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Sacral dimple guidelines

Experiment Findings · August 2022

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Elsayed Ibrahim Salama

Weill Cornell Medical College Qatar....Menoufyia university Egypt
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APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 1of 7

1. PURPOSE (AIM):
a) Introduction of a standardized protocol for infants born with sacral dimple.
b) To aid medical and midwifery staff to correctly identify those babies with a sacral dimple
that requires further investigation.
c) To enhance detection of both typical and atypical sacral dimple.
d) To ensure early diagnosis and timely management of underlying occult spinal
dysraphism or neural tube defects if there.

2. DEFINITION:
Sacral dimple defined as shallow or deep depressions occurring at the lower sacral region
close to or within the natal cleft. Sacral dimples, also known as sacrococcygeal or
coccygeal dimples or pits.

3. APPLIES TO: Physicians, Nurses, Midwifes.

4. PATIENT GROUP: All neonates

5. EXCEPTIONS: Nill

6. TARGET AREAS: NICU, Postnatal Wards, PHCC

7. GUIDELINES:

7.1 Introduction:
Simple sacral dimples are intergluteal pits, located below the top of a symmetrical
intergluteal crease. Sacral dimples, also known as sacrococcygeal or coccygeal dimples
or pits, they are the commonest cutaneous anomaly detected at neonatal spinal
examination. They are 2-4% of births, and are susceptible to local infection or
hirsutism, but not to pilonidal sinuses.

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APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 2of 7

7.1.1 Atypical Sacral Dimple: Not in midline, not in sacrococcygeal region, >5 mm deep, >2.5cm
from anal verge, multiple dimples, Skin lesions and Associations (duplicate gluteal cleft,
asymmetrical intergluteal crease, skin tag, tail like appendages, hairy tuft, pigmentation,
fatty lump, vascular lesions, atretic meningocele, dermal sinus, scar like lesion), +ve
neurological signs ( Weakness, spasticity; difficult to demonstrate in neonate).

7.1.2 Atypical dimples are associated with other findings and high risk for spinal dysraphism:
- Other cutaneous Findings: hypertrichosis, capillary hemangioma, atretic
meningocele, subcutaneous mass –e.g., (lipoma, caudal appendage), dermal sinus
as sinuses opening into skin surface.
- Orthopedic findings; Clubfeet, arthrogryposis of the lower extremities, hip
dislocation, abnormal curvature of the spine.
- Congenital abnormalities:
 CEARMS: Cloacal Exstrophy, Ano-rectal Malformation Spectrum.
 Genitourinary abnormalities.
 VACTERL: Vertebral, Anorectal, Cardiovascular, Trachea Esophageal fistula
Renal and Limb anomalies.

NB: Dermal sinus tracks may seem to be atypical dimples.

7.2 Differential Diagnosis & Pitfalls (Neonatal atrophic skin lesions):

 Intrauterine viral infections such as varicella
 Anetoderma of prematurity
 Genetic diseases (eg., focal dermal hypoplasia)
 Aplasia cutis.

Quality Improvement and Patient Safety (QPS) Quality Management Department

Regulatory & Accreditation
APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 3of 7

7.3 Occult spinal dysraphism (OSD):

7.3.1 The cutaneous syndrome in OSD:

 Patch of hyperkeratosis, hyperpigmentation, epidermal atrophy

 SC mass (lipoma or neurofibroma), Caudal cutaneous appendage (true tail
or pseudotail)
 Capillary hemangioma or cutaneous angioma
 Dorsal dermal sinus, Sacrococcygeal pit, Sacrococcygeal dimple
 Isolated deviation of the intergluteal fold

7.3.2 Why look for OSD ?

 3-8% of patients with significant skin lesions over the spine will have an underlying OSD.
Combinations of 2 or more cutaneous lesions are the highest indicator of OSD.
 When OSD is the primary finding at least 50% are associated with cutaneous marker.
 If untreated OSD can lead to neurological sequelae in the lower limbs, urinary and
bowel symptoms
 In Tethered Cord syndrome, cord traction due to growth may lead to progressive cord
ischemia.

7.4 Management:
In the newborn child, isolated midline sacral dimples and small pits can be safely
ignored. US of the neonatal lumbar spine is the investigation of choice; atypical dermal
dimples may warrant referral to a neurosurgeon and usually need examination by
MRI. Biopsy is not indicated with typical or atypical dimples.

In atypical sacral dimple: Arrange for a Urinary Tract Ultrasound at one month of age,
irrespective of spinal ultrasound finding.

Quality Improvement and Patient Safety (QPS) Quality Management Department

Regulatory & Accreditation
APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 4of 7

7.4.1 Sacral dimples (atypical dimples) requiring spinal Ultrasound:

1. Large (>5mm) or high (>2.5cms from anus).

2. Associated with any of the followings: skin tag/ fatty lump/ birth mark / hairy patch /
pigmentation / dermal sinus/ hemangioma.
5. Asymmetrical intergluteal crease.

Advantage of ultrasound:
 First line investigation, to identify bone anomalies.
 Best undertaken within 3 months of age, generally earlier the better. After 6 months
not possible as spinal ossification occurs, and quality of examination becomes very
poor.

MRI is indicated when:

1. US is abnormal, equivocal or sometimes if normal with clinical suspicion.
2. When there are neurological signs: eg., Paraplegia, Spasticity.
3. When there is a discharging lesion (eg., fistulae).

Advantage of MRI:
• Better visualization of bony structures.
• Identify fusion defects and segmentation anomalies such as hemivertebra.

