Management of Spine Infections in Children

Initial Management at Presentation

Spine infections in children

• Identify pathogen: Isolation of the pathogen is essential in the treatment and management of vertebral osteomyelitis. Percutaneous or open biopsies are recommended in all cases.
• Antibiotics primary treatment: Antibiotic therapy is recommended as initial treatment after isolation of the pathogen.
• Debridement +/- instrumentations for abscess or progression: Cases refractory to medical management, evolution of the disease clinically or radiographically, and abscess formation are indications for surgical intervention and debridement. Following debridement, spinal instrumentation may be necessary for stabilization.

Spinal epidural abscesses in children

• Drain abscess and debride: Often requires open surgery for evacuation, sampling, and wash-out. Selected cases could be evacuated by a guided percutaneous needle aspiration.
• Antibiotic treatment: Antibiotics are tailored after isolation of the pathogen on culture. Treatment typically requires up to 4 weeks to eradicate the soft tissue infection and usually many weeks longer if osteomyelitis is present (150).

Spinal subdural abscesses in children

• Drain abscess and debride: Of the 73 reported cases of pediatric spinal subdural infections, 99% of children with spinal subdural infections were treated surgically with limited laminectomy, overwhelmingly the procedure of choice (126).
• Antibiotic treatment: Treatment should be coordinated with an infectious disease specialist. A standard regimen usually includes 6 weeks of intravenous antibiotics tailored to the organism obtained at surgery (100, 101).

Intramedullary spinal cord abscesses in children

• Drain abscess and debride: The abscess is opened and debrided along with any infected adjacent tissue. This is followed with copious irrigation of the drained cavity.
• Resection of associated dermal sinus tract if present: In cases where the intramedullary spinal cord abscess was caused by a dermal sinus tract and/or dermoid cyst, it is imperative that the tract be obliterated and the cyst removed to prevent recurrence. A delayed resection may be indicated if sinus anatomy is complicated.
• Antibiotic treatment: Kurita et al. report that early broad-spectrum high-dose ampicillin and third-generation cephalosporin, covering gram-positive, gram-negative, and anaerobic organisms, should be the first choice of management for patients with intramedullary spinal cord abscess (102).

Adjunctive Therapies

Spinal epidural abscesses in children

• Rehabilitation: Physical and occupational therapy may be necessary for rehabilitation.
• Bowel and bladder management: If neurogenic bowel and bladder are present, a urologic and bowel specialist consultation may be required with special attention to urinary retention, infections, and dysautonomic episodes due to constipation.

Spinal subdural abscesses in children

• Rehabilitation: Physical and occupational therapy may be necessary for rehabilitation.
• Bowel and bladder management: If neurogenic bowel and bladder are present, a urologic and bowel specialist consultation may be required with special attention to urinary retention, infections, and dysautonomic episodes due to constipation.

Intramedullary spinal cord abscesses in children

• Steroids: Some advocate the use of steroids when infection is due to a dermal sinus tract (25, 122, 123).

Follow-up

Spine infections in children

• Follow for 12–18 months: Patients should be followed clinically and radiographically for 12–18 months. A follow-up MRI is recommended 3–4 months after treatment. ESR and CRP levels can be checked monthly/or at each clinic visit to follow the status of infection.

Spinal epidural abscesses in children

• Follow closely: Post-treatment follow-up within weeks and gadolinium-enhanced MRI within 6 months after treatment are recommended.
• Infectious disease follow-up: The infectious disease consultant will typically see the child for the duration of antibiotic treatment. Sometimes the antibiotic treatment can be adapted for delivery at home.
• Rehabilitation: Physical and occupational therapy follow-up as needed.
• Urology follow-up for neurogenic bladder: Consultants are used to evaluate urodynamics and need for catheterizations. The management goal is to avoid urinary infections.
• Consultant for neurogenic bowel: Not uncommonly a consultant is used to manage constipation and to avoid compaction and dysautonomic symptoms.

Spinal subdural abscesses in children

• Follow closely: Post-treatment follow-up within weeks and gadolinium-enhanced MRI within 6 months after treatment are recommended.
• Infectious disease follow-up: The infectious disease consultant will typically see the child for the length of antibiotic treatment. Sometimes the antibiotic treatment can be adapted for delivery at home.
• Rehabilitation: Physical and occupational therapy follow-up as needed.
• Urology follow-up for neurogenic bladder: Consultants are used to evaluate urodynamics and need for catheterizations. The management goal is to avoid urinary infections.
• Consultant for neurogenic bowel: Not uncommonly a consultant is used to manage constipation and to avoid compaction and dysautonomic symptoms.

Intramedullary spinal cord abscesses in children

• Follow closely: Post-treatment follow-up within weeks and gadolinium enhanced MRI within 6 months after treatment are recommended.