Case ReportLong-term follow-up of the surgical management of neuropathic arthropathy of the spine
Introduction
Neuropathic arthropathy of the spine, also called Charcot spine, is a degenerative process caused by the loss of deep sensation within a joint. The absence of protective sensation can cause progressive mechanical joint destruction, leading to chronic disability and paradoxical pain [1], [2], [3]. Neuropathic arthropathy is difficult to manage because of the extent of joint destruction and subsequent instability, and treatment is particularly challenging in the spine because instability of one neuropathic joint can transfer to adjacent joints. Progressive deformity and instability of one neuropathic joint can be transferred to adjacent joints.
The management of Charcot spine remains controversial. Historically, treatment was conservative and limited to activity restriction and braces because surgical treatment had poor outcomes. Recent advancements in instrumentation have facilitated the successful treatment of Charcot spine with surgical management. Studies report successful treatment of Charcot spine with posterior-only approaches, whereas others recommend combined anterior-posterior approaches.
Only a few case studies have described the successful treatment of Charcot spine with surgical management in the short-term, and none have discussed long-term treatment outcomes. We reviewed the presentation, management, and long-term results of nine patients with Charcot spine and eight patients who received surgery. Based on previous reports, the study hypothesis was that fusion across the Charcot region would reduce skin breakdown, instability, and paradoxical pain without a major loss of functional abilities, and that surgery would be effective in the long-term.
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Materials and methods
Nine cases of Charcot spine were reviewed Table 1, Table 2. Cases represented all Charcot spine patients treated by two orthopedic surgeons from 1979 to 2009. No known cases during this period were excluded. Patients included one female and eight male patients 15 to 47 years old with an average age of 29.6 years at the time of surgery. Four patients were under the age of 18. Average follow-up after treatment ranged from 5 to 30 years with a mean of 14.3 years.
Radiographs and computed tomography
Results
Clinical courses and treatments of all patients are summarized in Table 1, Table 2. Of nine patients, two underwent posterior fusion alone, six had both anterior-posterior fusion, and one was managed with thoracolumbar orthosis. The average time from initial instrumentation and fusion to development of Charcot spine was 7.6 years, and average time from initial stabilization to development of a second Charcot spine was 7.3 years with revision surgery required at 8 years. Reasons for revision
Discussion
Conservative and surgical options for Charcot spine have historically produced poor results. Early surgical treatment often yielded multiple complications [4], and management became limited to nonoperative immobilization of hypermobile segments by bracing, traction, and bed rest [5]. Although immobilization produced temporary relief of pain and bladder dysfunction, it did not stop deformity progression, and long-term results were poor [6], [7], [8].
With the advent of more advanced spinal
Conclusion
Long-term follow-up of patients treated for neuropathic spinal arthropathy shows that it is a progressive deformity, which is difficult to control. If the deformity itself does not cause seating difficulties or skin breakdown, some patients can tolerate fairly severe deformity for extended time periods. However, although some patients temporarily benefit from brace immobilization, almost all eventually require surgical stabilization. Surgery can reliably reduce pain and deformity in patients
References (25)
- et al.
Charcot arthropathy because of congenital insensitivity to pain in an adult
Spine J
(2008) - et al.
Charcot spine as a late complication of traumatic spinal cord injury
Arch Phys Med Rehabil
(1997) - et al.
Pathogenesis of the neurotrophic joint: neurotraumatic vs. neurovascular
Radiology
(1981) - et al.
Neurogenic arthropathy (Charcot joint) associated with diabetic neuropathy: report of two cases
Arch Neurol Psychiatry
(1947) - et al.
Charcot spine
Q Bull Northwest Univ Med Sch
(1956) - et al.
Fusion of the Charcot spine. Report of 3 cases
Clin Orthop Relat Res
(1967) - et al.
Nonoperative treatment of neuropathic spinal arthropathy
Spine
(1990) - et al.
Charcot disease of the spine; a report of two cases treated by spine fusion
J Bone Joint Surg Am
(1959) - et al.
Charcot joint of the lumbar spine
J Neurosurg
(1969) - et al.
Neuropathic spinal arthropathy. A review of the Charcot spine
Spine
(1980)
Neuropathic (Charcot) arthropathy of the spine after traumatic spinal paraplegia
Spine
Surgical treatment of neuropathic spinal arthropathy
J Spinal Disord
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Charcot arthropathy in the spine. Experience in our centre. About 13 cases. Review of the literature
2021, Revista Espanola de Cirugia Ortopedica y TraumatologiaDiagnostic Imaging: Spine
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2014, Spine JournalCitation Excerpt :Jacobs et al. [8] have reported an infection rate of 17% (n=4) in a case series of 23 patients with CSA. In the face of the progressive and destructive nature of the disease, surgical treatment is most commonly recommended for the management of CSA [3,5,6,8]. The goals of surgical treatment are the correction of spinal deformity (kyphosis) and stabilization (fusion) of the hypermobile segment [8].
Multi-rod fixation in spinal neuroarthropathy: a novel surgical technique
2023, Journal of Spine SurgerySurgical management of charcot spinal arthropathy in the face of possible infection
2021, International Journal of Spine Surgery
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Author disclosures: none.