Spinal Epidural Abscess in Children
Sometimes our medical training may steer us astray. Fortunately through our continued education and experience (and maybe a Morsel or seven) we can overcome these shortcomings and detect some of the covert dangerous conditions. Retropharyngeal abscess is a good example: presentation of fever, drooling, and stridor does occur… but late. The patient would be better off if we diagnosed the condition before there was airway narrowing causing stridor! This Morsel is gong to focus on a condition related to two symptoms (Back Pain and Fever of Unknown Origin) that can easily be missed upon first (and second and third) presentation, allowing it to fester and cause irreparable damage. Let’s take a moment to help prevent that from occurring by reviewing Spinal Epidural Abscess in Children:
Spinal Epidural Abscess: Basics
- Spinal Epidural Abscess is rare in children. [Spennato, 2020; Houston, 2019; Vergori, 2015; Hawkins, 2013]
- Often diagnosis is overlooked several times.
- Diagnostic delay is noted to be the “norm,” but is associated with worse morbidity.
- Spinal Epidural Abscess can occur by: [Spennato, 2020]
- Operative instrumentation (~20% of cases)
- Local trauma (~10% of cases)
- Hematogenous dissemination
- Ex, recent subcutaneous abscess, furuncles, paronychia
- Contiguous dissemination
- Spinal Epidural Abscess Microbiology: [Spennato, 2020; Auletta, 2001]
- Can be due to bacteria or fungal infections.
- Staphylococcus aureus is the most common cause.
- ~18% are Methicillin resistant.
- Streptococci and Gram-negative bacteria should also be considered.
- Mycobacterium tuberculosis is the second most common cause.
- Prognosis: [Spennato, 2020; Vergori, 2015]
- Generally, outcomes are good when diagnosed and managed before neurologic deficits.
- High risk for neurologic morbidity.
- Outcomes in children generally better than with adults.
- Mortality is rare in children.
- The presence of neurologic deficits on exam and delay in therapy are associated with worse prognosis.
Spinal Epidural Abscess: Presentation
- “Adult Risk Factors” are not common in children. [Spennato, 2020]
- IV Drug abuse, alcohol abuse, chronic renal insufficiency, and diabetes should be considered, but …
- Their absence of should not direct us away from the Dx.
- Risk Factors of greater significance in children: [Spennato, 2020]
- Risk Factors are present in less than third of pediatric cases.
- Sickle Cell Anemia
- Long-term use of Steroids
- Manifestations: [Spennato, 2020]
- Classic Triad:
- Fever, Back Pain, and Neurological Deficits
- Neurological deficits are a late finding and their presence are a poor prognostic factor.
- Four Clinical Stages:
- 1st = fever, back pain, tenderness
- 2nd = changes in reflexes, signs of meningeal or radicular irritation
- 3rd = neurologic deficits are evident (motor/sensory changes, bowel/bladder dysfunction)
- 4th = complete spinal cord injury
- Progression between the 1st two stages may take ~3 days whereas it may take only 24 hours between stage 3 and 4.
- Be alert to possible Spinal Epidural Abscess if patient has ANY TWO of the following: [Harris, 2014]
- Back or Neck Pain
- Extremity Weakness
- Inability to Walk
- Classic Triad:
Spinal Epidural Abscess: Evaluation
- Lab studies: [Spennato, 2020]
- Inflammatory markers (ESR, CRP, WBC) are often elevated.
- Alkaline phosphatase may be elevated with associated vertebral osteomyelitis.
- Imaging: [Spennato, 2020]
- MRI with gadolinium of the entire spine is preferred study.
- CT imaging may used to direct drainage of some abscesses, but MRI is preferred diagnostic study.
Spinal Epidural Abscess: Management
- Antibiotics – and lots of them! [Spennato, 2020]
- Medical treatment alone for some selective cases is possible, but generally surgery is required. [Ahluwalia, 2019]
- Broad spectrum antibiotics should be given to cover MRSA, Anaerobes, and Gram Negative organisms.
- IV antibiotics are usually given for ~ 3 weeks.
- Antibiotics often continued for 4-12 weeks.
- Urgent Surgery is generally considered in all cases as there is risk of neurologic deterioration. [Spennato, 2020; Houston, 2019]
Moral of the Morsel
- Look for Risk Factors and Red Flags. Don’t be surprised if you don’t find them though.
- Search the Skin! A recent abscess may be your one clue to the source of the persistent fever!
- Back Pain in Kids is Odd! Don’t just through “muscle relaxers” and NSAIDs at them like you would a young adult.