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Stan L. Block, MD, FAAP, is Professor of Clinical Pediatrics, University of Louisville, and University of Kentucky, Lexington, KY; President, Kentucky Pediatric and Adult Research Inc.; and General Pediatrician, Bardstown, KY.
Disclosure: Dr. Block has no relevant financial relationships to disclose.
Practical advice for treating newborns and toddlers.
In everyday practice, pediatricians routinely encounter congenital midline coccygeal and sacral dimples (Figures 1-6 ). These cutaneous coccygeal and sacral stigmas, most of which are below the intragluteal crease, occur in as many as 4.8% of all children.1 Yet the incidence of the "true" problematic lesions related to these dimples, such as spinal dysraphism, is only about 1 in every 2,500 births; spinal lipoma, which occurs in 1 of 4,000 births; and dermal sinuses, which occurs in 1 of 2,500 births.2 More importantly, as explained below, the more common coccygeal dimples seem to be uniformly benign. So, what is all the fuss about? And why are so many babies undergoing expensive evaluations?
Unfortunately, another study of nearly 2,000 consecutive neonates found that as many as 3% were observed to have a significant paraspinal abnormality above the intergluteal crease.3 These findings are among the more worrisome observations, and definitely require further evaluation. However, this high incidence for abnormal sacral dimples seems to be relegated merely to this one study from 40 years ago. Additionally, practitioners seem to be lumping together the rates from each dimple region -- those above (worrisome) with those below (usually innocuous) the intergluteal crease.
Therefore, apparently many practitioners feel compelled to further evaluate the mere simple dimple in the sacro-coccygeal area, at least by ultrasound in most of these children. During their training, they have been instilled with a persuasive fear that these sacro-coccygeal dimples may be the only manifestation of an occult spinal dermal sinus tract, tethered cord, spinal dysraphism, etc. Once they decide to perform the additional imaging, they must then explain their fear to the family in order to obtain permission to perform the test.
If as many as 4.8% of normal infants have this physical manifestation of the coccyx area, these usually unnecessary evaluations can become very expensive for the family, as well as from a public health perspective. The potential clinical ramifications for the infant also become manifested...