Br. J. Surg. Vol. 66 (1979)3-4
Spinal epidural abscess presenting as acute abdomen in a child G . W. T Y S O N , A. G R A N T A N D W. E. S T R A C H A N * SUMMARY
Spinal epidural abscess is seldom encountered in children and rarely occurs in the absence of spinalpain. A case is described in which a child with a thoracic epidural abscess presented with abdominal rather than spinal pain. Thoracolumbar radicular inflammation and visceroparietal refexes initiated by a 'spinal ileus' probably produced the symptoms and signs of acute intra-abdominal disease. Consideration of intraspinal disease is advisable in all cases of acute abdomen which exhibit atypical features. MOSTpaediatric surgeons have little experience with spinal epidural abscesses since these lesions account for only 0.2-1.2 of every 10000 general hospital admissions (Baker et al., 1975) and less than 1.5 per cent of the reported cases involve children (Davidson and Zajac, 1978). Fortunately, the early signs and symptoms of thicdisease usually direct the surgeon's attention to the spine before permanent motor and sensory paralysis supervenes. Spinal pain is the most important initial complaint (Messer et al., 1977) and was mentioned by all 20 patients reported by Heusner (1948), by all 39 reported by Baker et al. (1975) and by all 49 reported by Hancock (1973). In addition, local tenderness was elicited by spinal percussion in 90-100 per cent of these cases. Early diagnosis may be almost impossible when local spinal pain is inconspicuous or absent (Ashby, 1977), when toxic epiphenomena divert attention from subtle signs of neurologic dysfunction and when the patient is an acutely distressed and uncooperative child. The following case is unusual in that it involved a child in whom a history of spinal pain was not obtained and the clinical presentation was that of acute intraabdominal disease.
Case report A 7-year-old girl developed malaise, anorexia and dysuria 6 days before the eventual hospital admission. She subsequently complained of aching over the anterior aspect of both thighs. Two days before admission she developed constant central abdominal pain and intermittent vomiting. She had a single, normal bowel movement during this 6-day period. At no time did she complain of back pain. On examination the child appeared toxic and anxious. The blood pressure was 100/60 mmHg, the heart rate 130/min and the oral temperature 38.4 "C. The entire abdomen was distended and resonant. There was generalized tenderness and guarding, but these signs were more prominent in the right lower quadrant. Only mild tenderness was elicited on digital rectal examination. Bowel sounds were normal in pitch but decreased in frequency. The haemoglobin was 10.2 g/dl, the white blood cell count 16 x lOg/l and the erythrocyte sedimentation rate (Wintrobe) 58 mm/h. Urinalysis demonstrated 3 leucocytes per highpowered field. Urine culture was sterile. Serum electrolytes,urea and creatinine were all normal. Abdominal X-rays revealed gaseous distension of both the large and small bowels with several fluid levels. The patient underwent laparotomy on the night of admission in order to exclude appendicitis. A large volume of
non-purulent, free peritoneal fluid was encountered (which subsequently proved to be sterile). The entire bowel was dilated but otherwise normal. The appendix was not grossly inflamed. The retroperitoneal tissues also appeared normal. Needles were inserted into the psoas muscles but no pus could be aspirated. The following morning the patient was afebrile. She continued to complain of bilateral anterior thigh pain and developed cutaneous hyperaesthesias over these areas. Both groins were tender to palpation. Late in the day she became incontinent of urine. On the morning of the second postoperative day the nurse noted that the child did not move her legs when she was placed on the bed pan. Examination at that time disclosed a flaccid paraplegia. Deep tendon reflexes were difficult to obtain and plantar reflexes could not be elicited. Hypoalgesia to pin-prick was present to the level of the umbilicus (T10). Because of nuchal rigidity and headache, a lumbar puncture was performed at the L3-4 interspinous space. Viscous, yellow cerebrospinal fluid was obtained, but the flow soon ceased. Yellow-green pus (10 ml) was aspirated from the epidural space as the needle was withdrawn. A Gram stain demonstrated clumps of Gram-positive cocci. Staphylococcus aureus resistant to penicillin was cultured from both the spinal fluid and the epidural pus. The cerebrospinal fluid had a glucose content of 1.2 mmol/l (normal 2.85.6) and contained 22 polymorphonuclear leucocytes and 14 lymphocytes per cubic millilitre. The patient was given intravenous gentamicin and cloxacillin and was transfered to the neurosurgery service at Plymouth General Hospital. The midthoracic spinous processes were found to be tender to palpation. Plain X-rays of the entire spinal column showed no signs of osteomyelitis. A cisternal myelogram demonstrated a complete subarachnoid block at the T4 level. Less than 6 h after she was first noted to be paraplegic, the patient underwent a T4 laminectomy. More than 20 ml of pus were evacuated from the epidural space. Rubber catheters (8 Fr.) were inserted rostrally and caudally into the spinal canal and were brought out through a separate skin incision. The laminectomy incision was closed primarily. The epidural space was irrigated every 6 h with a solution containing cloxacillin (1 g/100 ml) which was instilled through the catheters. The catheters were removed after 5 days. The patient received flucloxacillin (1 g/d) parenterally for 10 days and then orally for 4 weeks. A myelogram on the seventh postoperative day was normal. The patient gradually regained lower extremity strength and bowel and bladder continence. Two months after laminectomy she was fully ambulatory, and motor, sensory and reflex examinations were normal.
