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|Year : 2020 | Volume
| Issue : 6 | Page : 1456-1458
Large Spinal Abscess in a Neonate
Bikasa B Triapthy1, Subrat K Sahoo1, Manoj K Mohanty1, Mantu Jain2, Sangeeta Sahoo3
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 Publication||19-Dec-2020|
Dr. Mantu Jain
106, Mahadev Orchid, Cosmopolis Road, Dumduma, Bhubaneswar, Odisha - 751019
Source of Support: None, Conflict of Interest: None
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
Spinal epidural abscess (SEA) unlike adults where it is secondary to immunosuppression/steroid injections, occurs after some spinal procedures in neonates. 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|
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|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|
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SEA is unusual in the neonates with diagnosis often delayed until significant weakness manifests. Staphylococcus epidermidis is the most common organism though our patient had Streptococci infection. The usual location is mid-thoracic or lower lumbar spine. 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. Our case was negative for TB on ZN staining, CBNAAT, histopathology, and also an USG (no hepatic involvement).
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Taken from patient's parents.
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There are no conflicts of interest.
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[Figure 1], [Figure 2]