Quality Improvement and Patient Safety (QPS) Quality Management Department

Regulatory & Accreditation
APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 5of 7

Neonatal Sacral Dimple Guidelines

Atypical Sacral Dimple * Typical or Simple Sacral Dimple

Single skin lesion, < 5 mm deep, 2.5
cm from anal verge, no other
cutaneous signs within or around the
US spine: lesions, no neurological signs.
- Abnormal
- Equivocal
- Normal ?
Yes

- MRI examination - Reassurance

- Parental counseling - No Ultrasound
£
- Referral to neurosurgeon

Notes:
* Atypical Sacral Dimples:
1. Large (>5mm) or high (>2.5cms from anus).
2. Associated with any of the followings: skin tag/ fatty lump/ birth mark / hairy patch / pigmentation /
dermal sinus/ hemangioma.
3. Asymmetrical with intergluteal crease.
4. Associated with neurological signs.
* In atypical sacral dimple: Arrange for a Urinary Tract Ultrasound at one month of age, irrespective of
spinal ultrasound finding.
? MRI to be done if there is clinical suspicion, even with normal ultrasound.
£
Careful neurological examination in lower limb: tone, deep tendon reflexes, patulous anus etc.

Quality Improvement and Patient Safety (QPS) Quality Management Department

Regulatory & Accreditation
APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 6of 7

7.5 REFERENCES:
1. Ackerman LL, Menenzes AH. Spinal Congenital dermal sinuses: a 30 year experience. Pediatrics
2003; 112: 641-647
2. ACW Lee, NS Kwong, YC Wong; Management of Sacral Dimples Detected on Routine Newborn
Examination: A Case Series and Review. HK J Paediatr (New Series) 2007; 12: 93-95.
3. Albert GW. Spine ultrasounds should not be routinely performed for patients with simple sacral
dimples. Acta Paediatr 2016; 105: 890.
4. Eichenfield LF, Lee PW, Larralde M, Luna P. Neonatal skin and skin disorders. In: Schachner LA,
Hansen RC, Krafchik BR, eds. Pediatric Dermatology. 4th ed. Edinburgh: Mosby Elsevier; 201:
323-326.
5. Helen Williams. Spinal Sinuses, Dimples, Pits and Patches: What lies beneath? Archives Diseases
Child Educ Pract Ed 2006; 91:ep75-ep80.
6. Kriss VM, Desai NS. Occult spinal dysraphism in neonates: assessment of high-risk cutaneous
stigmata on sonography. AJR Am J Roentgenol. 1998 Dec; 171(6): 1687-1692.
7. McGovern M, Mulligan S, Carney O, et al. Ultrasound investigation of sacral dimples and other
stigmata of spinal dysraphism. Arch Dis Child 2013; 98: 784.
8. Pediatrics in Review vol 32 no 3 March 2011 (copyright by the American Academy of Pediatrics).
9. Radic JA, Cochrane DD. Choosing Wisely Canada: Pediatric Neurosurgery. Paediatr Child Health
2018; 23: 282.
10. Sacral Dimple-Neonatal Postnatal Clinical Guidelines-King Edward Memorial Hospital. October
2014: 1-3.
11. Sacral Dimple- Neonatal Guideline-Royal Cornwall Hospital NHS Trust September 2016: 1-7.
12. Schropp C: Sorensen N, et al. Cutaneous lesions in occult spinal dysraphism- correlation with
intraspinal findings. Childs Nerv. System 2006; 22: 125-131.
13. Senayli A, Sezer E, Sezer T, et al. Coexistence of sacral dimple, solitary collagenoma and mid-
dorsal hypertrichosis in a child with occult spinal dysraphism. Br J Dermatol. 2007 May; 156(5):
1065-6.
14. Warder DE: Tethered Cord Syndrome and Occult spinal dysraphism. Neurosurg. Focus 2001; 10:
1-9.
15. Wong JH, Wong GK, Zhu XL, Chan YL, Fung E, Poon WS. Cervical meningocele with tethered
cervical cord in a Chinese infant. Hong Kong Med J 2005; 11: 113-5.

Quality Improvement and Patient Safety (QPS) Quality Management Department

Regulatory & Accreditation
 APPENDIX B-1
CLINICAL PRACTICE GUIDELINE

TITLE: Guidelines of Sacral Dimple in Neonate ORIGINAL DATE:

IDENTIFICATION LAST REVISION DATE:

NUMBER: 01/01/2021
HOSPITAL(S): ALL HMC HOSPITALS / ENTITIES NEXT REVIEW DATE:
01/01/2024
Sheet No. 7of 7

Authors:
Dr. Elsayed Salama
A/ Consultant, Neonatology, WWRC, HMC
A/ Professor of clinical pediatrics, WCM-Q
Corp. No. 044283

Dr. Linda Shaaban

Specialist, Neonatology, WWRC, HMC
Corp. No. 041928

Reviewed by:
Dr. Alaa El-din El-fakharany
Sr. Consultant Radiologist, WWRC, HMC
Corp. No. 016687

Dr. Azzam Alsaid

Sr. Consultant, Critical Care, WWRC, HMC
Corp. No. 000194

Approved by:
Dr. Mai Abdulla Al-Qubaisi
Senior Consultant, critical care
Deputy Director Neonatal Perinatal Medicine
Women’s Wellness and Research Centre

Quality Improvement and Patient Safety (QPS) Quality Management Department

Regulatory & Accreditation

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