Complications in the management of Charcot spinal arthropathy

Resection of hip heterotrophic ossification leads to resolution of autonomic nervous system dysfunction in a patient with spinal Charcot arthropathy: a case report

INTRODUCTION

Patients with complete spinal cord injury (SCI) may develop concurrent sequalae that interact and share symptoms; thus, a careful approach to diagnosis and management of new symptoms is crucial.

CASE PRESENTATION

A patient with prior T4 complete SCI presented with progressive autonomic nervous system (ANS) dysfunction. The initial differential diagnosis included syringomyelia and lumbar Charcot arthropathy. He had comorbid heterotopic ossification (HO) of the left hip. Surprisingly, his autonomic symptoms resolved following resection of the HO. In hindsight, loss of motion through the hip caused by HO may have led to hinging through a previously asymptomatic lumbar Charcot joint, causing dysautonomia.

DISCUSSION

ANS dysfunction is a disabling sequela of complete SCI and has a broad differential diagnosis. Hip immobility may be an indirect and overlooked cause due to the mechanical relationship between the hip and the lumbar spine.

Case 234: Neuropathic Spondyloarthropathy

History A 70-year-old woman presented to a peripheral hospital with signs and symptoms of acute chronic obstructive pulmonary disease (COPD) exacerbation. The patient also reported acute on chronic onset of thoracolumbar back pain over a period of 24 hours. She denied any history of recent trauma or intravenous drug use. She did not have any long-term indwelling catheters. The patient's medical history was also complicated by stage 4 renal failure from long-standing type II diabetes, hypertension, iron deficiency anemia, aortic stenosis, and prior bariatric surgery. The patient was not undergoing dialysis for her renal dysfunction, nor was she receiving steroids for COPD. On clinical examination, she was afebrile and tachypneic. Although she was not amenable to a full neurologic examination, she reported subjective leg weakness. There were no localizing signs or evidence of myelopathy. Perianal sensation and rectal tone were preserved. Pulmonary examination revealed wheezes and decreased basilar air entry. The patient's white blood cell count was 6.8 × 10(9)/L. Her blood chemistry was normal, aside from an elevated blood creatinine level of 158 mmol/L. Her erythrocyte sedimentation rate was elevated at 56 mm/h, and her C-reactive protein level was normal at 4.4 mg/L (41.9 nmol/L). Chest radiographs showed mild pulmonary edema with a small right pleural effusion. The patient was transferred to our facility for evaluation of findings on thoracic spine radiographs obtained at a peripheral hospital. Unenhanced thoracic spine magnetic resonance (MR) imaging was performed first and was followed by computed tomography (CT) to further delineate the findings. The patient's renal status precluded intravenous contrast material administration.

Perioperative complications associated with spine surgery in patients with established spinal cord injury

BACKGROUND CONTEXT

Only a small percentage of patients with spinal cord injury (SCI) require consideration for reconstructive surgery after their initial injury. For those who do, perioperative complications can be frequent and significant. There has been very little published literature examining treatment of these patients and essentially nothing to guide the surgeon in perioperative decision making and management.

PURPOSE

To identify some of the common challenges associated with surgery in this patient population and review the literature to highlight the perioperative concerns in patients with chronic SCI.

STUDY DESIGN

Review article.

METHODS

A primary PubMed literature search was performed and reviewed for patients with chronic SCI with emphasis on the complications and difficulties encountered during surgical treatment of patients with chronic SCI.

RESULTS

For those who do proceed with surgery in this patient population, preoperative nutrition, bone density, and skin should be evaluated and optimized. Preoperative inferior vena cava filters should be considered. The integrity of the reconstruction will be extensively challenged. In addition, augmented fixation and bracing should be contemplated.

CONCLUSIONS

Patients with chronic SCI who require spinal reconstruction provide many unique challenges. Indications for surgery must be strong as perioperative complications can be frequent and long-term outcomes unpredictable. Close monitoring for postoperative complications is essential.

Beyond broken spines-what the radiologist needs to know about late complications of spinal cord injury

OBJECTIVE

To describe expected imaging findings to assist the emergency room radiologist with recognising complications and pathology unique to the spinal cord injury (SCI) patient population to ensure rapid and accurate diagnosis.

METHODS

Pictorial review.

