The Operation for Spine Infections in Children

Patient Positioning

• Positioning dependent on approach: Patient positioning depends on the surgical approach and location of the infection. A prone position is typically used for posterior approaches, and a supine position is used for anterior/oblique and anterolateral approaches. Special attention must be paid to avoid wrinkles on the rolls that could cause pressure sores on the patient’s skin. Genitalia should be checked for being free of pressure. Pads or gel-pads should be located under areas of pressure.
• Head holder considered when operating on upper spine: Patients in prone position requiring exposure of the cervical and/or upper thoracic spine can benefit from use of a head holder. This allows for optimization of positioning and avoids pressure sores on the face.

Surgical Approach

• Approach dictated by location of abscess: The dorsal approach is used for debridement of dorsal lesions, and the transpedicular approach may be used for anterolateral and lateral epidural abscesses. The ventral approach for debridement and grafting for stabilization when there is vertebral body collapse is favored for anterior disease.
• Dorsal exposure limited: In the developing spine, the potential for postlaminectomy spinal deformity favors a limited exposure when possible (21, 56). A midline incision is centered over the level(s) of the abscess. A laminectomy is then performed to expose involved levels. The facet joints are preserved when possible.
• Flavotomy for infants: In premature babies, neonates, and infants, flavotomy alone with gentle irrigation and washing has been used for treatment of epidural abscesses (19).

Intervention

Spinal infections in children

• Debridement for resection of devitalized tissue and neural decompression: Decompression of the spinal cord and neural elements is vital. Additionally, there should be debridement of pus and devitalized tissue. Following debridement and drainage, extensive irrigation with antibiotic or saline is recommended.
• Tissue cultures: Tissue should be sent for aerobic/anaerobic/fungal/acid-fast bacterial cultures.

Spinal epidural, subdural, and intramedullary spinal cord abscesses in children

• Extensive extramedullary abscesses: If the abscess is extensive, it may be advisable to insert a catheter to drain the abscess and break up any septations rather than expose the patient to a more extensive laminectomy and the various orthopedic complications that may ensue (125).
• Needle aspiration: Needle aspiration of both extradural and intramedullary infections has been attempted with varying degrees of success (127, 128).
• Associated dermal sinus: In cases where the intramedullary spinal cord abscess was caused by a dermal sinus tract and/or dermoid cyst, it is recommended that the tract be obliterated and the cyst removed to prevent recurrence. In the presence of active infection, definitive resection of the associated dermoid or dermoid cyst can be exceedingly difficult and risks additional neurological damage; therefore, a staged approach is often more appropriate. First is an (emergency) operation to drain the abscess and establish the microbiological diagnosis and sensitivities. The surgeon may elect not to resect the capsule of the dermoid at this point. A delayed second procedure toward the end of antibiotic therapy (which will commonly be a number of weeks) can then be performed to resect the focus.
• Tissue cultures: Tissue should be sent for aerobic/anaerobic/fungal/acid-fast bacterial cultures.

Closure

• Drain surgical bed: A closed drainage system is placed as necessary.
• Routine closure: Muscle and fascia are closed in layers with dissolving sutures. The skin is closed with nonabsorbable sutures.