Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature AUTHORS: Melody Hawkins, MD,a and Michael Bolton, MDa,b
abstract Spinal epidural abscess (SEA) is a rare condition that requires prompt diagnosis and initiation of treatment for optimal outcome. Treatment generally consists of surgical intervention and systemic antibiotics. We present 1 of the largest cohorts of nontuberculous pediatric SEA in the English literature, emphasizing the outcomes of conservative (ie, nonoperative) management. We retrospectively identified 9 pediatric patients (#18 years of age) with SEAs at Our Lady of the Lake Children’s Hospital from 2002 to 2011. Cases were reviewed for demographic, clinical, diagnostic, and treatment characteristics and outcomes. The diagnosis of SEA was made by MRI in all cases, and methicillin-resistant Staphylococcus aureus (MRSA) was the only identified pathogen, isolated via blood culture in 6 of 9 patients. Although every patient received systemic antibiotics, only 2 had neurosurgical intervention. Four of the 7 patients treated conservatively received computed tomography-guided needle drainage. All patients recovered without significant sequelae. SEA is a potentially fatal illness that necessitates a heightened clinical awareness for diagnosis and treatment. Although official recommendations regarding management in pediatrics are lacking, treatment has generally been surgical decompression and drainage in combination with antibiotics; recent reports have suggested that antibiotic therapy alone may be successful in select patient populations. Although the adult literature has suggested that such management can be trialed in specific situations, only a handful of cases in the pediatric literature have reported this nonoperative approach. We present one of the largest reviews in support of successfully treating SEA with nonsurgical therapy. Pediatrics 2013;132:e1680–e1685
e1680
aDepartment of Pediatrics, and bSection of Infectious Diseases, Our Lady of the Lake Children’s Hospital, Baton Rouge, Louisiana
KEY WORDS abscess, infection, pediatrics ABBREVIATIONS CRP—C-reactive protein CT—computed tomography ESR—erythrocyte sedimentation rate MRSA—methicillin-resistant Staphylococcus aureus SEA—spinal epidural abscess Dr Hawkins conceptualized and designed the study, designed the data collection instruments, performed the review of the literature and interpretation of data, and drafted the initial manuscript; Dr Bolton conceptualized and designed the study, conducted data analyses, and reviewed and revised the manuscript; both authors approved the final manuscript as submitted. www.pediatrics.org/cgi/doi/10.1542/peds.2012-3805 doi:10.1542/peds.2012-3805 Accepted for publication Jul 1, 2013 Address correspondence to Melody Hawkins, MD, Department of Pediatrics, 7777 Hennessy Blvd, Suite 6003, Baton Rouge, LA 70808. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
HAWKINS and BOLTON
Downloaded from by guest on November 16, 2015
CASE REPORT
Spinal epidural abscess (SEA) is an infrequent diagnosis requiring prompt initiation of treatment for optimal outcome. SEAs are potentially increasing in incidence due to a rise in risk factors (spine trauma, previous skin infections, intravenous drug use, and immunodeficiency) and enhancement of imaging studies allowing increased detection.1–3 Treatment has traditionally been surgical decompression and drainage in combination with antibiotics4–6; recent reports suggest that antibiotic therapy alone can be successful in select patient populations.1,3,7–10 We present an institutional review revealing successful outcomes in patients who historically have had significant morbidity and mortality.
METHODS Institutional review board approval was obtained before review of medical records (classified as exempt). Nine pediatric patients (#18 years of age) with spinal epidural abscess (International Classification of Disease, Ninth Revision diagnosis code 324.1 as primary or secondary diagnosis) were identified at Our Lady of the Lake Children’s Hospital (a 95-bed hospital within a regional medical center) from 2002 to 2011. Cases were reviewed for the following characteristics: demographics, number of medical visits before diagnosis, length of stay, readmission rates, clinical features, diagnostic data (including vertebral body involvement, culture results, and concurrent osteomyelitis), treatments, and outcomes.
RESULTS The incidence of SEA was 1.5 cases per 10 000 admissions from 2002 to 2011. The average patient age was 9.2 years with a male predominance (56%). Sixtyseven percent of patients presented with fever; 33% had fever as the chief complaint. Six of the 9 cases had an
identifiable risk factor for SEA: recent skin/soft tissue infections or trauma. Four patients reported $1 skin or soft tissue infection in the preceding 6 months, 1 patient had lower-extremity cellulitis presumably secondary to Bartonella henselae infection, and 1 patient suffered a fall with resulting back pain 1 week before presentation. No patient had evidence of immunodeficiency. Four cases presented with weakness, and 1 patient had bowel and bladder incontinence, although none of the patients presented with or experienced paralysis (Tables 1 and 2). The groups were similar in age, length of stay, white blood cell count, and number of involved vertebral bodies. Inflammatory markers were obtained in every patient; average erythrocyte sedimentationrate(ESR) was82.9mm/hr and C-reactive protein (CRP) was 150.5 mg/L. Diagnosis was made by MRI in all cases. The average number of vertebral bodies involved was 6.7 (range 2–14). All but 2 patients had multiple medical visits before SEA was diagnosed. Methicillin-resistant Staphylococcus aureus (MRSA) was the only pathogen cultured (all via blood culture) in 6 of 9 cases (Table 3). Three patients had negative cultures, although 1 patient had epidemiologic factors and serologic evidence of B henselae infection. B henselae infection has been described in association with vertebral osteomyelitis and SEA infection in 3 children in reports published from 2005 to 20096 and presumably was the source of infection in this child. Seven of 9 SEA patients were successfully treated with conservative (nonoperative) management. Of these 7 patients, 4 had computed tomography (CT)-guided needle drainage of their abscesses (1 of the 7 patients had an exploratory laparotomy for abdominal pain on presentation). Only 2 of the 9 patients underwent neurosurgical intervention consisting of incision
PEDIATRICS Volume 132, Number 6, December 2013
Downloaded from by guest on November 16, 2015
and drainage and laminectomy. All patients received systemic antibiotics (Table 4). There were no significant sequelae in any patient upon documented followup. The rarity of this illness prohibited statistical analyses between surgical and nonsurgical groups.
