What is the management of a pseudo sinus tract in a newborn with a sacral pit?

Management of Sacral Dimples in Newborns

The management of a sacral dimple in a newborn should be determined by its location, with dimples located above an imaginary line connecting the tops of the gluteal cleft requiring imaging and surgical evaluation, while those at or below this line are typically benign and require no further workup. 1

What is a Pseudo Sinus Tract?

A pseudo sinus tract is a dermal sinus tract that appears to connect to deeper structures but is actually blind-ending or superficial. It differs from a true dermal sinus tract which creates an actual connection between the skin surface and deeper neural structures.

Assessment of Sacral Dimples

Location is Critical

• High-risk location: Dimples located on the flat part of the sacrum, cranial to the gluteal cleft 1
• Low-risk location: Dimples located within the gluteal cleft, within about 1 cm of the coccyx 1

Associated High-Risk Features

• Cutaneous markers surrounding the dimple:
  • Vascular anomalies
  • Tufts of hair (hypertrichosis)
  • Skin tags
  • Subcutaneous masses (especially lipomas)
  • Infantile hemangiomas
  • Deviated or forked gluteal cleft 1

Management Algorithm

For Low-Risk Sacral Dimples (at or below gluteal cleft line):

1. Document location in medical record
2. No further imaging or workup needed
3. Routine follow-up with primary care provider
4. Educate parents about normal hygiene practices

For High-Risk Sacral Dimples (above gluteal cleft line) or Those with Associated Cutaneous Markers:

1. Immediate referral for imaging (ultrasound in infants with open fontanelles, MRI for older infants)
2. Neurosurgical consultation
3. Consider surgical exploration and correction if:
   • Imaging reveals connection to deeper structures
   • Signs of tethered cord are present
   • Evidence of spinal dysraphism is found 2, 1

Potential Complications of Untreated Pathologic Dimples

• CNS infection
• Aseptic meningitis
• Spinal cord compression
• Neurologic deterioration
• Paraspinal or subdural abscess 1, 3

Important Clinical Pearls

• The visibility of the bottom of the dimple has little correlation with its pathologic nature - location is far more important 1
• Infection is the most feared complication of pathologic dimples, as it creates intradural scarring that complicates surgical correction 1, 4
• Even low-lying sacral dermal sinus tracts may require early surgical intervention as they can lead to extensive spinal abscesses 4
• A pseudo sinus tract may be associated with tethered cord requiring surgical intervention despite appearing superficial 5

Follow-up Recommendations

• For low-risk dimples: routine well-child care
• For high-risk dimples after evaluation:
  • If normal imaging and no intervention needed: yearly neurological assessment until age 3
  • If surgical intervention performed: follow neurosurgical recommendations for post-operative care

Remember that early identification and appropriate management of high-risk sacral dimples can prevent serious neurological complications and improve long-term outcomes for affected infants.