Imaging assessment of spine infection

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).

Critical infections in the head and neck: A pictorial review of acute presentations and complications

Non-traumatic head and neck emergencies include several disease processes such as infectious, inflammatory, and malignant. Infections are among the most common pathological processes that affect the head and neck, and are particularly important due to their acute, severe, and potentially life-threatening nature. Radiologists need to be well acquainted with these entities because any delay or misdiagnosis can lead to significant morbidity and mortality. Having a general understanding of such diseases is crucial, their prevalence, clinical presentation, common causative pathogens, route of spread, potential complications, and multimodality radiological appearance. Furthermore, understanding the relevant anatomy of the region, including the various fascial planes and spaces, is essential for radiologists for accurate image interpretation and assessment of potential complications. Our aim is to review the most common severe infections affecting the head and neck as well as other rare but potentially life-threatening infections. We will also describe their imaging features while focusing on the anatomy of the regions involved and describing their potential complications and treatment options.

Fungal Musculoskeletal Infections: Comprehensive Approach to Proper Diagnosis

Fungal musculoskeletal infections often have subacute or indolent manifestations, making it difficult to distinguish them from other diseases and infections, given that they are relatively uncommon. Fungal infections occur by hematogenous spread, direct inoculation, or contiguous extension and may be related to different risk factors, including immunosuppression and occupational activity. The infection can manifest in isolation in the musculoskeletal system or as part of a systemic process. The fungi may be endemic to certain regions or may be found throughout the world, and this can help to narrow the diagnosis of the etiologic agent. Infections such as candidiasis, cryptococcosis, aspergillosis, and mucormycosis are often related to immunosuppression. On the other hand, histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, and blastomycosis can occur in healthy patients in geographic areas where these infections are endemic. Furthermore, infections can be classified on the basis of the site of infection in the body. Some subcutaneous infections that can have osteoarticular involvement include mycetoma, sporotrichosis, and phaeohyphomycosis. Different fungi affect specific bones and joints with greater prevalence. Imaging has a critical role in the evaluation of these diseases. Imaging findings include nonspecific features such as osteomyelitis and arthritis, with bone destruction, osseous erosion, mixed lytic and sclerotic lesions, and joint space narrowing. Multifocal osteomyelitis and chronic arthritis with joint effusion and synovial thickening may also occur. Although imaging findings are often nonspecific, some fungal infections may show findings that aid in narrowing the differential diagnosis, especially when they are associated with the patient's clinical condition and history, the site of osteoarticular involvement, and the geographic location. ©RSNA, 2024.

Imaging of Spondylodiscitis: A Comprehensive Updated Review-Multimodality Imaging Findings, Differential Diagnosis, and Specific Microorganisms Detection

Spondylodiscitis is defined by infectious conditions involving the vertebral column. The incidence of the disease has constantly increased over the last decades. Imaging plays a key role in each phase of the disease. Indeed, radiological tools are fundamental in (i) the initial diagnostic recognition of spondylodiscitis, (ii) the differentiation against inflammatory, degenerative, or calcific etiologies, (iii) the disease staging, as well as (iv) to provide clues to orient towards the microorganisms involved. This latter aim can be achieved with a mini-invasive procedure (e.g., CT-guided biopsy) or can be non-invasively supposed by the analysis of the CT, positron emission tomography (PET) CT, or MRI features displayed. Hence, this comprehensive review aims to summarize all the multimodality imaging features of spondylodiscitis. This, with the goal of serving as a reference for Physicians (infectious disease specialists, spine surgeons, radiologists) involved in the care of these patients. Nonetheless, this review article may offer starting points for future research articles.

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.

