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World Neurosurg. 2019 Feb 21. pii: S1878-8750(19)30420-6. doi: 10.1016/j.wneu.2019.01.294. [Epub ahead of print]

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

Author information

1
BS, Medical Student, Rowan University School of Medicine (UMDNJ). Electronic address: Houstonr5@Rowan.edu.
2
MD, Attending, Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, NJ and Assistant Professor of Pediatrics, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
3
MD, Pediatric Hospitalist, Goryeb Children's Hospital, Atlantic Health System, Morristown, NJ.
4
MD, Chief Neuroradiology Division, Department of Radiology, Morristown Medical Center.
5
MD, FAANS, Director of Pediatric Neurological Surgery at Goryeb Children's Hospital.

Abstract

BACKGROUND:

Spinal epidural abscess (SEA) is a rare but serious infection that develops in the epidural space anywhere along the spinal cord. Early diagnosis is imperative to prevent permanent neurological sequelae. SEA should be considered in patients with backache, fever, neurological deficits and/ or spinal tenderness. Although these are non-specific symptoms, delayed diagnosis increases the risk of development of sepsis, which may be life threatening, or result in varying degrees of permanent neurological impairment.

METHODS:

We describe 31 cases of pediatric SEAs without risk factors: 30 from an English-language literature search from 2000 to January 2019, and a 13-year-old female with a spontaneous SEA due to methicillin-susceptible Staphylococcus aureus (MSSA).

RESULTS:

The average age was 7.5 years. The most common symptoms were fever, motor deficits and back pain. MRI was universally utilized. Location varied along the length of the spine; a surprising 4 (12.9%) of patients had holocord SEA. Most (77.4%) patients reported no residual deficits. Ten of the patients were managed medically, an eleventh attempted conservative management but required neurosurgical intervention due to declining neurological status.

CASE DESCRIPTION:

We report a case of lumbar SEA in a 13-year-old immunocompetent female who presented with 4-day history of fever, spinal tenderness and back pain radiating to the right gluteal region and down her right leg. Initially admitted to pediatrics to rule out a septic hip joint, a MRI of the right hip with and without contrast demonstrated diffuse, right sided intramuscular edema, though no abscess was visualized. She was admitted for myositis of the right paraspinal musculature. A later MRI of the lumbar spine with and without contrast demonstrated a large epidural abscess from L3-S1 with compression of the thecal sac and nerve roots. She was taken for emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus (MSSA). She was treated surgically and with long-term systemic antibiotics. She made a complete recovery of neurological function two months after surgery.

CONCLUSIONS:

SEA in an immunocompetent pediatric patient without risk factors is an extremely rare condition. In the English-language literature, there are only 30 such reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been reported as successful in both adult and pediatric patients under certain conditions. Still, there does exist a risk of deterioration with non-surgical management even in patients for whom treatment is begun in the absence of neurological deficits. This poses a significant risk, particularly considering that diagnosis of SEA in children is often delayed until neurological deficits are present; approximately 75% of this population develops neurological deficits.1 In our review, 25 (80.6%) of patients had abnormal neurological exams. Moreover, particularly patients 36 months and younger, those unable to communicate and/or who are not yet ambulatory may present with fever and irritability, only.1 Identification of and tracking deficits in these patients may prove to be significantly more challenging than in an adult population, and a reliable neurological exam is a critical component of non-surgical care. In consideration of these facts in combination with the accelerated time frame of deterioration one neurological deficits are present, surgical debridement with prolonged systemic antibiotic therapy remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.

KEYWORDS:

Child; MSSA; SEA; methicillin-susceptible Staphylococcus aureus; neurosurgery; pediatrics; spinal epidural abscess

PMID:
30797918
DOI:
10.1016/j.wneu.2019.01.294

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