Discussion No spinal cause of acute abdominal pain in children was encountered in a recent clinical series reported by Jones (1976) or in an earlier one reported by Winsey and Jones (1967). However, Cope (1972) notes that abdominal pain is a frequent symptom of vertebral osteomyelitis in children and he advocates inspection and palpation of the spine in those cases of abdominal pain in which diagnosis remains in doubt. The relatively high incidence of laparotomy in spinal diseases that present atypically with major abdominal complaints probably indicates that this suggestion is
* Neurosurgical Unit, Plymouth General Hospital. Correspondence to: G. W. Tyson, Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA.
G. W. Tyson et al.
often overlooked (Sullivan and Symmonds, 1964; Watkin, 1970). Suspicion should be raised by even minor symptoms that are not typical of intra-abdominal disease. For example, our patient complained of anterior thigh pain and paraesthesias, which were probably due to inflammation of upper lumbar nerve roots. She also had a persistent headache, which is common with spinal epidural abscess (Heusner, 1948; Baker et al., 1975) but is infrequent with intra-abdominal disease (Winsey and Jones, 1967). Urinary incontinence (or retention) often adumbrates motor and sensory paralysis, which may occur abruptly and then be only partially reversible. In addition to spinal tenderness, examination during the pre-paralytic phase of spinal cord compression often discloses hyperactive reflexes in the lower extremities and extensor plantar reflexes. Diagnosis and treatment during the pre-paralytic phase are of critical importance since the degree of residual functional impairment is directly related to the degree and duration of the preoperative neurological deficit (Heusner, 1948). Spinal epidural abscess and intra-abdominal sepsis may occasionally coincide since infection may spread haematogenously via veins that connect the epidural space with the thoracoabdominal wall and with the retroperitoneum (McLaurin, 1967). In addition, an epidural abscess may extend through intervertebral foramina and along spinal nerves to produce a perinephric abscess (Stammers, 1938). I n this case, however, laparotomy excluded these possibilities. Therefore, the patient’s signs and symptoms were probably referable to disturbances in the innervation of the abdominal wall and viscera. Abdominal pain, rigidity and local tenderness may be caused by inflammation of the lower thoracic nerve roots which supply the abdominal wall (Sullivan and Symmonds, 1964). These signs and symptoms are more commonly due to visceroparietal reflexes which are caused by visceral dysfunction. Intraspinal disease may not only enhance these reflexes (Ashby, 1977) but may also produce a ‘spinal ileus’ which initiates them (Watkin, 1970). This syndrome of colicky abdominal pain
associated with gaseous distension of the bowel and variable changes in bowel sounds may be encountered in a variety of spinal lesions, including fractures, herniated intravertebral discs and spinal cord infarcts (Watkin, 1970). The pathogenesis of this syndrome remains unclear, but probably involves an acute imbalance between the sympathetic and vagal innervations of the bowel (Morton et al., 1960).
Acknowledgement We wish to thank Dr M. A. Voyce, Consultant Paediatrician, who kindly referred this case to us.
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Paper accepted 22 June 1978.