DISCUSSION The classic presentation of SEA is a triad of back pain, fever, and neurologic deficits. However, only a minority of cases present with all 3 symptoms,1,9 and children are less likely to have aforementioned SEA risk factors.4 Consistent with previous results, our patients presented with fever, refusal to bear weight, pain with movement, and back pain; although none presented with all symptoms. Diagnosis in children is especially challenging because of nonspecific symptoms and frequently delayed until neurologic symptoms develop.11–13 The diagnosis is based on clinical suspicion, increasedinflammatorymarkers, and neurologic imaging.10 Hematogenous spread is the most common cause of infection in children as supported by the 6 positive blood cultures in our cohort.4,11,13,16,17 Untreated disease has variable progression, especially in young children.14,15 Acute-phase reactants (CRP and ESR) can provide insight into the level of inflammation and tissue involvement.3,18 ESR has been shown to be a strong indicator of disease, more so than leukocyte count.3,5,8,9 Table 3 demonstrates the rates of relatively normal white blood cell counts on presentation in contrast to the remarkable elevations of both CRP and ESR. Evaluation of inflammatory markers in a febrile patient with localized back pain should be considered as significant elevations may suggest SEA and may warrant diagnostic imaging.3 As suggested by this review, neurologic deficit does not need to be present to have heightened e1681
TABLE 1 Summary of Clinical Data on 9 Patients With SEA: Historical Information Pt Gender, Age (y)
Chief Complaint
Past Medical History
Past Surgical History
1
M, 1.2
Refusal to walk
Frequent otitis media Tympanostomy tube placement at 6 mo Ingrown toenail None 4 mo earlier, RSV infection at 5 mo Asthma Circumcision during neonatal period None None
2
F, 1.8
Fever, tachypnea, pneumonia
3
M, 3
Fever, stomach ache
4
F, 10
Flank pain
5
M, 10
6
M, 13
Back pain for 5–7 d, Asthma abdominal pain, shortness of breath Influenza-like symptoms None
None
7
M, 14
Difficulty walking
None
None
8
F, 17
Fever, nausea, vomiting
None
9
F, 13
Back pain for 2 wk
None
Tonsillectomy and adenoidectomy None
None
SEA Risk Factors
Previous Antibiotic Use
Number of Medical Visits Before Diagnosis
None
None
2
Left knee pain 1 week before presentation
Ceftriaxone for pneumonia
2
None
None
1
Left lower extremity cellulitis, Cephalexin exposure to kittens for cellulitis Fall 1 week earlier with Amoxicillin for resulting back pain unknown indication Recent soft tissue None abscess lanced with needle at home Soft tissue abscess within None previous 6 mo None None Soft tissue abscess within previous 6 mo
None
3 5
2
5 1 3
F, female; M, male; Pt, patient; RSV, respiratory syncytial virus.
TABLE 2 Summary of Clinical Data on 9 Patients With SEA: Symptoms on Presentation Pt Fever 1
None
2 3 4
Yes Yes Yes
5
Yes
6 7
None None
8 9
Yes Yes
Irritability
Weakness
Yes
Yes, bilateral lower extremities Yes Yes, left lower extremity None None None Brisk reflexes bilateral lower extremities None Yes, bilateral lower extremities None None None Decreased strength in bilateral hip flexors, increased reflexes bilateral lower extremities with clonus, left scapular protrusion. Ill appearing None None None
Enuresis/ Encopresis
Musculoskeletal
Yes, constipation Refusal to bear weight or sit up None None None
Slight left lower extremity limp None None
None
Bilateral flank pain
None None
Neck pain None
None None
None Back pain with significant decreased range of motion, mild swelling of thoracic area, alteration of gait
Pt, patient.
clinical suspicion because these findings do not typically present until later in the disease progression.10 All patients underwent MRI, the imaging modality of choice for the detection of SEA.1,3–5,13,19 Advances in such imaging e1682
have led to increased and earlier detection, more precise delineation of location and extent of infection (aiding in surgical technique planning), and improved evaluation of disease progression and resolution.2
The most common organism causing pediatric SEA is S aureus.2,4,7,9,11,12,16,17,19–22 There is increasing prevalence of community-acquired MRSA infections in children without risk factors.23,24 A thorough literature review performed by Auletta et al indicates high rates of methicillin-sensitive S aureus, in contrast to our review in which the 6 culturepositive patients grew MRSA, reinforcing the changing prevalence and invasiveness community-acquired MRSA can display.3,25 The incidence of MRSA could explain our higher CRP values but does not explain why only 22% of our patients required neurosurgical intervention (compared with 75% in previous reports4) and did not have disease progression after initiation of antibiotics. The outcome of no permanent neurologic effects was surprising in contrast to the expected worsened pathogenicity from MRSA in comparison with methicillin-sensitive S aureus. The prompt initiation of treatment necessitates a broad-spectrum empirical regimen, although coverage should
HAWKINS and BOLTON
Downloaded from by guest on November 16, 2015
CASE REPORT
TABLE 3 Summary of Laboratory and Imaging Results Pt
Laboratory Results
Radiologic Results
White Blood Cell/mL
Platelet Count, cells/mL
ESR, mm/h
CRP Level, mg/L
Positive Blood Culture
Pathogen Isolated
Imaging Received
Description of SEA Location and Features
1
13 800
423 000
104
N/A
No
None
2
6600
212 000
41
137.6
Yes
MRSA
Plain film, bone scan, CT, MRI (2) CT, MRI (3)
3
20 000
333 000
N/A
82.2
Yes
MRSA
PET, CT, MRI (2)
4
12 900
423 000
114
N/A
No
None
5
6400
212 000
105
174.5
Yes
MRSA
6
9800
197 000
140
N/A
Yes
MRSA
7
10 000
448 000
61
N/A
Yes
MRSA
Plain film, bone scan, CT, MRI (2) Bone scan CT (2), MRI (3) Plain, film, bone scan, CT (2), MRI (2) CT, MRI
8
15 800
130 000
10
182
No
None
MRI (2)
9
11 100
320 000
88
176.2
Yes
MRSA
CT (1), MRI (4)
L3–L4, posterior, no spinal stenosis, no osteomyelitis T1–T12, posterior, lateral spinal cord displacement, osteomyelitis of fibula T1–L2, posterior, no spinal stenosis, no osteomyelitis T7–11, anterior, lateral spinal cord displacement, T9 osteomyelitis L4–S1, posterior, no spinal stenosis, no osteomyelitis T1–L1, anterior, no spinal stenosis, T10 osteomyelitis T3–T6, anterior, no spinal stenosis, T5 anterior wedge fracture, no osteomyelitis L1–L4, posterior, no spinal stenosis, no osteomyelitis T5–T6, posterior, no spinal stenosis, T6 osteomyelitis
N/A, not available; PET, positron emission tomography; Pt, patient.