Exceptional Spinal Mobility Caused by Charcot Disease: Case Description with Several Years of Follow-Up

A spinal cord injury is now the most common cause of Charcot Spinal Arthropathy (CSA). Paraplegia, loss of pain sensation, laminectomies, and spinal fusions involving more than 5 levels are all risk factors for developing this condition. Low back pain and spinal abnormalities are common symptoms. Circumferential arthrodesis is the chosen treatment. Implant failure and new-onset CSA, which necessitates re-instrumentation, are some of the risks associated with this treatment. This is the case of a patient with a post-traumatic spinal cord injury presenting with spinal Charcot disease with a very long follow-up. We report a unique complication with the replacement of the discal space and portions of the vertebral bodies by fibrotic tissue with an extraordinary spinal movement in the coronal and sagittal planes. Recurrent Charcot disease at the same level or at a caudal level is a devastating complication in spinal surgery. Since this disease naturally exposes the patient to iterative surgeries, it would be wise to limit the extent of the arthrodesis to an optimal number of levels sufficient to ensure perfect stability of the construct and not to be very extensive from the first surge. The risk would increase the fused levels which limit the availability of mobile buffer levels and increase the stress on the remaining levels. Regular follow-ups to the patient should be done to detect recurrence at the same site or distal to the instrumentation.

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.

Imaging of Spine Infections

The incidence of spondylodiskitis has increased over the last 20 years worldwide, especially in the immunodepressed population, and it remains a complex pathology, both in terms of diagnosis and treatment. Because clinical symptoms are often nonspecific and blood culture negative, imaging plays an essential role in the diagnostic process. Magnetic resonance imaging, in particular, is the gold standard technique because it can show essential findings such as vertebral bone marrow, disk signal alteration, a paravertebral or epidural abscess, and, in the advanced stage of disease, fusion or collapse of the vertebral elements. However, many noninfectious spine diseases can simulate spinal infection. In this article, we present imaging features of specific infectious spine diseases that help radiologists make the distinction between infectious and noninfectious processes.

Spinal disorders mimicking infection

Spinal infections are very commonly encountered by radiologists in their routine clinical practice. In case of typical MRI features, the diagnosis is relatively easy to interpret, all the more so if the clinical and laboratory findings are in agreement with the radiological findings. In many cases, the radiologist is able to make the right diagnosis, thereby avoiding a disco-vertebral biopsy, which is technically challenging and associated with a risk of negative results. However, several diseases mimic similar patterns, such as degenerative changes (Modic) and crystal-induced discopathy. Differentiation between these diagnoses relies on imaging changes in endplate contours as well as in disc signal. This review sought to illustrate the imaging pattern of spinal diseases mimicking an infection and to define characteristic MRI and CT patterns allowing to distinguish between these different disco-vertebral disorders. The contribution of advanced techniques, such as DWI and dual-energy CT (DECT) is also discussed.

Syphilitic Spinal Disease: An Old Nemesis Revisited. A Case Series and Review of Literature

ABSTRACT

Syphilitic spinal disease is a rare condition caused by the spirochete Treponema pallidum, either from direct spirochete involvement of the cord or as a consequence of indirect spirochete involvement of the meninges, blood vessels, or the vertebral column. After the introduction of penicillin therapy in the 1940s, it has become an increasingly rare condition. We report 3 challenging cases of syphilitic spinal disease presenting as myelopathy-1 with an extra-axial gumma of tertiary syphilis causing cord compression and 2 with tabes dorsalis complicated by tabetic spinal neuroarthropathy-each presenting a diagnostic dilemma to their treating physicians. We also review the literature for updates on modern investigative modalities and discuss pitfalls physicians need to avoid to arrive at the diagnosis.

Surgical Management of Charcot Spinal Arthropathy in the Face of Possible Infection

BACKGROUND

The design is a retrospective cohort study. Charcot spinal arthropathy (CSA) is a rare and poorly understood progressive destructive spine condition that usually affects patients with preexisting spinal cord injury. The complexity of this condition, especially when additionally burdened by superimposed infection in the CSA zone, can potentially lead to suboptimal management such as protracted antibiotic therapy, predisposition to hardware failure, and pseudarthrosis. While in noninfected CSA primary stabilization is the major goal, staged surgical management has not been stratified based upon presence of a superinfected CSA. We compare clinical and radiological outcomes of surgical treatment in CSA patients with and without concurrent spinal infections.

METHODS

Our single-institution database was reviewed for all patients diagnosed with CSA and surgically treated, who were subsequently divided into 2 cohorts: spinal arthropathy with superimposed infection and those without. Those were comparatively studied for complications and reoperation rate.

