Presentation of Spine Infections in Children

Symptoms and Signs

Spine infections in children

• Back pain and altered gait: Back pain is a presenting complaint in only 50% of children with diskitis (1). A progressive limp, refusal to walk, and Gower’s sign in addition to back pain are the predominant symptoms of infection of the spine for children younger than 3 years (1). Older children (3–8 years) will show a decline in physical activities and have vague abdominal complaints, and children older than 8 years will develop radicular pain in the back, a buttock, or a leg (1, 79).
• Fever: Patients with diskitis may be afebrile, while patients with osteomyelitis are typically febrile (1, 79).
• Concurrent infection usually present: Families report concurrent or antecedent illnesses (1).

Age (years)	Symptoms
<3	Limp and refusal to bear weight
3-8	Back and abdominal pain, decline in physical activity
> 8	Back, abdominal, buttock or leg pain due to nerve root irritation

From references 1, 79.

Spinal epidural abscesses in children

• Neurological signs due to direct compression or ischemia: Spinal epidural abscesses may lead to significant neurological deficits via either direct pressure on the spinal cord or from impairment of blood supply. As such, the disease requires prompt recognition and treatment (21, 38).
• Fever, severe back pain, and localizing neurological signs: The early signs and symptoms of epidural abscess in adults and older children are uniform. The “classic” triad of febrile illness, localized excruciating spinal tenderness or back pain, and variable neurological deficit should help to make the diagnosis possible (19, 21, 37).
• Neonates – nonspecific symptoms of fever and irritability: In neonates and infants without a febrile illness, nonspecific symptoms and insidious neurological deterioration can progress, and the diagnosis can be overlooked. The sphincter’s function is not a clear indicator of spinal cord compression in this population (19, 21, 37).
• Post-procedure – progressive pain at surgical site: Patients presenting with spinal epidural abscess after invasive procedures or spinal instrumentation are often healthy looking children without notable comorbidities who develop a spinal epidural abscess days or weeks after the procedure. Patients present with worsening pain at or near the surgical or puncture site, accompanied by purulent drainage in many cases, with or without neurological symptoms.

Spinal subdural abscess

• No pathognomonic symptomatology: No pathognomonic presentation points to the diagnosis of spinal subdural infection. There is a suggestion in the adult literature that the clinician can differentiate spinal epidural infection from spinal subdural infection in that spinal tenderness is present in the former and absent in the latter (89, 101, 105, 106, 107).
• Signs of meningeal infection: Fever and meningismus commonly occurred in nearly half of cases in a large review (73). Recurrent attacks of pyogenic meningitis can be a presentation of infected intraparenchymal dermoid.
• Back pain: Back pain and neck pain are common and notoriously nonspecific symptoms in children, and most cases are self-limiting (17). Acute, severe, excruciating backache without constitutional symptoms or neurological deficits may be a presentation.
• Urological symptoms in 25%: Urinary incontinence, retention, and dysuria occur in a quarter of patients with subdural abscesses of the spine (73).
• Progressive myelopathy: Rapidly developing neurological deficits or a transverse myelitis-like clinical picture, constitutional symptoms in the form of high-grade fever, and backache in a child harboring a dermal sinus indicate serious inflammatory intradural pathology (6). As the lesion increases in size, symptoms and signs of compression of the cauda equina or spinal cord ensue.
• Dermal sinus: The dermal sinuses can have red skin surrounding the opening and may be subtle so as to be detectable only at skin pinch.

Intramedullary spinal cord abscesses in children

• Localizing neurological signs: Unlike pediatric vertebral osteomyelitis or diskitis, where neurological involvement is rare, children with intramedullary spinal cord abscesses present overwhelmingly with signs and symptoms of weakness, numbness, paralysis, paresthesias, and bowel/ bladder incontinence.
• Fever: Fevers are absent in up to 44% of children with intramedullary spinal cord infections.

