Pediatric Spinal Epidural Abscess: Recognition and Management in the Emergency Department

Table of Contents

 

About This Issue

Spinal epidural abscess (SEA) is a rare, rapidly progressive clinical entity. Due to the rarity and variability in presentation, diagnosis is often delayed, which can lead to irreversible neurologic damage. This issue reviews key findings on the history and physical examination that are associated with SEA, provides guidance for the laboratory tests and imaging studies that are indicated once SEA is suspected, and discusses treatment options based on current evidence. You will learn:

Pediatric-specific risk factors for SEA

Common etiologies of SEA, as well as common causative organisms

The stages of SEA and corresponding signs and symptoms

The classic triad of SEA symptoms, as well as other common presentations

Key aspects of the physical examination and special considerations for examining preverbal and nonverbal infants and children

Guidance for initial management

Which laboratory studies are most helpful and which should be avoided

When emergent magnetic resonance imaging (MRI) is indicated and when an urgent MRI may be appropriate

Which antibiotics should be started empirically

Which patients may be considered for medical management alone and which will need surgical management

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
   1. Discitis, Spondylodiscitis, and Vertebral Osteomyelitis
   2. Other Diagnoses on the Differential
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Initial Emergency Department Management
11. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
12. Treatment
    1. Antibiotics
    2. Surgical Management
    3. Medical Management
13. Special Populations
14. Controversies and Cutting Edge
15. Disposition
16. Summary
17. Risk Management Pitfalls for Pediatric Spinal Epidural Abscess
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Management of Pediatric Spinal Epidural Abscess in the Emergency Department
21. Tables and Figures
22. References

Abstract

Although rare in children, spinal epidural abscess (SEA) is a rapidly progressive clinical entity that can lead to irreversible neurologic damage if untreated. The rarity and variability in presentation can lead to initial misdiagnosis. Diagnosis requires a high index of suspicion and is often delayed until neurologic deficits are present. This issue reviews key findings on the history and physical examination that are associated with SEA, provides guidance for the laboratory tests and imaging studies that are indicated once SEA is suspected, and discusses treatment options based on current evidence.

Case Presentations

A 30-month-old girl presents by referral from her primary care physician for fever and refusal to walk…

• The parents tell you there is no history of trauma.
• You note the girl is febrile, tachycardic, and crying. Upon examination, her right hip and knee are in flexion, and she cries when you attempt to extend her knee. You cannot identify an area of focal tenderness to palpation. When the patient is prompted to bear weight on her right lower extremity, she touches her toes to the floor but refuses to bear weight.
• What is the differential diagnosis? What laboratory and radiographic studies would be helpful in making the diagnosis?

A 10-year-old boy is referred from a regional hospital for 5 days of fever and lumbar area pain...

• The boy is uncomfortable due to the pain, but he can walk.
• Upon examination, you discover midline spinal tenderness at the L2 level and edema of paraspinal muscles. You do not find any neurologic deficits on examination.
• What diagnostic studies and therapies should be initiated?

A 13-year-old girl presents with diffuse abdominal pain and fever...

• You admit her with the assumption that she has appendicitis. A few days later you receive an email from the quality division of your hospital to inform you that the patient’s ultimate diagnosis was spinal epidural abscess.
• You reflect on how you could have missed this diagnosis. What could you have done differently?

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Clinical Pathway for Management of Pediatric Spinal Epidural Abscess in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Auletta JJ, John CC. Spinal epidural abscesses in children: a 15-year experience and review of the literature. Clin Infect Dis. 2001;32(1):9-16. (Review of the literature; 8 patients) DOI: 10.1086/317527

2. * Hawkins M, Bolton M. Pediatric spinal epidural abscess: a 9-year institutional review and review of the literature. Pediatrics. 2013;132(6):e1680-e1685. (Retrospective review; 9 patients) DOI: 10.1542/peds.2012-3805

4. * Vergori A, Cerase A, Migliorini L, et al. Pediatric spinal epidural abscess in an immunocompetent host without risk factors: case report and review of the literature. IDCases. 2015;2(4):109-115. (Case report and review of the literature; 12 cases) DOI: 10.1016/j.idcr.2015.09.008

7. * Fotaki A, Anatoliotaki M, Tritou I, et al. Review and case report demonstrate that spontaneous spinal epidural abscesses are rare but dangerous in childhood. Acta Paediatr. 2019;108(1):28-36. (Review) DOI: 10.1111/apa.14579

13. * Vallejo JG, Cain AN, Mason EO, et al. Staphylococcus aureus central nervous system infections in children. Pediatr Infect Dis J. 2017;36(10):947-951. (Prospective surveillance study; 68 patients) DOI: 10.1097/inf.0000000000001603

14. * Houston R, Gagliardo C, Vassallo S, et al. Spinal epidural abscess in children: case report and review of the literature. World Neurosurg. 2019;126:453-460. (Case report and literature review; 1 patient) DOI: 10.1016/j.wneu.2019.01.294

27. * Fucs PM, Meves R, Yamada HH. Spinal infections in children: a review. Int Orthop. 2012;36(2):387-395. (Review) DOI: 10.1007/s00264-011-1388-2

48. * Mohanty CB, Fieggen G, Deopujari CE. Pediatric spinal infections-a review of non-tuberculous infections. Childs Nerv Syst. 2018;34(10):1947-1956. (Review) DOI: 10.1007/s00381-018-3885-8

51. * Arko Lt, Quach E, Nguyen V, et al. Medical and surgical management of spinal epidural abscess: a systematic review. Neurosurg Focus. 2014;37(2):E4. (Systematic review; 12 articles, 1099 patients) DOI: 10.3171/2014.6.Focus14127

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Keywords: spinal epidural abscess, SEA, pediatric spine infection, stages of spinal epidural abscess