Elsevier

The Spine Journal

Volume 10, Issue 6, June 2010, Pages e6-e16
The Spine Journal

Case Report
Long-term follow-up of the surgical management of neuropathic arthropathy of the spine

https://doi.org/10.1016/j.spinee.2010.03.030Get rights and content

Abstract

Background Context

No studies have discussed the long-term surgical management and outcomes of Charcot arthropathy of the spine. This case series presents nine patients treated over 30 years. The study hypothesis was that surgery would reduce instability, pain, recurrence, and the need for revision surgery in the long-term, given previous study findings of successful fusion of Charcot spine in the short-term.

Purpose

To evaluate the long-term outcomes of surgery for Charcot spine.

Study Design/Setting

Retrospective case series. Cases took place at Stanford University Medical Center and Santa Clara Valley Medical Center.

Methods

All patients had either complete paraplegia or dense paraparesis with both major motor and sensory deficits. Seven patients developed Charcot spine after spinal instrumentation for trauma, one after scoliosis repair for meningomyelocele, and one after spinal instrumentation for neuromuscular scoliosis caused by birth injury resulting in C6–C7 quadraplegia. Average time between initial instrumentation and development of Charcot spine was 7.6 years. Two patients underwent posterior fusion alone, six had anterior-posterior fusion, and one was managed with thoracolumbar orthosis.

Results

Average follow-up was 14.3 years. Revisions were necessary in 75% (6 of 8) of patients for complications including nonunion, new Charcot joints, recurrent hardware failure, and osteomyelitis. Achieving fusion often required multiple operations, and there were no deaths or neurologic complications.

Conclusions

Long-term follow-up showed a high rate of revision surgery. Solid fusions often resulted in late breakdown or new junctional Charcot arthropathies. Patients initially fused to the lumbar spine instead of the sacrum or pelvis had a higher rate of developing another Charcot joint. Fusion was often difficult with persistent nonunions and functional deficits because of decreased mobility. We recommend that Charcot spine well tolerated without skin, seating problems, or dysreflexia should be cautiously observed with conservative management. For surgical care, we recommend three-column stabilization with either combined anterior-posterior or all posterior approaches with anterior support to obtain and secure greater long-term stability.

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.

Section snippets

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

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