TABLE 4 Treatment and Outcomes Pt Antibiotics Used in Hospital 1
Nafcillin, vancomycin
2 3
Ceftriaxone, vancomycin Clindamycin, vancomycin, rifampin Vancomycin, gentamycin, rifampin Vancomycin, ceftriaxone, clindamycin, rifampin, doxycycline
4 5
6 7 8 9
Vancomycin, ceftriaxone, rifampin, linezolid Clindamycin, rifampin, vancomycin, linezolid Daptomycin, doripenem, doxycycline Vancomycin, metronidazole, ceftriaxone, rifampin
Discharge Antibiotics
Surgery
CT-Guided Needle Drainage
Readmission
Neurologic Outcome
Clindamycin, vancomycin None added on readmission Vancomycin, clindamycin None Vancomycin, rifampin Left hemilaminectomy T5–T6, T7–T8, T9–T10, T11–T12, L1–L2 Gentamicin, rifampin None
Yes
Yes
None None
Yes, PICC line issues Yes, PICC line issues
Standing with assistance on discharge No deficits No deficits
Yes
No
No deficits
Vancomycin, rifampin
Exploratory laparotomy, no neurosurgical intervention
None
Vancomycin, rifampin
None
None
Yes, diagnosis partial No deficits bowel obstruction, underwent lysis of adhesions from laparotomy No No deficits
Linezolid, rifampin
Yes
No
No deficits
Doripenem, doxycycline
T4–T5 corpectomy for thecal sac decompression None
None
No
No deficits
Vancomycin, rifampin
None
None
Yes, 1.5 mo later (unrelated to SEA)
No deficits
PICC, peripherally inserted central catheter; Pt, patient.
eventually be tailored to the offending organism. Due to increased rates of MRSA, vancomycin should be used for antistaphylococcal coverage as was done for all but 1 patient in this cohort.1,10 Duration of intravenous antibiotic therapy should be a minimum of 4 to 6 weeks.6 The length of therapy is dependent on the
level of immunocompetence, clinical improvement, and response to treatment demonstrated by subsequent ESR and MRI.8 The typical treatment of SEA is surgical decompression and drainage in combination with several weeks of antibiotics,4,13,26 although no consensus on
PEDIATRICS Volume 132, Number 6, December 2013
Downloaded from by guest on November 16, 2015
management has been reported.2 Some studies have shown improved outcomes with surgery,5,16,17,22,26 whereas others have shown success with alternative treatment options in select adult populations.2,7–9,27,28 There are limited data pertaining to the pediatric population. Enberg reviewed e1683
46 pediatric cases described in the literature spanning 1835 to 1972.17 In this review, 8 of 13 patients who received surgery before paralysis had full recovery (although 1 developed kyphoscoliosis 6 months later). Outcomes in cases when surgery was performed within 24 hours of neurologic deficit were also favorable,17 consistent with other reports.29 Unfortunately, nonsurgical management was fatal in 10 of 10 cases spanning 1835 to 1961.17 In Rubin’s review of 57 pediatric cases before 1993, 50 patients (88%) received surgery; the remaining 7 did not undergo surgery because of poor clinical condition or an incorrect diagnosis, and 6 of these patients died.16 In Auletta’s review of 8 pediatric cases from 1984 to 1999, 6 received surgical drainage, 1 received CT-guided needle drainage, and 1 received no surgical intervention; no patients died, and only 2 had minor neurologic sequelae.4 Our review of 9 cases from 2002 to 2011 demonstrates successful outcomes in all 9 patients with only 2 patients receiving neurosurgical intervention and 4 patients undergoing CT-guided needle drainage. All patients in our review presented before onset of paralysis, which historically has greatly improved outcomes
compared with presentation after the onset of neurologic symptoms.5,16 There are 4 scenarios based on adult data in which nonsurgical management may be considered: no neurologic deficit because these patients are likely less advanced in the disease course, extensive disease to the entire spinal column that would require a multilevel laminectomy, .48 hours of paraplegia (reports have shown much less chance of neurologic recovery), and extensive comorbid conditions that preclude safely undergoing surgery.1,9,29 The absence of neurologic deficit in our review accompanied by a favorable outcome lends support to the aforementioned nonsurgical approach. There is a risk of deterioration with conservative treatment even in those without neurologic symptomatology.2,4,7 Reviews of the adult literature have shown that 19% to 23% of patients with nonsurgical management develop worsening neurologic symptoms despite appropriate antibiotic therapy.26,30 Nonsurgical management can include serial neurologic exams, inflammatory marker evaluation, and repeat MRI to ensure resolving infection.3,8
neurologic deficit are the 2 factors most predictive of outcome.1,5,9,20 There is less neurologic recovery with prolonged neurologic deficit before initiation of therapy; paralysis for .24 hours is commonly irreversible.14,26 Although data are limited, children tend to have improved outcomes compared with adults.4 In rare disease processes such as SEA, it is not feasible to form a clinical trial to compare interventions; therefore, we must rely on past experiences reported and tailor management decisions based on the details of each case. We present 1 of the largest cohorts of pediatric SEA from a single institution successfully managed with nonoperative treatment. This pediatric review demonstrates the potentialsuccess of such management (ie, minimally invasive drainage techniques, serial laboratory studies, and imaging) in combination with systemic antimicrobial treatment and may be a prudent approach in select children.
The length of time before initiation of treatment and the severity of
ACKNOWLEDGMENTS We would like to acknowledge Karen Simpson MD for her critical review of the manuscript and Louis McLaughlin MPS for her research assistance.