RESULTS

Fifteen patients with CSA underwent surgical intervention; mean follow up of 15.3 months (range, 0-43). Eleven patients received stabilization with a quadruple-rod thoracolumbopelvic construct, while 4 patients with superinfected CSA underwent a staged procedure. Patients treated with a staged approach experienced fewer intraoperative complications (0% versus 18%) and fewer revision surgeries (25% versus 36%). Both cohorts had the same eventual healing.

CONCLUSIONS

Surgical management in CSA patients with primary emphasis on stability and modified surgical treatment based on presence of an active infection in the zone of neuropathic destruction will lead to similar eventual successful results with relatively few and manageable complications in this challenging patient population.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The proposed treatment algorithm including the use of a quadruple-rod construct with lumbopelivic fixation and a staged approach in patients with superinfected CSA represents a reasonable option in the surgical treatment of CSA.

MRI-based early diagnosis: a diabetic Charcot spine case report

BACKGROUND

Spinal neuroarthropathy (SNA), also known as Charcot spine, is an uncommon aggressive arthropathy, secondary to loss of proprioceptive and nociceptive feedback from the spine. A diagnosis of SNA is frequently delayed due to the scarcity of symptoms in its early stages, leading to significant neurological deterioration. Therefore, prompt suspicion of the disease is critical to providing better outcomes. This case assembles two rare characteristics of SNA: diabetic aetiology and a precocious time of diagnosis, and aims to highlight the magnetic resonance imaging (MRI) findings that allowed for the diagnosis.

CASE PRESENTATION

A 44-year-old woman, with long-term type 1 diabetes, presented with a two-month history of progressive lumbar pain, difficulty in maintaining an upright position, and discrete trunk forward-leaning. Diabetes-related vasculopathy and nephropathy were already known, and laboratory test results did not show any new abnormalities. A lumbar MRI revealed extensive signal intensity changes of the L2 and L3 vertebral bodies associated with marginal areas of enhancement and the involvement of regions adjacent to interapophyseal articulations and spinous processes from L2-L3 to L5-S1, in association with degenerative changes of the thoracolumbar spine. These findings were identified by the radiologist as suggestive of SNA. To rule out neoplastic and infectious disease, a bone biopsy at the L2-L3 level was executed. The pathology report revealed intervertebral disc material and fragments of fibrous tissue, with a complete absence of inflammatory cells. It was decided to perform a six-month MRI follow-up, which showed stability of the findings, confirming the hypothesis of Charcot spine. The patient was under clinical and radiological follow-up and did not require surgical fixation at the moment of diagnosis. After 2.5 years from the initial diagnosis, a new MRI revealed progression of the lesions with oedema and enlarged paravertebral soft tissues; these findings are compatible with the patient's latest complaints of lumbar pain recurrence.

CONCLUSION

To the best of our knowledge, this is the first case report of an MRI-based early diagnosis of diabetic SNA, a rare disease with nonspecific symptoms in its initial stages and a wide spectrum of differential diagnoses. The MRI findings, distinctly the involvement of both anterior and posterior spinal elements, were the key to allowing for the proper diagnosis. A precocious diagnosis, although challenging, is fundamental to providing early intervention and to preventing further neurological impairment.

Pathophysiology and MRI Findings of Infectious Spondylitis and the Differential Diagnosis

MRI에서 추간판의 이상 신호와 위, 아래 척추체 종판의 파괴, 종판 주변의 골수부종 등은 감염성 척추염의 전형적인 소견으로 여겨지나 퇴행성 척추질환, acute Schmorl's node, 척추관절병증, synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO)/chronic recurrent multifocal osteomyelitis, 척추신경관절병증, calcium pyrophosphate dehydrate 결절침착질환 등 다양한 비감염성 척추질환에서도 나타날 수 있다. MRI에서 이러한 비감염성 척추질환과 감별되는 감염성 척추염의 영상 소견은 추간판의 고신호와 농양, 척추 연부조직의 농양, 그리고 T1 강조영상에서 저신호로 보이는 종판의 경계가 불명확해지는 점 등이다. 그러나 이러한 감별점이 항상 적용되는 것은 아니며 감염성, 비감염성 질환의 영상 소견에 유사점이 많기 때문에 정확한 진단을 위해서는 감염성 척추염뿐만 아니라 감염과 감별해야 하는 다양한 질환의 병태생리와 연관된 영상학적 특징을 아는 것이 중요하다.

