Major destructive asymptomatic lumbar Charcot lesion treated with three column resection and short segment reconstruction. Case report, treatment strategy and review of literature

Diagnosis behind the mask: A rare case of infected Charcot's spine

Charcot's spine is a very uncommon long-term complication of spinal cord injury. Infection of the spine is a common pathology, but infection of a Charcot's spine is rare and is challenging to diagnose, especially in differentiating between the Charcot defect and the osteomyelitis defect. Surgical reconstruction has to be extremely individualized. A 65-year-old man with a history of thoracic spinal cord injury with paraplegia 49 years ago was admitted to our hospital with high fever and aphasia. After a thorough diagnostic process, destructive Charcot's spine and secondary infection were diagnosed. This report additionally reviews the surgical management of secondary infected destructive lumbar Charcot's spine and follows the patient's recovery and postoperative quality of life.

Charcot Arthropathy of the Spine

Charcot arthropathy of the spine (CSA), also known as spinal neuroarthropathy, is a progressive disease process in which the biomechanical elements of stability of the spine are compromised because of the loss of neuroprotection leading to joint destruction, deformity, and pain. Initially thought to be associated with infectious causes such as syphilis; however in the latter part of the century, Charcot arthropathy of the spine has become associated with traumatic spinal cord injury. Clinical diagnosis is challenging because of the delayed presentation of symptoms and concurrent differential diagnosis. Although radiological features can assist with diagnosis, the need for recognition and associated treatment is vital to limit the lifelong disability with the disease. The goals of treatment are to limit symptoms and provide spinal stabilization. Surgical treatment of these patients can be demanding, and alternative techniques of instrumentation are often required.

Thecal Transection and Canal Fusion With Structural Allograft for Refractory Charcot Spinal Arthropathy: Technical Note

Charcot spinal arthropathy presents significant surgical challenges, with large bony defects and limitations in fixation and reconstruction which are exacerbated in often numerous revision surgeries. These challenges make the development of additional salvage techniques useful. We report on a technique of thecal transection and canal fusion with structural allograft as a salvage technique for refractory cases of Charcot spinal arthropathy. We illustrate the technique with 4 procedures done in 3 patients, over a period of 10 years.

Kyphectomy with anterior column reconstruction using titanium mesh cage in meningomyelocele patients

Study design: Prospective case series. Purpose: To describe a new technique for anterior column reconstruction after kyphectomy in myelomeningocele patients using titanium mesh cage and to evaluate outcomes and complications. Methods: Sixteen patients with severe dorsolumbar kyphosis 2ry to myelomeningocele were enrolled with a mean age of 10.1 years. Kyphectomy procedure and long spinopelvic fixation were done, titanium mesh cage was used to reconstruct the anterior column. Operative time and intraoperative blood loss were calculated. Using the Cobb method, pre and postoperative measurements of local/regional kyphosis were done. Degree and mean percentage of correction were calculated. Anterior intervertebral height of the kyphotic area was also measured. The mean follow-up period was 27 months. Results: Operative time was 271.3 min ± 25, and estimated intraoperative blood loss was 781.3 mL ± 92.3. On average, 2.5 vertebrae were resected. All 16 patients were able to lie supine immediately postoperatively. The mean preoperative local/regional kyphosis was 107.5°, and 106.9° respectively, corrected to 22.5° and 28.8° postoperatively, with a mean degree of correction of 85° and 78.1° respectively. Mean preoperative anterior intervertebral height was 3.54 cm, improved to 4.64 cm postoperatively. Only 2 cases had a superficial wound infection managed conservatively. At the latest follow-up, no loss of correction pseudoarthrosis occurred, and all patients showed solid fusion. Conclusion: Titanium mesh cage is an efficient, easy method for anterior reconstruction following kyphectomy in myelomeningocele patients, to maintain postoperative correction.

Level of evidence: Therapeutic studies, Level IV study

Cerebrospinal fluid-cutaneous fistula associated with post-traumatic Charcot spinal arthropathy: a case report and review of literature

BACKGROUND

Charcot spinal arthropathy, also known as Charcot spine and neuropathic spinal arthropathy, is a progressive and destructive condition that affects an intervertebral disc and the adjacent vertebral bodies following loss of spinal joint innervation. We report the first case of Charcot spinal arthropathy (CSA) associated with cerebrospinal fluid (CSF)-cutaneous fistula.

CASE PRESENTATION

A 54-year-old male who underwent T10-L2 posterior instrumented spinal fusion seven years prior for treatment of T11 burst fracture and accompanying T11 complete paraplegia visited our department complaining of leakage of clear fluid at his lower back. The patient had also undergone various types of skin graft and myocutaneous flap surgeries for treatment of repetitive pressure sores around his lumbosacral area. The patient presented with persistent CSF leakage from a cutaneous fistula (CSF-cutaneous fistula) formed in a lumbosacral pressure sore. The CSF-cutaneous fistula arose from the L5 post-traumatic CSA. Surgery was planned for management of CSF-cutaneous fistula and post-traumatic L5 CSA. We successfully treated the CSF-cutaneous fistula with ligation and transection of the dural sac and cauda equina at the L2-L3 level. In addition, the post-traumatic L5 CSA was successfully treated with a posterior four-rod spinopelvic fixation from T9 to ilium and S2 foramina. After surgery, the CSF leakage stopped and no other adverse neurological changes were found. The four-rod spinopelvic construct was well maintained five years later.

CONCLUSIONS

CSA associated with CSF-cutaneous fistula is a very rare disorder. Only surgical treatment for both CSA and CSF-cutaneous fistula with ligation and transection of the dural sac and posterior four-rod spinopelvic fixation can bring satisfactory results.

Charcot spinal arthropathy presenting as adjacent segment disease after lumbar spinal fusion surgery in Parkinson's disease: A case report

Charcot spinal arthropathy (CSA) is a rare spinal disorder presenting neuropathic osteoarthropathy of facet joints leading to progressive destruction. After L4-5 PLIF, a 63-year-old woman with Parkinson's disease (PD) underwent L3-4 and L5-S1 PLIF for primary adjacent segment disease caused by degenerative change, which was found as facet joint osteophytes and a vacuum disc phenomenon with endplate sclerosis. However, her postural disorder from PD deteriorated, and strong opioid analgesics were administered for severe recurring low back pain. Anterior subluxation at L2-3 occurred because of destructive secondary adjacent segment disease, which was found as destruction of the endplate and the facet without degenerative change, and formation of paravertebral osteophytes and fluid collection in the intervertebral space. The appearance on imaging met that for neuroarthropathic change, which was previously reported as CSA. L2-3 PLIF following extension of posterior fusion to T10 was additionally performed, and the postoperative course was uneventful with symptomatic improvement. In this case, the important finding was in the different appearance of the disease between adjacent segments on imaging. It is possible that deterioration of PD and administration of the analgesics inhibited deep pain sensation, and concentration of mechanical stress in the proximal adjacent segment by the long lever arm because of extension of the fusion level resulted in neuroarthropathic change of the facets in the secondary adjacent segments. The pathophysiology of association of CSA and PD remains unknown. However, we recommend vigilance for destructive neuroarthropathic facet change as CSA after spinal surgery in patients with severe PD.