5. Pereira CE, Lynch JC. Spinal epidural abscess: an analysis of 24 cases. Surg Neurol. 2005;63(suppl 1):S26–S29 6. Tasher D, Armarnik E, Mizrahi A, Liat BS, Constantini S, Grisaru-Soen G. Cat scratch disease with cervical vertebral osteomyelitis and spinal epidural abscess. Pediatr Infect Dis J. 2009;28(9):848–850 7. Karikari IO, Powers CJ, Reynolds RM, Mehta AI, Isaacs RE. Management of a spontaneous spinal epidural abscess: a singlecenter 10-year experience. Neurosurgery. 2009;65(5):919–923, discussion 923–924 8. Siddiq F, Chowfin A, Tight R, Sahmoun AE, Smego RA Jr. Medical vs surgical management of spinal epidural abscess. Arch Intern Med. 2004;164(22):2409–2412
9. Chen WC, Wang JL, Wang JT, Chen YC, Chang SC. Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. J Microbiol Immunol Infect. 2008;41(3):215–221 10. Pradilla G, Nagahama Y, Spivak AM, Bydon A, Rigamonti D. Spinal epidural abscess: current diagnosis and management. Curr Infect Dis Rep. 2010;12(6):484–491 11. Liu KA, Luhmann JD. Spinal epidural abscess in preverbal children: A case report with Currarino triad. Pediatrics. 1999;104(5 pt 1): 1139–1142 12. Grevitt MP, Mehdian SH. Epidural abscess in an infant. Eur Spine J. 1998;7(5):413–415 13. Walter RS, King JC Jr, Manley J, Rigamonti D. Spinal epidural abscess in infancy:
REFERENCES 1. Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. 1999;52(2):189–196, discussion 197 2. Wheeler D, Keiser P, Rigamonti D, Keay S. Medical management of spinal epidural abscesses: case report and review. Clin Infect Dis. 1992;15(1):22–27 3. Nussbaum ES, Rigamonti D, Standiford H, Numaguchi Y, Wolf AL, Robinson WL. Spinal epidural abscess: a report of 40 cases and review. Surg Neurol. 1992;38(3):225–231 4. Auletta JJ, John CC. Spinal epidural abscesses in children: a 15-year experience and review of the literature. Clin Infect Dis. 2001;32(1):9–16
e1684
HAWKINS and BOLTON
Downloaded from by guest on November 16, 2015
CASE REPORT
14.
15.
16.
17.
18.
19.
successful percutaneous drainage in a nine-month-old and review of the literature. Pediatr Infect Dis J. 1991;10(11):860– 864 Schweich PJ, Hurt TL. Spinal epidural abscess in children: two illustrative cases. Pediatr Emerg Care. 1992;8(2):84–87 Fischer EG, Greene CS Jr, Winston KR. Spinal epidural abscess in children. Neurosurgery. 1981;9(3):257–260 Rubin G, Michowiz SD, Ashkenasi A, Tadmor R, Rappaport ZH. Spinal epidural abscess in the pediatric age group: case report and review of literature. Pediatr Infect Dis J. 1993;12(12):1007–1011 Enberg RN, Kaplan RJ. Spinal epidural abscess in children. Early diagnosis and immediate surgical drainage is essential to forestall paralysis. Clin Pediatr (Phila). 1974;13(3):247–248, passim Sáez-Llorens X, Lagrutta F. The acute phase host reaction during bacterial infection and its clinical impact in children. Pediatr Infect Dis J. 1993;12(1):83–87 Bair-Merritt MH, Chung C, Collier A. Spinal epidural abscess in a young child. Pediatrics. 2000;106(3). Available at: www.pediatrics.org/cgi/content/full/106/3/e39
20. Quach C, Tapiero B, Noya F. Group A streptococcus spinal epidural abscess during varicella. Pediatrics. 2002;109(1). Available at: www.pediatrics.org/cgi/content/full/ 109/1/e14 21. Darwish B, Stanley TV, Wickremesekera A, Bowkett B, Leadbitter M. Presacral neuroenteric fistula in a newborn presenting with an epidural abscess: case report and review of the literature. Pediatrics. 2004; 114(4). Available at: www.pediatrics.org/ cgi/content/full/114/4/e527 22. Hlavin ML, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: a ten-year perspective. Neurosurgery. 1990;27(2):177–184 23. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillinresistant Staphylococcus aureus in children with no identified predisposing risk. JAMA. 1998;279(8):593–598 24. Suggs AH, Maranan MC, Boyle-Vavra S, Daum RS. Methicillin-resistant and borderline methicillin-resistant asymptomatic Staphylococcus aureus colonization in children without identifiable risk factors. Pediatr Infect Dis J. 1999;18(5):410–414 25. Bruns AS, Sood N. Community-acquired methicillin-resistant Staphylococcus aureus
PEDIATRICS Volume 132, Number 6, December 2013
Downloaded from by guest on November 16, 2015
26.
27.
28.
29.
30.
