Presentation of Dermal Sinus Tracts in Children

Symptoms and Signs

• Various presentations: Dermal sinus tracts cause a wide spectrum of clinical manifestations ranging from asymptomatic occurrence of cutaneous findings to infection, neurological deficits, urinary problems, and orthopedic deformities (2).
• Decreasing incidence of neurological signs: With increased knowledge of primary care physicians, asymptomatic skin findings are the most common clinical manifestation of the disease (2). Neurological deficits can occur, however, when there is a delay in diagnosis, and a spinal abscess or inclusion tumor lead to injury of the spinal cord.
• CNS infections: Infectious manifestations including meningitis and spinal abscess are still seen (16).
• Hydrocephalus: Hydrocephalus symptoms in neglected cases with repeated meningitis have been described (16).

Midline cutaneous pit of dermal sinus tract: After an incomplete resection, there was recurrent discharge from the incision site. This occurrence confirms the importance of total resection of the lesion from skin orifice to spinal cord.

Patterns of evolution

• Variable depending on time of diagnosis: The natural course of disease is unknown. Almost all children with spinal dermal sinus tracts are neurologically intact at birth. However, there is obvious risk of neurological deterioration due to tethered cord, infection, and inclusion tumors.

Time for evolution

• Unclear: Although the complications of postponing treatment are well established, the timing of such complications is not known.

Intervention at Presentation

• Imaging: A spinal MRI is done at the time of presentation if such an image set has not been done previously.
• Urological assessment: An extensive urological evaluation including VCUG, kidney and bladder ultrasound, and urodynamic studies is performed at presentation. Typically, the bladder is catheterized if there is any concern about urinary retention or when neurological deficits are present.
• Treat any associated infection: If the dermal sinus is complicated by an infectious process, systemic antibiotics and dexamethasone are advised before corrective surgery.

Preparation for definitive intervention, nonemergent

• Preoperative laboratory studies: Routine laboratory studies are done in anticipationof surgery.
• Consider steroids: Dexamethasone, 0.15 mg/kg/dose four times/day, can be used to manage any intradural inflammation.

Preparation for definitive intervention, emergent

• Antibiotics: Antibiotics are given for signs of infection.
• Steroids: Dexamethasone, 0.15 mg/kg/dose four times/day, is commonly used to stabilize sepsis and decrease inflammation that is present.

Admission Orders

• Bed rest: Bed rest might be advisable if the patient has back pain and intraspinal infection.
• LP: A CSF sample is obtained if there is suspicion of meningitis.