A comprehensive review of the treatment and management of Charcot spine

Charcot spine arthropathy (CSA), a result of reduced afferent innervation, is an occurrence of Charcot joint, a progressive, degenerative disorder in vertebral joints, related mostly to spinal cord injury. The repeated microtrauma is a result of a lack of muscle protection and destroys cartilage, ligaments, and disc spaces, leading to vertebrae destruction, joint instability, subluxation, and dislocation. Joint destruction compresses nerve roots, resulting in pain, paresthesia, sensory loss, dysautonomia, and spasticity. CSA presents with back pain, spinal deformity and instability, and audible spine noises during movement. Autonomic dysfunction includes bowel and bladder dysfunction. It is slowly progressive and usually diagnosed at a late stage, usually, on average, 20 years after the first initial insult. Diagnosis is rarely clinical related to the nature of nonspecific symptoms and requires imaging with computed tomography (CT) and magnetic resonance imaging (MRI). Conservative management focuses on the prevention of fractures and the progression of deformities. This includes bed rest, orthoses, and braces. These could be useful in elderly or frail patients who are not candidates for surgical treatment, or in minimally symptomatic patients, such as patients with spontaneous fusion leading to a stable spine. Symptomatic treatment is offered for autonomic dysfunction, such as anticholinergics for bladder control. Most patients require surgical treatment. Spinal fusion is achieved with open, minimally-open (MOA) or minimally-invasive (MIS) approaches. The gold standard is open circumferential fusion; data is lacking to determine the superiority of open or MIS approaches. Patients usually improve after surgery; however, the rarity of the condition makes it difficult to estimate outcomes. This is a review of the latest and seminal literature about the treatment and chronic management of Charcot spine. The review includes the background of the syndrome, clinical presentation, and diagnosis, and compares the different treatment options that are currently available.

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.

An Institutional Review of Tuberculosis Spine Mimics on MR Imaging: Cases of Mistaken Identity

Although MRI has a spectrum of findings which help in the diagnosis of tuberculosis (TB) spine, a broad spectrum of spine pathologies resemble Pott's spine on MRI and are often missed due to inadequate clinical details. As a result, patients are often subject to unnecessary biopsy. A blinded radiologist may misdiagnose such mimic cases as TB. Our aim is to enable the reader to learn the main criteria that differentiate spine TB from other spine etiologies that mimic TB. A retrospective search was done and authors collected only MRI spine reports that showed a differential diagnosis or diagnosis of TB spine from the computer-based data records of the institution over a four-year period. This revealed 306 cases of TB spine out of which 78 cases with an alternate diagnosis that resembled TB spine were included. We describe a single institute review of 78 such cases that resemble and mimic Pott's spine on MRI. The cases being: (n = 15) pyogenic spondylitis, (n = 1) brucellar spondylodiscitis, (n = 12) rheumatoid arthritis, (n = 12) metastases, (n = 8) lymphoma, (n = 5) post-trauma fractures, (n = 10) degenerative disc disease, (n = 2) Baastrup's disease, (n = 9) osteoporotic fracture, (n = 3) spinal neuropathic arthritis, and (n = 1) case of Rosai-Dorfman disease. The clinical and radiological findings of all these cases were correlated with lab findings and histopathology wherever necessary. Appropriate recognition of these entities that resemble and mimic TB spine on MRI is important for optimal patient care. This paper exposes radiologists to a variety of spine pathologies for which biopsy is not indicated, and highlights key imaging findings of these entities to facilitate greater diagnostic accuracy in clinical practice.

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.

A Rare Case of Cervical Charcot After Spinal Cord Injury: A Case Report

CASE

We present a rare case of cervical Charcot disease that was diagnosed in a paraplegic patient by loss of function caudal to the original level of spinal cord injury. Clinical imaging, diagnosis, differentials, and operative management are discussed.

