J Neurosurg Pediatrics 7:205–208, 7:000–000, 2011
Spinal epidural abscess in a neonate Case report Zulma Tovar-Spinoza, M.D.,1 and Michelle Bode, M.D. 2 Departments of 1Neurosurgery and 2Pediatrics, SUNY Upstate Medical University, Syracuse, New York Spinal epidural abscess constitutes a neurosurgical emergency in which early diagnosis and prompt decompression are necessary to avoid permanent cord damage. This entity is rare in premature infants and neonates in whom diagnosis can be challenging. The authors present a case of a premature twin neonate who developed an epidural abscess with complete paraparesis after coagulase-negative Staphylococcus epidermidis bacteremia that was treated with a single-level flavotomy and catheter irrigation. (DOI: 10.3171/2010.11.PEDS10159)
Key Words • spinal epidural abscess • bacteremia • neonate
A
spinal epidural abscess constitutes a neurosurgical emergency in which early diagnosis and prompt decompression are necessary to avoid permanent cord damage.17 This entity has an incidence of 0.2–1.2 per 10,000 total hospital admissions and is particularly rare in neonates and infants. Neonates exhibit nonspecific symptoms and an insidious presentation in which severe neurological deterioration can be identified only at late progression of the disease.15,21 We present a case of a premature twin neonate who developed an epidural abscess with complete paraparesis after coagulase-negative Staphylococcus epidermidis bacteremia and lumbar puncture.
Case Report
This female infant, Twin B, was born at 27 2/7 weeks’ gestation weighing 880 g. The pregnancy was complicated by diamniotic dichorionic twin gestation with prolonged rupture of the membranes of Twin A, and both twins were delivered by cesarean section. The patient, Twin B, had Apgar scores of 8 and 9. Initially, she had mild respiratory distress and she received antibiotic therapy for 48 hours. A PICC was placed on DOL 6. Radiographic confirmation of PICC placement showed it entering from the left inguinal area with the tip at the superior margin of the sacroiliac joint. Abbreviations used in this paper: DOL = Day of Life; PICC = percutaneous intravenous central catheter.
J Neurosurg: Pediatrics / Volume 7 / February 2011
On DOL 26, the infant developed multiple small feeding aspirates and her breathing became more labored. A blood sample was sent for laboratory analysis and culture, and antibiotic therapy was initiated; 72 hours later, the culture results were reported as negative and the antibiotic therapy was discontinued. On DOL 31, 35 hours later, the infant was lethargic, had multiple feeding aspirates, and required intubation for severe apnea. Additional blood samples were obtained and sent for laboratory analysis and culture; treatment with ampicillin and gentamicin was started. Abdominal examination was significant for redness and firmness in the left lower quadrant. The patient’s white blood cell count (in 103 cells/mm3) was 7.5 (down from 27): segmented neutrophils, 71%; band neutrophils, 13% (increased from 0%); and lymphocytes, 5%. Her platelet count had decreased from 341 × 103 cells/mm3 to 219. A plain frontal radiograph revealed no free air and the presence of mildly dilated intestinal loops consistent with ileus. The blood culture demonstrated growth of coagulase-negative S. epidermidis. The PICC was removed, a repeat blood sample was sent for culture, and the antibiotic agents were changed to vancomycin and ceftazidime. Ceftazidime was discontinued when the repeat culture was only positive for coagulase-negative S. epidermidis. Seizure activity developed on DOL 33 and a lumbar puncture was attempted without successful collection of fluid. The patient self-extubated and was clinically stable until the evening of DOL 36, when it was noted that she did not move either of her lower extremities, had minimal spontaneous abduction at the hips, and had significant edema in both lower extremities. Fullness was also evi205
Z. Tovar-Spinoza and M. Bode dent in the left lower quadrant. Abdominal ultrasonography was performed and the results were reported as negative. On DOL 37, the infant had further seizure activity. Spinal ultrasonography was performed, and the question of a fluid collection at the T12–L1 level was noted. A noncontrast MR imaging study of the brain and spine was performed with a fiducial applied on the midline L1–2 area for surgical opening localization. Because the infant weighed only 1100 g, 1-mm slices were used. The MR images revealed a large dorsal epidural fluid collection measuring approximately 6.8 mm (anteroposterior) × 9.4 mm (transverse) × 74.9 mm (craniocaudal), extending from the T8–9 level through the sacrum, and resulting in moderate to severe compression of the conus compatible with epidural hematoma versus abscess (Fig. 1). The MR imaging of the brain showed no abnormality. The patient was taken to the operative room. A 2-cm lumbar incision was performed in the midline at the L2–3 level, where the epidural collection appeared widest on the MR images. Subsequent L2–3 distraction with a small self-retaining retractor and flavotomy with the help of a microdissector and microscissors were performed. The conus appeared to be anteriorly displaced and flattened. Nine milliliters of pus was aspirated with the assistance
Fig. 1. Sagittal T2-weighted MR image showing an epidural collection extending from the midthoracic area to the sacrum.
