Where do you refer a baby with a sacral dimple?

Referral Pathway for Infants with Sacral Dimples

Babies with sacral dimples located above an imaginary line connecting the tops of the gluteal cleft should be referred to a pediatric neurosurgeon for evaluation, while those with dimples below this line (coccygeal dimples) require no further workup or referral. 1

Assessment of Sacral Dimples

Location-Based Evaluation

• Determine if the dimple is a true lumbosacral dimple (pathologic) or a coccygeal dimple (benign) based on anatomical location 1:
  • Draw an imaginary line between the tops of the two forks of the gluteal cleft
  • Dimples at or below this line are normal coccygeal dimples (no referral needed)
  • Dimples above this line on the flat part of the sacrum are lumbosacral dimples (require referral) 1

Associated Findings Requiring Immediate Referral

• Presence of any of these additional findings warrants prompt referral to a pediatric neurosurgeon 1:
  • Surrounding cutaneous manifestations (vascular anomalies, hemangiomas)
  • Tufts of hair emerging from the dimple
  • Skin tags near the dimple
  • Subcutaneous masses or dermoid cysts
  • Deviated gluteal cleft

Referral Guidelines

When to Refer to Pediatric Neurosurgeon

• All infants with lumbosacral dimples (above the gluteal cleft line) 1
• Any infant with a sacral dimple plus associated cutaneous findings 1
• Cases with suspected dermal sinus tract (DST) 1

Urgency of Referral

• Routine referral for isolated lumbosacral dimples without other findings 2
• Urgent referral (within 1-2 weeks) if there are concerning associated findings 1
• Emergency referral if there are signs of infection, neurological symptoms, or cerebrospinal fluid leakage 3

Clinical Significance and Outcomes

Potential Complications of Untreated Lumbosacral DSTs

• Dermal sinus tracts can lead to serious complications if not addressed 1:
  • CNS infections (meningitis, intraspinal abscess)
  • Aseptic meningitis from desquamation of epithelial cells
  • Spinal cord compression from dermoid or epidermoid cyst growth
  • Neurologic deterioration from tethering

Outcomes of Screening

• Most infants with isolated sacral dimples have benign findings on imaging 2, 4
• Studies show that 13.6-23.3% of infants with sacral dimples may have some form of spinal anomaly requiring follow-up 5
• Only approximately 0.13% of infants with simple sacral dimples ultimately require surgical intervention 4

Common Pitfalls to Avoid

• Do not rely on visibility of the dimple base ("bottom") to determine if referral is needed - this is an incorrect approach 1
• Do not confuse coccygeal dimples (benign) with lumbosacral dermal sinus tracts (pathologic) 1
• Do not delay referral for dimples with concerning associated findings, as early intervention can prevent serious complications 1, 3
• Avoid unnecessary imaging for typical coccygeal dimples, as these are benign variations 1

Remember that while most sacral dimples are benign, proper assessment of location and associated findings is crucial to identify the small percentage of cases that require specialist evaluation and potential intervention.