CONCLUSIONS

Charcot disease of the cervical spine is rare and very difficult to diagnose in the paraplegic patient population. High clinical suspicion should be maintained in these patients who demonstrate any form of neurologic deterioration, mechanical instability, or change in spinal alignment. It is often necessary to rule out infection. Spinal decompression and surgical stabilization is the treatment of choice.

Very early Charcot spinal arthropathy associated with forward bending after spinal cord injury: a case report

Introduction

Charcot spinal arthropathy (CSA) is an uncommon clinical entity following spinal cord injury (SCI). It is characterized by progressive cartilaginous and bony destruction and is felt to be due to loss of proprioceptive and nociceptive feedback from the spine. CSA is typically diagnosed many years following SCI and has the potential to lead to progressive neurologic decline if left untreated.

Case presentation

We describe the case of a 49-year-old male who fell approximately thirty feet from a ladder and sustained a fracture/dislocation at T3-4 and T8-9 resulting in a T4 ASIA A SCI. He underwent T2-T12 posterior spinal stabilization and, within 1 year and 2 months of initial injury, developed an unusual back protuberance, decreased spasticity, and change in bladder function. The patient's imaging and physical exam were consistent with CSA.

Discussion

This case is notable in two respects. First, this is one of the earliest cases of CSA identified in the literature. Although CSA is generally considered a late complication of SCI, CSA should be placed in the differential for all individuals with spinal cord presenting with clinical findings typical of CSA. Second, this case was associated with unsupervised attempts to improve range of motion (ROM) in a SCI patient with a fused spine. The association of unsupervised stretching and CSA has not been previously described.

Spinal Manifestations of Systemic Disease

The spine is frequently involved in systemic diseases, including those with neuropathic, infectious, inflammatory, rheumatologic, metabolic, and neoplastic etiologies. This article provides an overview of systemic disorders that may affect the spine, which can be subdivided into disorders predominantly involving the musculoskeletal system (including bones, joints, disks, muscles, and tendons) versus those predominantly involving the nervous system. By identifying the predominant pattern of spine involvement, a succinct, appropriate differential diagnosis can be generated. The importance of reviewing the medical record, as well as prior medical imaging (including nonspine imaging), which may confer greater specificity to the differential diagnosis, is stressed.

Imaging of Acute Low Back Pain

Acute low back pain, defined as less than 6 weeks in duration, does not require imaging in the absence of "red flags" that may indicate a cause, such as fracture, infection, or malignancy. When imaging is indicated, it is important to rule out a host of abnormalities that may be responsible for the pain and any associated symptoms. A common mnemonic VINDICATE can help ensure a thorough consideration of the possible causes.

Infectious Spondylitis Mimics: Mechanisms of Disease and Imaging Findings

Infectious processes of the spine are on the rise; in this scenario recognition of entities imitating infection is very important. The discovertebral unit is regarded as one of the most important and active sites in the spine. Importantly, the vertebral bony rim and the anterior corners of the vertebral bodies have significant vascularization, they are the last regions to ossify in the developmental process and suffer mechanical forces. Early septic or aseptic discitis-osteomyelitis, properly called spondylitis, involves these anterior regions. Early degeneration is characterized by disc desiccation; however, there is preferential involvement for the corners of the vertebral bodies as well. Many entities to include degenerative changes, inflammatory spondyloarthropathies, neuropathic spine, or pseudo arthrosis, among others, affect the discovertebral unit and can imitate infection. With some exceptions, important imaging findings for the identification of an infectious mimic include the absence of soft tissue enhancement or fluid collections in the paraspinal or epidural regions, and the involvement of multiple levels or the posterior elements. We review developmental, anatomical, and pathologic concepts correlating with imaging clues. Overall, our goal is to increase awareness and to improve recognition of mimicking entities.

Neuropathic spinal arthropathy leading to spine disruption, spinal cord transection, and aortic displacement: brief case report

Introduction

Charcot spinal arthropathy (CSA) is an infrequent but potentially devastating complication after spinal cord injury.

