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Radiological Case of the Month
Don Seidman, MD
From Elmhurst Pediatrics of the DuPage Medical Group, Elmhurst, Ill.
Arch Pediatr Adolesc Med. 2000;154:415-416.
A PREVIOUSLY healthy 8-year-old boy with no history of trauma was seen during influenza season with a temperature of 100° to 104°F and lower back pain of 4 days' duration, which woke him at night. On examination, he had tense paraspinal muscles with absence of normal lumbar lordosis and normal findings from neurological examination. Possible diagnoses included myositis or possible discitis. Findings from laboratory tests included white blood cell count, 9.9 x 109/L; neutrophils, 0.83; lymphocytes, 0.09; monocytes, 0.06; basophils, 0.02; erythrocyte sedimentation rate, 50 mm/h; aldolase, 5.8 U/L (reference range, 1.2-8.8 U/L); and creatine phosphokinase, 56 U/L. Because of the elevated erythrocyte sedimentation rate and lack of muscle enzyme elevation, a lumbar spine magnetic resonance imaging (MRI) scan was obtained (Figure 1) and showed enhancement and an increased T2-weighted signal in the paraspinal muscles, with normal findings in the vertebral bodies and discs.
The following day the pain persisted, and findings from examination were unchanged. Findings from urinalysis and complete blood cell count were normal. A computed tomographic scan of the abdomen showed paraspinous muscle enhancement (Figure 2). A possible parenchymal infiltrate was identified in the left lung base. Treatment with cefuroxime sodium was begun. The pain persisted, and erythrocyte sedimentation rate on the second day of admission was 81 mm/h. Creatine phosphokinase levels were 24 U/L. Antinuclear antibodies and rheumatoid factor titers were both below 1:20. A blood culture did not grow organisms. Gradually, the paraspinal tenderness decreased and localized point tenderness was established over lumbar vertebra 3. Another MRI of the spine was obtained (Figure 3).
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Figure 1.
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Figure 2.
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Figure 3.
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Denouement and Discussion: Spinal Epidural Abscess
Figure 1. Edema of the posterior paraspinal muscles is shown on axial T2-weighted image.
Figure 2. Enhancement of the posterior paraspinal muscles is seen on axial computed tomographic scan following intravenous contrast administration.
Figure 3. An epidural abscess with inflammatory change extending into the posterior paraspinal muscles is shown on sagittal (top) and axial (bottom) T1-weighted magnetic resonance images of the lumbar spine following intravenous gadolinium administration.
A repeated lumbar MRI (Figure 3) showed a large epidural abscess with erosion into the paraspinal muscles. The child was transferred to a tertiary care hospital for surgical drainage and has completely recovered. Staphylococcus aureus was grown from a culture specimen obtained directly from the abscess.
Spinal epidural abscess is rare in childhood. In this case, findings from the initial MRI and computed tomographic scan were confusing as the pus decompressed into the paraspinal muscles, resulting in a secondary pyomyositis. Rubin et al1 reviewed spinal epidural abscess in 1993, and they note that childhood spinal epidural abscess is usually of hematogenous origin, and S aureus is the usual etiologic agent (79% of all cases). It is seen more often in patients younger than 2 years or older than 12 years. The symptoms differ according to age. In a child younger than 2 years, neurological compromise at presentation is common. Older children often are seen for back pain and fever, although abdominal and hip pain are also presenting signs. The outcome correlates with the presence or absence of neurological signs at presentation. The definitive treatment is surgical drainage and antibiotic administration.
Obtaining an MRI is the diagnostic method of choice, although negative findings from MRI cannot exclude spinal epidural abscess.2 Most false-negative MRI findings seem to be secondary to motion artifact or adjacent similar-signal intensity from coexistent meningitis. To my knowledge, drainage into adjacent muscle groups, as in this case, has not been described in the literature.
AUTHOR INFORMATION
Accepted for publication October 20, 1998.
Corresponding author: Don Seidman, MD, Elmhurst Pediatrics of the DuPage Medical Group, 103 Haven Rd, Elmhurst, IL 60126.
REFERENCES
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1. Rubin G, Michowiz SD, Ashkenasi A, Tadmor R, Rappaport ZH. Spinal epidural abscess in the pediatric age group: case report and review of the literature. Pediatr lnfect Dis J. 1993;12:1007-1011.
2. Jacobsen FS, Sullivan B. Spinal epidural abscess in children. Orthopedics. 1994;17:1131-1138.
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