Charcot spinal disease after spinal cord injury

Clinical article

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Object

The authors investigated the background, risk factors, and treatment strategies for Charcot spinal disease (CSD) after spinal cord injury (SCI).

Methods

The authors retrospectively examined the clinical and radiological findings in 9 patients with a total of 10 Charcot spine lesions that occurred after SCI. The mean age of the 9 patients was 54 years, and all patients presented with complete SCIs. In all but 1 patient, symptoms did not develop until 10 years postinjury. All 10 Charcot spine lesions were located below the thoracolumbar junction. Surgical treatment was performed in 7 patients (7 lesions), and the mean duration of postoperative follow-up was 84 months.

Results

All patients reported audible noises when changing posture, 5 of 9 patients reported low-back pain, and 7 patients displayed increasing instability while sitting. In 8 patients, spasticity disappeared and limbs became flaccid several years after SCI. Two patients had associated bacterial infections in the Charcot spine lesions, and 1 patient complained of autonomic dysreflexic symptoms associated with trunk movements. Although postoperative complications occurred in 3 patients, all patients who underwent surgical treatment made a good recovery and were able to return to daily life in a wheelchair. On lateral radiography, the mean range of motion at the lesion site was 43°, and fluid collections between the involved vertebrae were observed in 8 patients on MR images; ankylosing spinal hyperostosis was observed in 7 patients. Charcot spine lesions tended to occur at the junction between or at the end of an ankylosing spinal hyperostotic lesion. Postoperatively, solid arthrodesis was obtained within 6 months in all surgically treated lesions.

Conclusions

Disappearance of spasticity in the lower extremities is thought to be an important physical sign suggestive of CSD after SCI. Sitting imbalance and the fluid volume of the Charcot spinal lesions are related to range of motion at the lesion site. In addition to a combined approach, a single posterior approach with acquisition of anterior support is an option for surgical treatment even in cases of infected CSD.

Abbreviations used in this paper: ASH = ankylosing spinal hyperostosis; CSD = Charcot spine disease; MRSA = methicillin-resistant Staphylococcus aureus; ROM = range of motion; SCI = spinal cord injury; VB = vertebral body.

Article Information

Address correspondence to: Masahiro Morita, M.D., Department of Orthopaedic Surgery, Izumi City Hospital, 4-10-10 Fuchu, Izumi City, Osaka, 594-0071, Japan. email: m1908130@msic.med.osaka-cu.ac.jp.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 5. Images obtained in a 55-year-old man with a 36-year history of paraplegia at T-12. He had a large fluid collection within the Charcot spinal lesion communicating with the subcutaneous cyst in the back; MRSA was detected on smear culture. Although nonsurgical treatments such as antibiotic therapy and debridement of subcutaneous fistula in the back were performed for 1 year, the infection did not resolve. Anterior debridement and fusion followed by posterior instrumentation was performed. A: Lateral radiograph obtained with the patient in a sitting position. B: Extension radiograph demonstrating gross instability of the segment and absence of a large portion of the L-2 VB between ankylosing spinal hyperostotic lesions. C: Enhanced CT scan showing a subcutaneous cyst in the back with ring enhancement (arrow). D: Photograph of a fistula on the patient's back (arrow). E: Lateral radiograph obtained 9 years postoperatively demonstrating solid arthrodesis.

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    Case 8. Anteroposterior radiograph (A), lateral radiograph obtained with the patient in a sitting position (B), and lateral extension radiograph (C) demonstrating giant ball-and-socket appearance and dislocation between the L-3 and L-4 vertebrae.

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    Case 2. A: Lateral radiograph in extension showing a giant cavity between L-2 and L-3. B: T2-weighted MR image demonstrating a large volume of fluid collection replacing the disc space within the lesion (arrow), and low intensity of adjacent VB margins. C: Lateral radiograph obtained 5 years postoperatively showing solid arthrodesis.

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    Case 7. Images obtained in a 73-year-old man with a 33-year history of L-1 paraplegia. Because the subcutaneous cyst in the back had not ruptured, needle biopsy of the lesion was performed and MRSA was detected. Nonsurgical treatment with antibiotics for 2 years did not have an effect on the infection. Anterior debridement and fusion through a single posterior approach followed by posterior instrumentation was preformed. A: Lateral radiograph obtained with the patient in a sitting position showing progressive destruction of the lesion and absence of a large portion of the L-5 VB. B: T2-weighted MR image demonstrating destruction at the L5–S1 interspace and fluid collection within a lesion communicating with the subcutaneous cyst in the patient's back. C: Lateral radiograph obtained 7 years postoperatively showing solid arthrodesis with an interbody fibular strut graft.

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