Case presentation

We report a case of a man with longstanding T3 complete (AIS A) paraplegia who developed severe CSA with spine disruption and aortic displacement.

Discussion

Acute management of this patient is described along with both conservative and surgical management considerations and challenges as described in other reports.

Infected charcot spine arthropathy

Background

Charcot spinal arthropathy (CSA), a destructive spinal pathology, is seen in patients with impaired sensation. Superimposed infection in the affected spinal segments can lead to a challenge in the diagnosis and management. Spinal cord injury (SCI) is the leading cause of CSA as persons with SCI have significantly impaired sensation. Though infection of the CSA is rare, SCI persons are prone to superimposed infection of the Charcot spine. We report atypical presentations of three cases of CSA with superimposed infection.

Case descriptions

A 47-year-old male with complete T7-8 SCI developed symptoms suggestive of infection and CSA. He was managed with a posterior vertebral column resection (PVCR) of T12 and intravenous antibiotics as the intraoperative culture showed the growth of E. coli and Pseudomonas. A 26-year-old male with T12 complete paraplegia, post status post open reduction and internal fixation with subsequent implants removal developed infection and CSA over the pseudo-arthrotic lesion with destruction of T12 and L1 vertebrae and an external fistulous track. He was managed with debridement and anterior column T11-L1 reconstruction with a Titanium cage and four-rod pedicle screw stabilization construct. A 25-year-old male with complete paraplegia with CSA at L4-S1. He underwent PVCR of L5 and L3-S2 posterior stabilization. The intraoperative culture and histopathology were suggestive of tuberculous infection.

Conclusion

Pyogenic or tubercular infection of CSA should be considered as a diagnostic possibility in persons with SCI who are more prone to infections. The management includes aggressive debridement and circumferential fusion along with appropriate medications to control the infection.

Management of autonomic dysreflexia associated with Charcot spinal arthropathy in a patient with complete spinal cord injury: Case report and review of the literature

Background:

Charcot spinal arthropathy (CSA) clearly represents a challenge in long-term spinal cord injury patients, one that can have extremely uncomfortable and potentially lethal outcomes if not managed properly.

Case Description:

A 66-year-old man with a history of complete C7 quadriplegia presented with new-onset autonomic dysreflexia that resulted from Charcot spinal arthropathy (CSA). Pathologic instability, in the atypical site of the mid-thoracic spine, spanning from the T8–T9 vertebral levels was appreciated on physical exam as an audible, palpable, and visible dynamic kyphosis; kyphosis was later confirmed on neuroimaging. Based on the CSA severity and sequelae, the patient underwent bilateral decompression laminectomy with lateral extracavitary arthrodesis and posterior instrumentation. Symptoms dramatically improved and at 1-year follow-up, dynamic thoracic kyphosis and most symptoms of autonomic dysreflexia had resolved.

Conclusions:

Based on our case and published reports, vigilant imaging and thorough physical examination in long-standing spinal cord injury could help early diagnosis and treatment of CSA, theoretically preventing development of cord atrophy and subsequent long-term sequelae. Surgical correction rather than bracing may be recommended in patients who have complete injury at or above T6 in patients with symptoms of autonomic dysreflexia associated with CSA confirmed on neuroimaging.

Challenge of handling a Charcot spinal arthropathy with a novel hybrid fibular autograft and expandable cage

A 26-year-old man, who was paraplegic for 6 years due to a motor vehicle accident, presented to the authors' clinic following his incapacity to withstand a sitting posture, the frequent sensation of "clicks" in his back, and a complaint of back pain while in his wheelchair. On imaging, his dorsal spine showed a complete arthrodesis of the primarily fused vertebrae. However, distal to this segment, a Charcot spinal arthropathy with subluxation of T12-L1 was evident. Repair of this complex, uncommon, late complication of his paraplegia by the frequently used fusion techniques was shown to be inappropriate. A novel and elaborate surgical procedure is presented by which a complete fusion of the affected spine was secured. A left retrodiaphragmatic approach was used. Complete corpectomy of both the T-12 and L-1 vertebrae to the preserved endplates was performed. Most of the patient's fibula was resected and shaped for engrafting. The segment of the fibula was introduced into a mesh cage, before its intramedullary implantation into the T-12 and L-1 vertebrae. This 2-step procedure combined the hybrid use of a fibular autograft and an expandable mesh cage, incorporated one into the other, in an innovative intramedullary position. This intervention allowed the patient to resume his former condition as an extremely physically active patient with paraplegia. Nine years later, an asymptomatic early-stage Charcot spine was found at L5-S1, but no treatment is planned at this point.

