Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 11481  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,781 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 »  References
 »  Article Figures

 Article Access Statistics
    Viewed572    
    Printed4    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1456-1458

Large Spinal Abscess in a Neonate


1 Department of Pediatric Surgery, AIIMS, Bhubaneswar, Odisha, India
2 Department of Orthopedics, AIIMS, Bhubaneswar, Odisha, India
3 Department of Trauma and Emergency (Anesthesia), AIIMS, Bhubaneswar, Odisha, India

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Mantu Jain
106, Mahadev Orchid, Cosmopolis Road, Dumduma, Bhubaneswar, Odisha - 751019
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.304112

Rights and Permissions

 » Abstract 


Spontaneous spinal epidural abscess is rare entity in neonates. These are surgical emergency in which early diagnosis and prompt decompression is necessary to avoid permanent cord damage. The diagnosis is based on clinical findings of paraplegia supported by radiological findings on an MRI. We found a large extra spinal abscess in an infant that on further evaluation showed a communicating epidural component, yet the baby was neurologically intact. The abscess was drained in emergency with clearance of epidural component and appropriate antibiotics instituted for Streptococcus pyogenes as per sensitivity. The patient is doing well at 6 months follow up.


Keywords: Extra-spinal, epidural, spinal abscess, spontaneous, neonate
Key Messages: SEA in neonates needs a surgical clearance for best chance of neurological recovery due to lack of literature in pediatric population on the conventional management of SES with antibiotics alone. In our case it was preventive with child at risk for cross fluctuation. A major concern is the risk late onset postoperative kyphosis following extensive laminectomy.


How to cite this article:
Triapthy BB, Sahoo SK, Mohanty MK, Jain M, Sahoo S. Large Spinal Abscess in a Neonate. Neurol India 2020;68:1456-8

How to cite this URL:
Triapthy BB, Sahoo SK, Mohanty MK, Jain M, Sahoo S. Large Spinal Abscess in a Neonate. Neurol India [serial online] 2020 [cited 2021 Jan 20];68:1456-8. Available from: https://www.neurologyindia.com/text.asp?2020/68/6/1456/304112




Spinal epidural abscess (SEA) unlike adults where it is secondary to immunosuppression/steroid injections[1],[2] occurs after some spinal procedures in neonates.[3] Spontaneous SEA has not been described. A delay in the diagnosis can lead to catastrophic complications and permanent sequel.

A 4-week neonate presented with swelling without fever over upper back of 10 days, irritable for 2 days and actively moving his limbs (ASIA E) [Figure 1]. The birth was at term, institutional without any significant antenatal history of mother [no missed vaccination or tuberculosis (TB) contact or any familial history of immune-compromised (IC) state]. Postnatally there was no umbilical/skin/respiratory infection. X-ray did not show any abnormality [Figure 2]a, [Figure 2]b, but MRI revealed a large epidural abscess (D4-D8 vertebral levels) with para-spinal and extra-spinal extension[Figure 2]d, [Figure 2]e. Emergent aspiration of some pus was positive for Gram's staining and negative for Cartridge Based Nucleic Acid Amplification Test (CBNAAT). Blood parameters were raised in terms of leukocyte count and acute phase reactants but were negative for viral markers (mother and child). An USG did not show any organomegaly or deep foci. A CT showed left sided widening of inter-laminar space at D5-6 space [Figure 2]c. The baby was operated in emergency through a mid-line incision and about 25 ml of pus was drained out[Figure 1]b, [Figure 1]c. Through the pathological flavotomy (D5-6 left), an Adson's hook/16-gauge outer cannula was used to deliver the epidural component [Figure 1]d, [Figure 1]e, [Figure 1]f. Postoperatively, MRI confirmed adequate drainage of all components [Figure 2]f. The pus (extra-spinal and epidural) grew Streptococcus pyogenes and histopathology reports the presence of granuloma not otherwise specified (NOS). The baby received intravenous amoxycillin-clavulanate 15 mg/kg for 2 weeks and further oral antibiotics for 3 weeks. At 6 months of follow-up, the infant is neurologically intact and doing well.
Figure 1: (a & b) Antero-posterior and lateral radiographs of spine appears normal, (c) 3D CT reformatted image shows an increased space (arrow) between the left side posterior elements of C5 & C6, (d) T2 sagittal image shows a large subcutaneous abscess with an epidural component (arrow), (e) T2 axial images show the same subcutaneous abscess with epidural extension (left side) and paravertebral abscess (all arrow marked), (f) Postoperative T2 sagittal image shows post intervention subcutaneous edema without any residual subcutaneous or epidural abscess

Click here to view
Figure 2: (a) Clinical picture of midline abscess in upper back, (b) aspiration showing purulent material, (c) midline incision and drainage of pus, (d) Adson's hook inserted in left D5-6 space (natural flavotomy shown in arrow), (e) the number 16 gauge cannula tried to break the septa ofabscess (arrow), (f) the epidural component finally delivering out

Click here to view


SEA is unusual in the neonates with diagnosis often delayed until significant weakness manifests.[3] Staphylococcus epidermidis is the most common organism though our patient had Streptococci infection.[3] The usual location is mid-thoracic or lower lumbar spine.[3] Neurological weakness was absent in our case probably due to connection between the epidural and extra-spinal component via rupture of ligamentum flavum at D5-6 level. A potential risk of cross fluctuation remains if the superficial abscess is pressed during examination or child is placed supine even accidentally during sleep. Tubercular cold abscess forms an important differential diagnosis in endemic countries. Congenital or postnatal acquired TB can be diagnosed based on criterion laid by Cantwell in 1994.[4] Our case was negative for TB on ZN staining, CBNAAT, histopathology, and also an USG (no hepatic involvement).

Consent for publication

Taken from patient's parents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Kaul S, Meena AK, Sundaram C, Reddy JM, Naik RT, Murthy JM. Spinal extradural abscess following local steroid injection. Neurol India 2000;48:181-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Rao MB, Misra BK, Rout D. Spinal subdural abscess. Neurol India 1997;45:279-80.  Back to cited text no. 2
[PUBMED]    
3.
Tovar-Spinoza Z, Bode M. Spinal epidural abscess in a neonate. J Neurosurg Pediatr 2011;7:205-8.  Back to cited text no. 3
    
4.
Cantwell M, Sehab Z, Costello A, Sands L, Green W, Ewing E, et al. Congenital tuberculosis. N Engl J Med 1994;330:1051-4.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow