Management of Sacral Dimples in Neonates

Assessment and Diagnosis

A dimple at or below an imaginary line drawn between the tops of the gluteal cleft is considered a normal coccygeal dimple and requires no further workup or treatment, as recommended by the American Academy of Pediatrics 1, 2
A dimple located above this line is considered a lumbosacral dermal sinus tract and requires further evaluation, according to the American Academy of Pediatrics 1, 2
Examine for associated cutaneous manifestations that increase risk of spinal dysraphism, including vascular anomalies, tufts of hair, skin tags, and subcutaneous masses, as suggested by the American Academy of Pediatrics 1, 2

Spinal ultrasonography is recommended as the initial imaging study for infants under 6 months of age with lumbosacral dimples or those with concerning features, as recommended by the American College of Radiology 3
MRI is indicated when ultrasonography reveals abnormal findings, or when there is high suspicion for spinal abnormalities despite normal ultrasonography, according to the American Academy of Pediatrics 4
MRI is also indicated in cases of associated markers of dysraphism, bowel and bladder dysfunction, or lower limb upper motor neuron signs, as recommended by the American Academy of Pediatrics and the American College of Medical Genetics and Genomics 4, 5

Potential complications of untreated pathologic dermal sinus tracts include CNS infection, aseptic meningitis, spinal cord compression, and neurologic deterioration from tethering, as reported by the American Academy of Pediatrics 1, 2
The American Academy of Pediatrics recommends avoiding outdated approaches, such as relying on visibility of the base of the dimple to determine if it's pathologic, and instead using location and associated findings to guide decision-making 1, 2