RESULTS

We review several imaging findings common to persons with chronic SCI, emphasising imaging in the emergency setting and on CT.

CONCLUSION

SCI patients present a unique diagnostic challenge, as they may present with symptoms that are difficult to localise because of abnormal sensation and autonomic instability. Imaging plays an important role in the emergent setting, rapidly differentiating the most commonly encountered complications from less common, unanticipated complications. Radiologists need to be attuned to both the expected findings and potential complications, which may be unique to SCI patients, to ensure accurate diagnosis and treatment in the emergency setting.

MAIN MESSAGES

• Medical complications after spinal cord injury are common and associated with significant morbidity. • Radiologists should be aware of complications unique to the SCI population to aid diagnosis. • Due to abnormal sensation, SCI patients often present with symptoms that are difficult to localise. • In the ED, imaging helps to rapidly differentiate common complications from less anticipated ones.

Sitting imbalance cause and consequence of post-traumatic Charcot spine in paraplegic patients

PURPOSE

To analyze the role of spine alignment in post-traumatic paraplegic patient as a potential cause of late Charcot spine disease (CSD).

METHOD

A retrospective review of three cases in which the disease appeared more than 15 years after a spinal cord injury treated by posterior fusion. A review of the literature concerning spine balance in sitting position, especially referred to paraplegic patients, is done to validate this hypothesis.

RESULTS

Lumbar kyphosis in paraplegic patients during the sitting position may increase the mechanical load on disks and ligament below the previously fused area. This phenomenon, in combination with lack of protective mechanism because of poor muscular support and lack of sensitivity can speed up and amplify the normal degenerative changes in the disk and ligaments.

CONCLUSIONS

More investigations are required to fully understand all the mechanisms underlying CSD pathogenesis to prevent it. Until then, a systematic long-term clinical and radiological follow-up in all post-trauma paraplegic patients is suggested. Combined anterior and posterior fusion, when feasible, can restore the sagittal balance providing a better quality of life in these patients.

Surgical management of Charcot spinal arthropathy: a single-center retrospective series highlighting the evolution of management

OBJECT

Charcot spinal arthropathy (CSA) is an uncommon disorder that occurs in the setting of conditions with decreased protective sensation of the vertebral column, resulting in vertebral joint degeneration, pain, and deformity. Historically, CSA treatment has been fraught with high failure rates. Over time, the authors' institution has trended toward a CSA treatment paradigm of intralesional debridement, circumferential fusion, and four-rod lumbopelvic fixation. As such, the overall objectives of this study were to define the specific clinical characteristics of this rare condition and to determine whether the authors' treatment paradigm has decreased the incidence of revision due to hardware failure/presumed pseudarthrosis or the development of a new CSA over the course of the study and in comparison with historical controls.

METHODS

The authors performed a retrospective review of the clinical and radiographic records for all patients with CSA treated by the Spine Service at the University of Washington between 1997 and 2009.

RESULTS

Twenty-three patients with CSA were identified. The mean age at presentation was 43.1 years, and the mean latency between spinal cord injury and CSA diagnosis was 19.6 years. The mean follow-up was 33.1 months. Pain and progressive deformity were the major presenting symptoms. Concomitant infection was identified in 17% of patients. Patients with CSA were noted to have long initial fusion constructs spanning an average of 8.4 vertebral levels. Charcot spinal arthropathy did not occur above the level of neurological injury. The vast majority of CSA cases occurred caudally along the spinal axis, with 65% occurring within 1 level of the caudal end of the index fusion construct and 35% occurring even farther distally. Revision due to hardware failure or the development of a new CSA level occurred in 35% of patients. Rates of treatment failure requiring revision significantly decreased over the course of the study, with revision occurring in 6 (66%) of 9 patients who underwent surgery before 2002, in comparison with only 2 (14%) of 14 treated between 2002 and 2009. During a mean follow-up period of 34 months, no treatment revision occurred in the subgroup of 9 patients who underwent four-rod lumbopelvic fixation.

CONCLUSIONS

This study represents the largest reported modern surgical series of CSA patients. While revision rates were initially high and comparable to previous reports, the authors' multimodal treatment paradigm, which includes the use of bone morphogenetic protein and four-rod lumbopelvic fixation, dramatically reduced the incidence of treatment failure requiring revision over the course of the study period and represents a significant improvement in the treatment of CSA.