Epidural cervical abscess in a neonate

Abstract

Spinal epidural abscess (SEA) has an incidence of 0.2–1.2 per 10000 hospital admissions and is particularly rare in neonates and infants [6]. It can be potentially devastating, thus prompt diagnosis is essential for a good outcome. A 3-week-old infant boy, who was born after an uneventful pregnancy and delivery, was admitted to our hospital due to progressively decreasing movement of the upper limbs, which had been first noticed 1 week prior to admittance. During this time, he had a brief febrile episode. Upon admission he was irritable, with a tympanic temperature of 37.4°C. Paresis and areflexia of both arms were found, but finger movements were still present in the right arm. No other abnormalities were found upon clinical examination. Laboratory tests showed a slightly elevated level of C-reactive protein (16) and a white blood cell count of 10,400 cells/mm. There was an elevated protein level (1.32 g/L) and pleocytosis (51) in the cerebrospinal fluid (CSF). The blood, CSF and urine cultures were found to be microbiologically negative. Magnetic resonance imaging (MRI) of the cervical spine revealed discitis at level C4/C5 and anterior epidural and prevertebral abscesses (Fig. 1a). The boy was immediately operated on using an anterior approach to C4/C5: after the incision of a glossy, bulging anterior longitudinal ligament, yellowish pus was released and washed-out. Particles of the intervertebral disc C4/C5 were removed and the intervertebral space was enlarged by a bone spreader and irrigated with antibiotics. The postoperative course was uneventful. Beta haemolytic streptococci were grown on culture. Systemic antibiotic therapy with ampicillin, clindamycin and gentamicin was started before surgery and continued for 3 weeks. The boy recovered without any sequaelae. No abnormalities were found on clinical or neurological examination 2 months after surgery. His development was normal on follow-up 2 and 13 months later. MRI 2 months postoperative revealed a complete resolution of the abscess and no abnormalities in the cervical spine or spinal cord (Fig. 1b). While in adults a classic clinical course of SEA with back pain, spinal root pain, paresis and paralysis is obvious, the presentation in infants is unspecific. The localising signs of a SEA are related to the anatomical configuration of the epidural space, which dorsally contains a relatively large amount of areolar tissue and a rich venous plexus, therefore providing an available focus for infection, which may reach the epidural space by direct extension from local vertebral osteomyelitis or by hematogenous spreading [1, 3]. The most frequently isolated etiologic agent is Staphylococcus aureus. Streptococcus sp., Candida and coliform bacteria have also been reported [4]. MRI is considered to be the investigation methodology of choice. Gadolinium-enhanced images have increased the sensitivity of MRI for infectious processes. Our experience shows that early recognition and a combination of surgical intervention and antibiotic therapy provides excellent results, although a good outcome without surgical intervention has been reported [2, 5]. D. Paro-Panjan (*) Neonatal Unit, Division of Pediatrics, University Medical Centre, 1000 Ljubljana, Slovenia e-mail: darja.paro@volja.net Tel.: +386-1-5229274 Fax: +386-1-5229357