epidural abscess with bacteremia and multiple lung abscesses: case report. Am J Crit Care. 2009;18(1):88–, 86–87 Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore). 1992;71(6):369–385 Sethna NF, Clendenin D, Athiraman U, Solodiuk J, Rodriguez DP, Zurakowski D. Incidence of epidural catheter-associated infections after continuous epidural analgesia in children. Anesthesiology. 2010;113 (1):224–232 Leys D, Lesoin F, Viaud C, et al. Decreased morbidity from acute bacterial spinal epidural abscesses using computed tomography and nonsurgical treatment in selected patients. Ann Neurol. 1985;17(4): 350–355 Del Curling O Jr, Gower DJ, McWhorter JM. Changing concepts in spinal epidural abscess: a report of 29 cases. Neurosurgery. 1990;27(2):185–192 Khanna RK, Malik GM, Rock JP, Rosenblum ML. Spinal epidural abscess: evaluation of factors influencing outcome. Neurosurgery. 1996;39(5):958–964
e1685
Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature Melody Hawkins and Michael Bolton Pediatrics 2013;132;e1680; originally published online November 4, 2013; DOI: 10.1542/peds.2012-3805 Updated Information & Services
including high resolution figures, can be found at: /content/132/6/e1680.full.html
References
This article cites 30 articles, 7 of which can be accessed free at: /content/132/6/e1680.full.html#ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Neurology /cgi/collection/neurology_sub Neurological Surgery /cgi/collection/neurological_surgery_sub Rheumatology/Musculoskeletal Disorders /cgi/collection/rheumatology:musculoskeletal_disorders_sub
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: /site/misc/reprints.xhtml
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on November 16, 2015
Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature Melody Hawkins and Michael Bolton Pediatrics 2013;132;e1680; originally published online November 4, 2013; DOI: 10.1542/peds.2012-3805
The online version of this article, along with updated information and services, is located on the World Wide Web at: /content/132/6/e1680.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on November 16, 2015
abstract Spinal epidural abscess (SEA) is a rare condition that requires prompt diagnosis and initiation of treatment for optimal outcome. Treatment generally consists of surgical intervention and systemic antibiotics. We present 1 of the largest cohorts of nontuberculous pediatric SEA in the English literature, emphasizing the outcomes of conservative (ie, nonoperative) management. We retrospectively identified 9 pediatric patients (#18 years of age) with SEAs at Our Lady of the Lake Children’s Hospital from 2002 to 2011. Cases were reviewed for demographic, clinical, diagnostic, and treatment characteristics and outcomes. The diagnosis of SEA was made by MRI in all cases, and methicillin-resistant Staphylococcus aureus (MRSA) was the only identified pathogen, isolated via blood culture in 6 of 9 patients. Although every patient received systemic antibiotics, only 2 had neurosurgical intervention. Four of the 7 patients treated conservatively received computed tomography-guided needle drainage. All patients recovered without significant sequelae. SEA is a potentially fatal illness that necessitates a heightened clinical awareness for diagnosis and treatment. Although official recommendations regarding management in pediatrics are lacking, treatment has generally been surgical decompression and drainage in combination with antibiotics; recent reports have suggested that antibiotic therapy alone may be successful in select patient populations. Although the adult literature has suggested that such management can be trialed in specific situations, only a handful of cases in the pediatric literature have reported this nonoperative approach. We present one of the largest reviews in support of successfully treating SEA with nonsurgical therapy. Pediatrics 2013;132:e1680–e1685
e1680
aDepartment of Pediatrics, and bSection of Infectious Diseases, Our Lady of the Lake Children’s Hospital, Baton Rouge, Louisiana
KEY WORDS abscess, infection, pediatrics ABBREVIATIONS CRP—C-reactive protein CT—computed tomography ESR—erythrocyte sedimentation rate MRSA—methicillin-resistant Staphylococcus aureus SEA—spinal epidural abscess Dr Hawkins conceptualized and designed the study, designed the data collection instruments, performed the review of the literature and interpretation of data, and drafted the initial manuscript; Dr Bolton conceptualized and designed the study, conducted data analyses, and reviewed and revised the manuscript; both authors approved the final manuscript as submitted. www.pediatrics.org/cgi/doi/10.1542/peds.2012-3805 doi:10.1542/peds.2012-3805 Accepted for publication Jul 1, 2013 Address correspondence to Melody Hawkins, MD, Department of Pediatrics, 7777 Hennessy Blvd, Suite 6003, Baton Rouge, LA 70808. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
HAWKINS and BOLTON
Downloaded from by guest on November 16, 2015
CASE REPORT
Spinal epidural abscess (SEA) is an infrequent diagnosis requiring prompt initiation of treatment for optimal outcome. SEAs are potentially increasing in incidence due to a rise in risk factors (spine trauma, previous skin infections, intravenous drug use, and immunodeficiency) and enhancement of imaging studies allowing increased detection.1–3 Treatment has traditionally been surgical decompression and drainage in combination with antibiotics4–6; recent reports suggest that antibiotic therapy alone can be successful in select patient populations.1,3,7–10 We present an institutional review revealing successful outcomes in patients who historically have had significant morbidity and mortality.
METHODS Institutional review board approval was obtained before review of medical records (classified as exempt). Nine pediatric patients (#18 years of age) with spinal epidural abscess (International Classification of Disease, Ninth Revision diagnosis code 324.1 as primary or secondary diagnosis) were identified at Our Lady of the Lake Children’s Hospital (a 95-bed hospital within a regional medical center) from 2002 to 2011. Cases were reviewed for the following characteristics: demographics, number of medical visits before diagnosis, length of stay, readmission rates, clinical features, diagnostic data (including vertebral body involvement, culture results, and concurrent osteomyelitis), treatments, and outcomes.
RESULTS The incidence of SEA was 1.5 cases per 10 000 admissions from 2002 to 2011. The average patient age was 9.2 years with a male predominance (56%). Sixtyseven percent of patients presented with fever; 33% had fever as the chief complaint. Six of the 9 cases had an
identifiable risk factor for SEA: recent skin/soft tissue infections or trauma. Four patients reported $1 skin or soft tissue infection in the preceding 6 months, 1 patient had lower-extremity cellulitis presumably secondary to Bartonella henselae infection, and 1 patient suffered a fall with resulting back pain 1 week before presentation. No patient had evidence of immunodeficiency. Four cases presented with weakness, and 1 patient had bowel and bladder incontinence, although none of the patients presented with or experienced paralysis (Tables 1 and 2). The groups were similar in age, length of stay, white blood cell count, and number of involved vertebral bodies. Inflammatory markers were obtained in every patient; average erythrocyte sedimentationrate(ESR) was82.9mm/hr and C-reactive protein (CRP) was 150.5 mg/L. Diagnosis was made by MRI in all cases. The average number of vertebral bodies involved was 6.7 (range 2–14). All but 2 patients had multiple medical visits before SEA was diagnosed. Methicillin-resistant Staphylococcus aureus (MRSA) was the only pathogen cultured (all via blood culture) in 6 of 9 cases (Table 3). Three patients had negative cultures, although 1 patient had epidemiologic factors and serologic evidence of B henselae infection. B henselae infection has been described in association with vertebral osteomyelitis and SEA infection in 3 children in reports published from 2005 to 20096 and presumably was the source of infection in this child. Seven of 9 SEA patients were successfully treated with conservative (nonoperative) management. Of these 7 patients, 4 had computed tomography (CT)-guided needle drainage of their abscesses (1 of the 7 patients had an exploratory laparotomy for abdominal pain on presentation). Only 2 of the 9 patients underwent neurosurgical intervention consisting of incision
PEDIATRICS Volume 132, Number 6, December 2013
Downloaded from by guest on November 16, 2015
and drainage and laminectomy. All patients received systemic antibiotics (Table 4). There were no significant sequelae in any patient upon documented followup. The rarity of this illness prohibited statistical analyses between surgical and nonsurgical groups.