Patterns of evolution

Spine infections in children

• Diskitis/osteomyelitis – no definitive evolution: There is no prototypic pattern of evolution for children with diskitis or osteomyelitis, but typically patients present initially with local spinal tenderness that may progress to paraspinal muscle spasms, which leads to decreased range of motion (4). Hamstring tightness is also noted as well, as children have difficulty picking up objects off the floor and bend and squat to keep the back straight (4).

Spinal epidural abscesses in children

• Four phases – pain and fever, then radicular pain, then bowel/bladder symptoms, then paralysis: The clinical picture has been defined as having four phases (21, 38). Initially, the patient experiences fever and back pain. Then, level-dependent root pain (including abdominal pain) may develop, along with changes in reflexes and motor weakness. This phase may then progress to bowel and bladder symptoms, ultimately followed by paralysis.

Spinal subdural abscesses in children

Based upon Heusner’s stages of symptomatology for spinal epidural infections, Bartels and associates proposed a sequence of signs and symptoms that appears to occur in infections of the spinal subdural space (100, 119).

• Fever: The infection is usually heralded by fever, which may or may not be accompanied by back pain.
• Onset of neurological signs: As the infection grows in size, neurological sequelae develop, including motor deficit, sensory loss, and sphincter dysfunction (88).
• Progression to plegia: If left untreated, the natural history of spinal subdural infections is complete paralysis and sensory loss below the lesion. The temporal progression of symptoms from one stage to the next varies among patients (89, 90).

Intramedullary spinal cord abscesses in children

• Not clear: While the progression of symptoms for intramedullary spinal cord abscesses is poorly described, it is clear that when the disease is left untreated, the natural history of intramedullary spinal cord infections is complete paralysis and sensory loss below the lesion (91, 92).

Time for evolution

Spine infections in children

• Variable

Spinal epidural abscesses in children

• Hours to weeks: The rate of progression of clinical symptoms may vary from hours to weeks (47).

Spinal subdural abscesses in children

• Hours to years: The rate of progression may vary, and some cases could present acutely while others could have repetitive bouts of pyogenic meningitis. In a recent review it was found that the majority of children with spinal subdural abscesses present within days to hours of spinal subdural infection (126).

Intramedullary spinal cord abscesses in children

• Not clear but probably rapid: Currently, the exact rate of progression of symptoms in intramedullary spinal cord abscesses in children is unknown but can perhaps be extrapolated from that of spinal subdural infections, in which a rapid time course is most commonly seen.

Intervention

Spine infections in children

• Stabilization: Immobilization is recommended across the literature for the management of diskitis (2, 78, 80). Antibiotic use is controversial in diskitis; however, hospital length of stay is shorter with use of antibiotic therapy (2, 78, 80). Favorable results have been achieved with patients who have received 1–2 weeks of parenteral treatment followed by 4–6 weeks of an oral regimen (2, 78, 80). Empiric coverage of S. aureus is successful in most cases; however, if symptoms do not abate after 1–2 weeks, biopsy is recommended to determine a pathogen (2, 78, 80). Patients should be admitted with a plan for biopsy prior to aggressive antibiotic therapy when osteomyelitis is suspected.
• Preparation for definitive intervention, nonemergent: If symptoms do not abate after 1–2 weeks, biopsy is recommended to determine a pathogen (2, 78, 80). Systemically ill patients with known abscesses or evolving neurological deficits or a depreciating examination may require surgical intervention. Routine CT guided biopsy of infected vertebral segments is preferred for osteomyelitis. If inadequate sampling is obtained, open biopsy may be considered. If the patient’s condition clinically worsens despite 1–2 weeks of antibiotic therapy or there is new abscess formation, surgical intervention may be necessary (81).