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of a 5 Fr nasogastric tube inserted 5 mm in the upper and lower direction into the epidural space. This device was also use for gentle irrigation and washing with saline solution until the returning fluid was clear. Culture of the surgical abscess specimen demonstrated growth of coagulase-negative S. epidermidis despite 6 days of vancomycin therapy and 48 hours of treatment with rifampin, which had been added when the repeat blood culture was still positive. Postoperative noncontrast spine MR images obtained 24 hours after surgery (Fig. 2) revealed a significant decrease in the abscess size. A week later, another spinal ultrasonographic examination showed no evidence of an abscess. Improvement of lower-extremity spontaneous movement occurred over the following 3 weeks at the hip and knee levels. Bilateral foot drop continued at 4 weeks after surgery. Electromyography was then performed and demonstrated no denervation bilaterally. The patient completed 6 weeks of antibiotic therapy (vancomycin and rifampin) in the hospital and was then discharged home for physical therapy and rehabilitation. Progressive recovery on bilateral foot movement has been observed 6 months after surgery.
Discussion
Spontaneous spinal epidural abscess is very rare in neonates in the absence of any history of spinal instrumentation. Staphylococcus epidermidis is the usual causative organism and can infect the site by hematogenous spread from a distant focus, local extension from a contiguous source, or direct inoculation following surgery, trauma, or lumbar puncture.1,16,17,20 Lumbar punctures are performed for either diagnostic or therapeutic reasons. This procedure in a neonate is not without risk. Stated indications for lumbar puncture in neonates include routine sepsis workup8 treatment of posthemorrhagic hydrocephalus,1 and epidural anesthesia.20 Traumatic tap and unsuccessful lumbar puncture are quite frequent occurrences in newborns, with only 45%–54% of attempted lumbar punctures being completed successfully.18 Complications from lumbar punctures are rare, but include hemorrhage into the epidural, subdural, or subarachnoid space;4,7 trauma to spinal ligaments, the periosteum, or an intervertebral disc;3 herniation of a nerve root through a dural tear;22 late development of an intradural epidermoid tumor;19 severe headache;14 abducens nerve palsy;9 transtentorial herniation;14 cardiac arrest in infants with pulmonary or cardiac disease;11 and infection of a vertebral body, an intervertebral disc, the epidural space, the meninges, or the spinal cord.1 The spinal epidural space is only present dorsal to the spinal nerve attachments; anteriorly, the dura is in contact with the vertebral bodies and their ligaments.2 In the cervical region the space is only a potential one as far down as C-7, but then it begins to deepen between the T-4 and T-8. It becomes shallow again from T-11 to L-2, and thereafter attains its greatest depth. Consequently, the usual location of spinal epidural empyema is the lower thoracic or lumbar spine, owing to the narrowing of the spinal cord at these levels leading to a large dorsal extradural space containing a rich venous plexus. This venous plexus is the J Neurosurg: Pediatrics / Volume 7 / February 2011
Spinal epidural abscess in a neonate triad of febrile illness, localized excruciating back pain, and variable neurological deficit should help to make the diagnosis possible.5 But in a neonate or a premature baby without a febrile illness, nonspecific symptoms and insidious neurological deterioration can progress, and the diagnosis can be overlooked. Our case illustrates how easy it is to miss the subtle deterioration in the neonate’s leg movements, which can take place over a number of days.21 The sphincter’s function is not a clear indicator of spinal cord compression in this population. Magnetic resonance imaging of the spine best demonstrates the extent and location of the abscess. Multiplanar imaging and visualization of the soft tissues, including the spinal cord, paraspinal muscles, and discs, confer a distinct advantage to MR imaging over CT and myelography.24 Gadolinium-enhanced images have increased the sensitivity of MR imaging for infectious processes. However, ultrasound can have a valuable use in premature infants and neonates for the diagnosis of cord compression and epidural collections.6,23 In our case, due to the patient’s weight of 1100 g, the MR imaging settings needed to be changed from 3-mm slices to 1-mm slices to enable visualization of the cord. The T2-weighted sequences were adequate for visualizing the epidural collection; therefore, contrast injection was not necessary. It has been described that rapid onset of spinal cord compression leads to permanent neurological deficit if decompression is not achieved within a few hours. Prognosis depends predominantly on the patient’s preoperative neurological state.10 Several types of surgical decompression procedures have been described, including needle aspiration,17 corpectomy,13 laminotomy,12 and laminectomy.21 To our knowledge, this is the first case treated with vertebral distraction, flavotomy, and the use of a cannula for aspiration of the empyema and irrigation of the epidural space. This technique avoided any concern regarding spine instability and the risk of late postoperative kyphosis following bilateral laminectomy or extensive laminotomy.6,21 In the presence of large epidural collections, drainage via single- or multiple-level distraction and flavotomy should be considered in the neonatal population, given the small and mobile vertebral structures in this age group. After immediate surgical decompression, appropriate antibiotic treatment should be initiated according to culture sensitivity and maintained for at least 6 weeks. Our experience and that of others shows that early recognition and a combination of surgical decompression and antibiotic therapy provide excellent results with full recovery of the neurological function. Disclosure
Fig. 2. Postoperative sagittal T2-weighted MR image showing the evacuated epidural abscess with a single-level flavotomy.
presumed route of infection, with blood from the inferior vena cava communicating with the extradural space.21 The early signs and symptoms of epidural abscess in adults and older children are uniform. The “classic” J Neurosurg: Pediatrics / Volume 7 / February 2011
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: Tovar-Spinoza. Ac quisition of data: both authors. Analysis and interpretation of data: Tovar-Spinoza. Drafting the article: both authors. Critically revising the article: both authors. Reviewed final version of the manuscript and approved it for submission: both authors. Administrative/technical/material support: Tovar-Spinoza.
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[email protected].
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