Spinal Manifestations in a Patient with Congenital Insensitivity to Pain

Orthopaedic manifestations of congenital indifference to pain with anhidrosis (Hereditary Sensory and Autonomic Neuropathy type IV)

BACKGROUND

Congenital indifference to pain with anhidrosis (CIPA) is a rare hereditary neuropathy, which is associated with defective sensation to noxious stimuli and autonomic dysfunction. The objective of the study was to report on the orthopaedic manifestations of this condition and provide an evidence-based approach for management.

METHODS

Retrospective review of 14 consecutive patients with CIPA referred to a single tertiary centre. Mean age of diagnosis was 2.5 years (range 0.5 to 11 years).

RESULTS

Patients presented with a range of orthopaedic problems including fractures, infections, growth disturbance, joint subluxation and Charcot joints affecting the limbs and spine. Conservative treatment with closed reduction and cast immobilisation was satisfactory for stress fractures of the lower extremity and Charcot joints. Posterior instrumented correction of scoliosis was associated with a high-risk of infection requiring reoperation for debridement and removal of posterior instrumentation. Growth disturbance leading to leg-length discrepancies were managed with shoe raises and corrective osteotomies. Aspiration and cultures may be used to differentiate between acute fracture and infection.

CONCLUSIONS

Preventative treatment strategies with appropriately padded shoe-wear, gait and posture modification, parental education regarding environmental thermoregulation, and behavioural support are essential for improving prognosis and reducing long-term complications.

Charcot spinal arthropathy in patients with congenital insensitivity to pain: a report of two cases and review of the literature

Charcot spine, or neuropathic spinal arthropathy, involves the progressive destruction of the spinal joint due to the lack of normal protective sensations and proprioception. A rare cause of Charcot spine is congenital insensitivity to pain, which is an absent or abnormal response to painful stimuli. There are few case reports describing this condition, and long-term follow-up data are limited. The presentation and treatment of two patients with Charcot spine secondary to congenital insensitivity to pain are described. Both cases were characterized by lumbar involvement and were treated with circumferential decompression and an extended lumbo-pelvic fusion construct. The cases described here demonstrate stable neurological status at 1.5 and 5 years follow-up. Patient characteristics, pre- and post-operative imaging, operative approach, and outcomes are described. The literature regarding this rare condition is also reviewed, with an emphasis on operative management and outcomes. Surgical management is traditionally complicated by a high rate of hardware failure and adjacent segment degeneration. The current review highlights the importance of prompt and aggressive management following diagnosis of Charcot spine, as well as extended follow-up.

Do all Charcot Spine require surgery?

INTRODUCTION

Spinal neuroarthropathy (SNA), also called "Charcot spine", is very uncommon disease of unknown etiology. Kronig first reported this pathology in 1884 on a patient with Tabes dorsalis (also known as syphilitic myelopathy). As syphilis tends to disappear in developed countries, spinal cord lesion is the most frequent etiology of SNA.

OBJECTIVES

To describe clinical and radiographic results in 12 patients suffering from spinal neuroarthropathy (SNA).

METHODS

Twelve patients diagnosed with SNA were included in the study. All patients were wheelchair users. The average delay between the neurological disease and the diagnosis of SNA was 18 years. All patients were initially treated conservatively. Surgery was only indicated in persistent symptomatic or instable cases, and for infected SNA. Surgery was a circumferential arthrodesis.

RESULTS

From 12 patients, with a median follow-up of 4 years, five patients were operated on and 7 patients were still conservatively treated. Two patients with back pain and evolutive destruction were declined for surgery. One suffered of bilateral hip ankylosis and extensive spinal surgery would have confined him to bed, and one due to an evolutive bedsore. One patient improved with a complete regression of back pain.

CONCLUSION

Nowadays, surgical treatment is recommended with an extensive and circumferential fusion, in order to prevent relapses. Good radiographic outcome is reported but functional results have not been studied. Natural evolution of SNA remains unknown but can be less disabling than surgery. This pathologic mobility can contribute to patient's autonomy and can therefore be considered as opportune. Conservative therapy can be considered for SNA.

LEVEL OF EVIDENCE

Level IV.

Spinal neuroarthropathy associated with Guillain-Barré syndrome

Since the rarefaction of neurosyphilis, axial neuroarthropathy is mostly secondary to spinal cord pathologies. Peripheral manifestations of neuroarthropathy resulting from Guillain-Barré syndrome have already been reported but to our knowledge, this is the first case of a patient diagnosed with axial involvement. After the acute phase, a 47-year-old woman suffered of paraparesia with a partial loss of sensibility under the tenth thoracic vertebra. As a consequence, she developed first of all neuroarthropathy of both knees and few years later, a spinal involvement was discovered. Multiple surgeries of both knees and of the spine were required, due to non-union, relapse, and infection. Natural evolution of Charcot spine remains unknown. Surgical treatment is recommended but even with circumferential fusion, failures do frequently occur. This observation allows us to report an original case and to discuss the etiology of axial neuroarthropathy, the classical radiographic findings, and the inherent difficulties of its treatment.