Spinal epidural abscesses in children

• Stabilization: Bed rest and an age- and location-appropriate back brace should be used for pain control and stability in cases of epidural abscesses. A Foley catheter is used for a neurogenic bladder and stool softeners are given for a neurogenic bowel.
• Preparation for definitive intervention, nonemergent: A complete history and physical examination, including bowel and bladder evaluations in lumbosacral lesions, are needed. Blood cultures and infectious panels are typically performed. Plain radiographs seeking dysraphic posterior neural elements or bony involvement are obtained. Flexion and extension films may be necessary if spine stability could be compromised. Contrast-enhanced MRI of the spine remains the investigation of choice. In neonates and infants, real-time spinal ultrasound is advised. Intravenous broad-spectrum antibiotics should be initiated after blood cultures or needle-guided samples are obtained.
• Preparation for definitive intervention, emergent: Secure the airway and hemodynamic status for critically ill patients. A complete history and physical examination (including bowel and bladder evaluations for lumbosacral lesions) are then obtained. Preoperative blood tests as per surgeon as well as blood cultures and infectious panel are done. Insert a Foley catheter for fluid management and when a neurogenic bladder is suspected. Contrast-enhanced MRI of the spine remains the investigation of choice. If there is no access to MRI, CT with contrast including coronal and sagittal reconstructions should be performed. In neonates and infants, real-time spinal ultrasound is advised. An intraoperative ultrasound is also advisable.

Spinal subdural abscesses in children

• Stabilization: Bed rest and bracing should be used for pain control and stability. Pain and fever management should be provided. A Foley catheter is inserted when a neurogenic bladder is suspected, and stool softeners are prescribed for a neurogenic bowel.
• Preparation for definitive intervention, nonemergent: Currently, there are insufficient data to suggest whether a neurologically intact child with a spinal subdural abscess can be treated with antibiotics alone. If such a conservative approach is taken, there should remain a low threshold for operative intervention if symptoms develop or if the child remains febrile despite the initiation of antibiotics. Contrast-enhanced MRI of the spine remains the investigation of choice. Plain radiographs looking for dysraphic posterior neural elements or bony involvement can be done. Flexion and extension films may be necessary if spine stability is questioned.
• Preparation for definitive intervention, emergent: Preparation is similar to that with nonemergent cases. If a MRI cannot be obtained, CT of the spine with and without contrast can be done.

Intramedullary spinal cord abscesses in children

• Stabilization: Bed rest and back bracing should be used for pain control and stability. Pain and fever management should be provided. A Foley catheter should be inserted for a neurogenic bladder, and stool softeners should be administered for a neurogenic bowel.
• Preparation for definitive intervention, nonemergent: Contrast-enhanced MRI of the spine remains the investigation of choice. In neonates and infants, real-time spinal ultrasound is an alternative. If the disease found is not surgical, intravenous broad-spectrum antibiotics should be initiated after blood cultures or needle-guided samples are obtained.
• Preparation for definitive intervention, emergent: Contrast-enhanced MRI of the spine remains the investigation of choice. In neonates and infants, real-time spinal ultrasound is advised. If there is no access to MRI, CT with contrast and axial, coronal, and sagittal reconstructions should be performed. Intraoperative ultrasound is advisable for real-time imaging. Intraoperative neuromonitoring of motor evoked potentials and SSEPs should be done.

Admission Orders

Spine infections in children

• Activity restrictions: The child is kept at bed rest, with activity requiring the use of a corset.
• Cultures: A percutaneous CT-guided sample of the infection should be obtained, if feasible. Send cultures for Gram stain, fungus, aerobic and anaerobic, and TB culture.
• Medications: Analgesics and muscle relaxants are used as needed. Broad-spectrum antibiotics are given until the infecting microorganism and its antibiotic sensitivities are identified.

Spinal epidural abscesses in children

• Standard preoperative orders
• Infectious disease consultation

Spinal subdural abscesses in children

• Standard preoperative orders
• Infectious disease consultation

Intramedullary spinal cord abscesses in children

• Standard preoperative orders
• Infectious disease consultation