within normal limits.Prompt recognition and follow-up for clinical signs of sepsis are vital when caring for premature infants. Inclusion of pediatric subspecialist recommendations to assure all diagnostic studies and treatments are completed can significantly impact the patient's outcome. Long-term follow-up is needed for premature infants with the diagnosis of SEA. 

Disseminating MSSA Infection in a Preterm Infant With Rare Finding of Spinal Epidural Abscess

A spinal epidural abscess is not a common entity in pediatric patients and requires a high index of suspicion for diagnosis. Initially, symptoms may be nonspecific, but patients may develop back pain and difficulty ambulating. The diagnosis of a spinal epidural abscess is based on history, physical examination, laboratory evaluation, and imaging test results. While a peripheral white blood cell count may be normal or elevated, elevated inflammatory markers, such as an erythrocyte sedimentation rate or C-reactive protein, should prompt the clinician to consider obtaining imaging. Plain radiography is commonly utilized as an initial test but is not able to detect a spinal epidural abscess. Magnetic resonance imaging is the modality of choice to detect a spinal epidural abscess and associated localized osteomyelitis, if present. Computed tomography may detect signs of an infection but is not a first-line modality due to lack of sensitivity and specificity. Treatment is somewhat controversial and may consist of antimicrobial therapy alone, in combination with computed tomography–guided drainage of the abscess, or in combination with surgical incision and drainage. 

More than an achy back: Spinal epidural abscess

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

/pdf/successful-treatment-of-pediatric-holo-spinal-epidural-2cphwquh.pdf

Rebecca Houston

Papers

Spinal Epidural Abscess in Children: Case Report and Review of the Literature.