DISCUSSION The classic presentation of SEA is a triad of back pain, fever, and neurologic deficits. However, only a minority of cases present with all 3 symptoms,1,9 and children are less likely to have aforementioned SEA risk factors.4 Consistent with previous results, our patients presented with fever, refusal to bear weight, pain with movement, and back pain; although none presented with all symptoms. Diagnosis in children is especially challenging because of nonspecific symptoms and frequently delayed until neurologic symptoms develop.11–13 The diagnosis is based on clinical suspicion, increasedinflammatorymarkers, and neurologic imaging.10 Hematogenous spread is the most common cause of infection in children as supported by the 6 positive blood cultures in our cohort.4,11,13,16,17 Untreated disease has variable progression, especially in young children.14,15 Acute-phase reactants (CRP and ESR) can provide insight into the level of inflammation and tissue involvement.3,18 ESR has been shown to be a strong indicator of disease, more so than leukocyte count.3,5,8,9 Table 3 demonstrates the rates of relatively normal white blood cell counts on presentation in contrast to the remarkable elevations of both CRP and ESR. Evaluation of inflammatory markers in a febrile patient with localized back pain should be considered as significant elevations may suggest SEA and may warrant diagnostic imaging.3 As suggested by this review, neurologic deficit does not need to be present to have heightened e1681
TABLE 1 Summary of Clinical Data on 9 Patients With SEA: Historical Information Pt Gender, Age (y)
Chief Complaint
Past Medical History
Past Surgical History
1
M, 1.2
Refusal to walk
Frequent otitis media Tympanostomy tube placement at 6 mo Ingrown toenail None 4 mo earlier, RSV infection at 5 mo Asthma Circumcision during neonatal period None None
2
F, 1.8
Fever, tachypnea, pneumonia
3
M, 3
Fever, stomach ache
4
F, 10
Flank pain
5
M, 10
6
M, 13
Back pain for 5–7 d, Asthma abdominal pain, shortness of breath Influenza-like symptoms None
None
7
M, 14
Difficulty walking
None
None
8
F, 17
Fever, nausea, vomiting
None
9
F, 13
Back pain for 2 wk
None
Tonsillectomy and adenoidectomy None
None
SEA Risk Factors
Previous Antibiotic Use
Number of Medical Visits Before Diagnosis
None
None
2
Left knee pain 1 week before presentation
Ceftriaxone for pneumonia
2
None
None
1
Left lower extremity cellulitis, Cephalexin exposure to kittens for cellulitis Fall 1 week earlier with Amoxicillin for resulting back pain unknown indication Recent soft tissue None abscess lanced with needle at home Soft tissue abscess within None previous 6 mo None None Soft tissue abscess within previous 6 mo
None
3 5
2
5 1 3
F, female; M, male; Pt, patient; RSV, respiratory syncytial virus.
TABLE 2 Summary of Clinical Data on 9 Patients With SEA: Symptoms on Presentation Pt Fever 1
None
2 3 4
Yes Yes Yes
5
Yes
6 7
None None
8 9
Yes Yes
Irritability
Weakness
Yes
Yes, bilateral lower extremities Yes Yes, left lower extremity None None None Brisk reflexes bilateral lower extremities None Yes, bilateral lower extremities None None None Decreased strength in bilateral hip flexors, increased reflexes bilateral lower extremities with clonus, left scapular protrusion. Ill appearing None None None
Enuresis/ Encopresis
Musculoskeletal
Yes, constipation Refusal to bear weight or sit up None None None
Slight left lower extremity limp None None
None
Bilateral flank pain
None None
Neck pain None
None None
None Back pain with significant decreased range of motion, mild swelling of thoracic area, alteration of gait
Pt, patient.
clinical suspicion because these findings do not typically present until later in the disease progression.10 All patients underwent MRI, the imaging modality of choice for the detection of SEA.1,3–5,13,19 Advances in such imaging e1682
have led to increased and earlier detection, more precise delineation of location and extent of infection (aiding in surgical technique planning), and improved evaluation of disease progression and resolution.2
The most common organism causing pediatric SEA is S aureus.2,4,7,9,11,12,16,17,19–22 There is increasing prevalence of community-acquired MRSA infections in children without risk factors.23,24 A thorough literature review performed by Auletta et al indicates high rates of methicillin-sensitive S aureus, in contrast to our review in which the 6 culturepositive patients grew MRSA, reinforcing the changing prevalence and invasiveness community-acquired MRSA can display.3,25 The incidence of MRSA could explain our higher CRP values but does not explain why only 22% of our patients required neurosurgical intervention (compared with 75% in previous reports4) and did not have disease progression after initiation of antibiotics. The outcome of no permanent neurologic effects was surprising in contrast to the expected worsened pathogenicity from MRSA in comparison with methicillin-sensitive S aureus. The prompt initiation of treatment necessitates a broad-spectrum empirical regimen, although coverage should
HAWKINS and BOLTON
Downloaded from by guest on November 16, 2015
CASE REPORT
TABLE 3 Summary of Laboratory and Imaging Results Pt
Laboratory Results
Radiologic Results
White Blood Cell/mL
Platelet Count, cells/mL
ESR, mm/h
CRP Level, mg/L
Positive Blood Culture
Pathogen Isolated
Imaging Received
Description of SEA Location and Features
1
13 800
423 000
104
N/A
No
None
2
6600
212 000
41
137.6
Yes
MRSA
Plain film, bone scan, CT, MRI (2) CT, MRI (3)
3
20 000
333 000
N/A
82.2
Yes
MRSA
PET, CT, MRI (2)
4
12 900
423 000
114
N/A
No
None
5
6400
212 000
105
174.5
Yes
MRSA
6
9800
197 000
140
N/A
Yes
MRSA
7
10 000
448 000
61
N/A
Yes
MRSA
Plain film, bone scan, CT, MRI (2) Bone scan CT (2), MRI (3) Plain, film, bone scan, CT (2), MRI (2) CT, MRI
8
15 800
130 000
10
182
No
None
MRI (2)
9
11 100
320 000
88
176.2
Yes
MRSA
CT (1), MRI (4)
L3–L4, posterior, no spinal stenosis, no osteomyelitis T1–T12, posterior, lateral spinal cord displacement, osteomyelitis of fibula T1–L2, posterior, no spinal stenosis, no osteomyelitis T7–11, anterior, lateral spinal cord displacement, T9 osteomyelitis L4–S1, posterior, no spinal stenosis, no osteomyelitis T1–L1, anterior, no spinal stenosis, T10 osteomyelitis T3–T6, anterior, no spinal stenosis, T5 anterior wedge fracture, no osteomyelitis L1–L4, posterior, no spinal stenosis, no osteomyelitis T5–T6, posterior, no spinal stenosis, T6 osteomyelitis
N/A, not available; PET, positron emission tomography; Pt, patient.