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

Charcot's spine is a long-term complication of spinal cord injury. The lesion is often localized at the caudal end of long fusion constructs and distal to the level of paraplegia. However, cases are rare and the literature relevant to the management of Charcot's arthropathy is limited. This paper reviews the clinical features, diagnosis, and surgical management of post-traumatic spinal neuroarthropathy in the current literature. We present a rare case of adjacent level Charcot's lesion of the lumbar spine in a paraplegic patient, primarily treated for traumatic spinal cord lesion 39 years before current surgery. We have performed end-to-end apposition of bone after 3 column resection of the lesion, 3D correction of the deformity, and posterior instrumentation using a four-rod construct. Although the natural course of the disease remains unclear, surgery is always favorable and remains the primary treatment modality. Posterior long-segment spinal fusion with a four-rod construct is the mainstay of treatment to prevent further morbidity. Our technique eliminated the need for more extensive anterior surgery while preserving distal motion

Rheumatoid arthritis-associated spinal neuroarthropathy with double-level isthmic spondylolisthesis

INTRODUCTION

To the best of our knowledge, there has been no report regarding rheumatoid arthritis associated with spinal neuroarthropathy and combined double-level isthmic spondylolisthesis. Here, we report a rare case of spinal neuroarthropathy with double-level isthmic spondylolisthesis in a rheumatoid arthritis (RA) patient. A 56-year-old female patient under medical treatment for RA during the last 13 years presented aggravating radiating pain to her right lower extremity and a limping gait developed 4 months ago. The disease activity of RA had remained low for a long time. Serial radiographs during last 8-year follow-up showed progressive dislocation at L4-L5 and L5-S1 with double-level isthmic spondylolisthesis and severe destructive status at the last follow-up. The patient underwent decompression and circumferential fusion with sacropelvic fixation and acceptable reduction was obtained.

CONCLUSION

A RA patient with double-level isthmic spondylolisthesis showed a progressive destructive lesion. In addition to clinical presentations, the imaging findings were very similar to ones of spinal neuroarthropathy. The authors conclude that this Grand Round case probably had SNA secondary to RA and that this, combined with two-level isthmic spondylolisthesis, resulted in her rapidly progressing destructive lumbar lesion.

Imaging Spectrum of Invasive Fungal and Fungal-like Infections

Invasive fungal and fungal-like infections contribute to substantial morbidity and mortality in immunocompromised individuals. The incidence of these infections is increasing-largely because of rising numbers of immunocompromised patients, including those with neutropenia, human immunodeficiency virus, chronic immunosuppression, indwelling prostheses, burns, and diabetes mellitus, and those taking broad-spectrum antibiotics. Invasive fungal pathogens include primary mycotic organisms such as Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, and Paracoccidioides brasiliensis, which are true pathogens and inherently virulent. Secondary mycotic organisms such as Candida and Aspergillus species, Cryptococcus neoformans, Pneumocystis jirovecii, and Mucorales fungi are opportunistic, less virulent pathogens. Nocardia and Actinomyces species are gram-positive bacteria that behave like fungi in terms of their growth pattern and cause fungal-like invasive indolent infections; thus, these organisms are included in this review. Fungal and fungal-like infections can affect a variety of organ systems and include conditions such as meningitis, sinusitis, osteomyelitis, and enteritis. As awareness of these infections increases, timely diagnosis and treatment will become even more important. Imaging has a critical role in the evaluation of disease activity, therapy response, and related complications. Using an organ-based approach with computed tomography, magnetic resonance imaging, and ultrasonography to gain familiarity with the appearances of these infections enables timely and accurate diagnoses. ^©RSNA, 2017.