TABLE 4 Treatment and Outcomes Pt Antibiotics Used in Hospital 1
Nafcillin, vancomycin
2 3
Ceftriaxone, vancomycin Clindamycin, vancomycin, rifampin Vancomycin, gentamycin, rifampin Vancomycin, ceftriaxone, clindamycin, rifampin, doxycycline
4 5
6 7 8 9
Vancomycin, ceftriaxone, rifampin, linezolid Clindamycin, rifampin, vancomycin, linezolid Daptomycin, doripenem, doxycycline Vancomycin, metronidazole, ceftriaxone, rifampin
Discharge Antibiotics
Surgery
CT-Guided Needle Drainage
Readmission
Neurologic Outcome
Clindamycin, vancomycin None added on readmission Vancomycin, clindamycin None Vancomycin, rifampin Left hemilaminectomy T5–T6, T7–T8, T9–T10, T11–T12, L1–L2 Gentamicin, rifampin None
Yes
Yes
None None
Yes, PICC line issues Yes, PICC line issues
Standing with assistance on discharge No deficits No deficits
Yes
No
No deficits
Vancomycin, rifampin
Exploratory laparotomy, no neurosurgical intervention
None
Vancomycin, rifampin
None
None
Yes, diagnosis partial No deficits bowel obstruction, underwent lysis of adhesions from laparotomy No No deficits
Linezolid, rifampin
Yes
No
No deficits
Doripenem, doxycycline
T4–T5 corpectomy for thecal sac decompression None
None
No
No deficits
Vancomycin, rifampin
None
None
Yes, 1.5 mo later (unrelated to SEA)
No deficits
PICC, peripherally inserted central catheter; Pt, patient.
eventually be tailored to the offending organism. Due to increased rates of MRSA, vancomycin should be used for antistaphylococcal coverage as was done for all but 1 patient in this cohort.1,10 Duration of intravenous antibiotic therapy should be a minimum of 4 to 6 weeks.6 The length of therapy is dependent on the
level of immunocompetence, clinical improvement, and response to treatment demonstrated by subsequent ESR and MRI.8 The typical treatment of SEA is surgical decompression and drainage in combination with several weeks of antibiotics,4,13,26 although no consensus on
PEDIATRICS Volume 132, Number 6, December 2013
Downloaded from by guest on November 16, 2015
management has been reported.2 Some studies have shown improved outcomes with surgery,5,16,17,22,26 whereas others have shown success with alternative treatment options in select adult populations.2,7–9,27,28 There are limited data pertaining to the pediatric population. Enberg reviewed e1683
46 pediatric cases described in the literature spanning 1835 to 1972.17 In this review, 8 of 13 patients who received surgery before paralysis had full recovery (although 1 developed kyphoscoliosis 6 months later). Outcomes in cases when surgery was performed within 24 hours of neurologic deficit were also favorable,17 consistent with other reports.29 Unfortunately, nonsurgical management was fatal in 10 of 10 cases spanning 1835 to 1961.17 In Rubin’s review of 57 pediatric cases before 1993, 50 patients (88%) received surgery; the remaining 7 did not undergo surgery because of poor clinical condition or an incorrect diagnosis, and 6 of these patients died.16 In Auletta’s review of 8 pediatric cases from 1984 to 1999, 6 received surgical drainage, 1 received CT-guided needle drainage, and 1 received no surgical intervention; no patients died, and only 2 had minor neurologic sequelae.4 Our review of 9 cases from 2002 to 2011 demonstrates successful outcomes in all 9 patients with only 2 patients receiving neurosurgical intervention and 4 patients undergoing CT-guided needle drainage. All patients in our review presented before onset of paralysis, which historically has greatly improved outcomes
compared with presentation after the onset of neurologic symptoms.5,16 There are 4 scenarios based on adult data in which nonsurgical management may be considered: no neurologic deficit because these patients are likely less advanced in the disease course, extensive disease to the entire spinal column that would require a multilevel laminectomy, .48 hours of paraplegia (reports have shown much less chance of neurologic recovery), and extensive comorbid conditions that preclude safely undergoing surgery.1,9,29 The absence of neurologic deficit in our review accompanied by a favorable outcome lends support to the aforementioned nonsurgical approach. There is a risk of deterioration with conservative treatment even in those without neurologic symptomatology.2,4,7 Reviews of the adult literature have shown that 19% to 23% of patients with nonsurgical management develop worsening neurologic symptoms despite appropriate antibiotic therapy.26,30 Nonsurgical management can include serial neurologic exams, inflammatory marker evaluation, and repeat MRI to ensure resolving infection.3,8
neurologic deficit are the 2 factors most predictive of outcome.1,5,9,20 There is less neurologic recovery with prolonged neurologic deficit before initiation of therapy; paralysis for .24 hours is commonly irreversible.14,26 Although data are limited, children tend to have improved outcomes compared with adults.4 In rare disease processes such as SEA, it is not feasible to form a clinical trial to compare interventions; therefore, we must rely on past experiences reported and tailor management decisions based on the details of each case. We present 1 of the largest cohorts of pediatric SEA from a single institution successfully managed with nonoperative treatment. This pediatric review demonstrates the potentialsuccess of such management (ie, minimally invasive drainage techniques, serial laboratory studies, and imaging) in combination with systemic antimicrobial treatment and may be a prudent approach in select children.
The length of time before initiation of treatment and the severity of
ACKNOWLEDGMENTS We would like to acknowledge Karen Simpson MD for her critical review of the manuscript and Louis McLaughlin MPS for her research assistance.
5. Pereira CE, Lynch JC. Spinal epidural abscess: an analysis of 24 cases. Surg Neurol. 2005;63(suppl 1):S26–S29 6. Tasher D, Armarnik E, Mizrahi A, Liat BS, Constantini S, Grisaru-Soen G. Cat scratch disease with cervical vertebral osteomyelitis and spinal epidural abscess. Pediatr Infect Dis J. 2009;28(9):848–850 7. Karikari IO, Powers CJ, Reynolds RM, Mehta AI, Isaacs RE. Management of a spontaneous spinal epidural abscess: a singlecenter 10-year experience. Neurosurgery. 2009;65(5):919–923, discussion 923–924 8. Siddiq F, Chowfin A, Tight R, Sahmoun AE, Smego RA Jr. Medical vs surgical management of spinal epidural abscess. Arch Intern Med. 2004;164(22):2409–2412
9. Chen WC, Wang JL, Wang JT, Chen YC, Chang SC. Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. J Microbiol Immunol Infect. 2008;41(3):215–221 10. Pradilla G, Nagahama Y, Spivak AM, Bydon A, Rigamonti D. Spinal epidural abscess: current diagnosis and management. Curr Infect Dis Rep. 2010;12(6):484–491 11. Liu KA, Luhmann JD. Spinal epidural abscess in preverbal children: A case report with Currarino triad. Pediatrics. 1999;104(5 pt 1): 1139–1142 12. Grevitt MP, Mehdian SH. Epidural abscess in an infant. Eur Spine J. 1998;7(5):413–415 13. Walter RS, King JC Jr, Manley J, Rigamonti D. Spinal epidural abscess in infancy:
REFERENCES 1. Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. 1999;52(2):189–196, discussion 197 2. Wheeler D, Keiser P, Rigamonti D, Keay S. Medical management of spinal epidural abscesses: case report and review. Clin Infect Dis. 1992;15(1):22–27 3. Nussbaum ES, Rigamonti D, Standiford H, Numaguchi Y, Wolf AL, Robinson WL. Spinal epidural abscess: a report of 40 cases and review. Surg Neurol. 1992;38(3):225–231 4. Auletta JJ, John CC. Spinal epidural abscesses in children: a 15-year experience and review of the literature. Clin Infect Dis. 2001;32(1):9–16
e1684
HAWKINS and BOLTON
Downloaded from by guest on November 16, 2015
CASE REPORT
14.
15.
16.
17.
18.
19.
successful percutaneous drainage in a nine-month-old and review of the literature. Pediatr Infect Dis J. 1991;10(11):860– 864 Schweich PJ, Hurt TL. Spinal epidural abscess in children: two illustrative cases. Pediatr Emerg Care. 1992;8(2):84–87 Fischer EG, Greene CS Jr, Winston KR. Spinal epidural abscess in children. Neurosurgery. 1981;9(3):257–260 Rubin G, Michowiz SD, Ashkenasi A, Tadmor R, Rappaport ZH. Spinal epidural abscess in the pediatric age group: case report and review of literature. Pediatr Infect Dis J. 1993;12(12):1007–1011 Enberg RN, Kaplan RJ. Spinal epidural abscess in children. Early diagnosis and immediate surgical drainage is essential to forestall paralysis. Clin Pediatr (Phila). 1974;13(3):247–248, passim Sáez-Llorens X, Lagrutta F. The acute phase host reaction during bacterial infection and its clinical impact in children. Pediatr Infect Dis J. 1993;12(1):83–87 Bair-Merritt MH, Chung C, Collier A. Spinal epidural abscess in a young child. Pediatrics. 2000;106(3). Available at: www.pediatrics.org/cgi/content/full/106/3/e39
20. Quach C, Tapiero B, Noya F. Group A streptococcus spinal epidural abscess during varicella. Pediatrics. 2002;109(1). Available at: www.pediatrics.org/cgi/content/full/ 109/1/e14 21. Darwish B, Stanley TV, Wickremesekera A, Bowkett B, Leadbitter M. Presacral neuroenteric fistula in a newborn presenting with an epidural abscess: case report and review of the literature. Pediatrics. 2004; 114(4). Available at: www.pediatrics.org/ cgi/content/full/114/4/e527 22. Hlavin ML, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: a ten-year perspective. Neurosurgery. 1990;27(2):177–184 23. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillinresistant Staphylococcus aureus in children with no identified predisposing risk. JAMA. 1998;279(8):593–598 24. Suggs AH, Maranan MC, Boyle-Vavra S, Daum RS. Methicillin-resistant and borderline methicillin-resistant asymptomatic Staphylococcus aureus colonization in children without identifiable risk factors. Pediatr Infect Dis J. 1999;18(5):410–414 25. Bruns AS, Sood N. Community-acquired methicillin-resistant Staphylococcus aureus
PEDIATRICS Volume 132, Number 6, December 2013
Downloaded from by guest on November 16, 2015
26.
27.
28.
29.
30.
epidural abscess with bacteremia and multiple lung abscesses: case report. Am J Crit Care. 2009;18(1):88–, 86–87 Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore). 1992;71(6):369–385 Sethna NF, Clendenin D, Athiraman U, Solodiuk J, Rodriguez DP, Zurakowski D. Incidence of epidural catheter-associated infections after continuous epidural analgesia in children. Anesthesiology. 2010;113 (1):224–232 Leys D, Lesoin F, Viaud C, et al. Decreased morbidity from acute bacterial spinal epidural abscesses using computed tomography and nonsurgical treatment in selected patients. Ann Neurol. 1985;17(4): 350–355 Del Curling O Jr, Gower DJ, McWhorter JM. Changing concepts in spinal epidural abscess: a report of 29 cases. Neurosurgery. 1990;27(2):185–192 Khanna RK, Malik GM, Rock JP, Rosenblum ML. Spinal epidural abscess: evaluation of factors influencing outcome. Neurosurgery. 1996;39(5):958–964
e1685
Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature Melody Hawkins and Michael Bolton Pediatrics 2013;132;e1680; originally published online November 4, 2013; DOI: 10.1542/peds.2012-3805 Updated Information & Services
including high resolution figures, can be found at: /content/132/6/e1680.full.html
References
This article cites 30 articles, 7 of which can be accessed free at: /content/132/6/e1680.full.html#ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Neurology /cgi/collection/neurology_sub Neurological Surgery /cgi/collection/neurological_surgery_sub Rheumatology/Musculoskeletal Disorders /cgi/collection/rheumatology:musculoskeletal_disorders_sub
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: /site/misc/reprints.xhtml
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on November 16, 2015
Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature Melody Hawkins and Michael Bolton Pediatrics 2013;132;e1680; originally published online November 4, 2013; DOI: 10.1542/peds.2012-3805
The online version of this article, along with updated information and services, is located on the World Wide Web at: /content/132/6/e1680.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on November 16, 2015
