Paraplegic with Charcot Spine: Complains of Back Pain and Instability
The patient is a 40-year-old female complaining of back pain and instability. She was involved in a parachuting accident at the age of 16, rendering her paraplegic secondary to trauma at T5 and T6. She was treated with posterior instrumentation at the time and subsequently required all instrumentation to be removed.
She can independently transfer and attend to her daily needs. She requires disimpaction and is able to void spontaneously. She is having increased difficulty managing her daily functions due to pain and clunking in the back with motion. She has tried brace treatment for the past 6 months without resolution of her symptoms. She has been unable to tolerate sitting in her wheelchair for more than one hour at a time.
She has no history of fevers or recent infections.
She has a complete paraplegia with a T12 sensory level. Her posterior spinal wound is well-healed.
At age 16, she was treated with posterior instrumentation and fusion for thoracic trauma. She has not required any other surgeries, and her medications include a bowel routine and baclofen.
Work-up: ESR of 8, CRP of 5, and a white count of 7.2
Figures 1A and 1B: AP (left) and lateral (right) radiographs show destruction of the T10-T11 disc space with anterior subluxation. There’s destruction of the superior end plate of T11 and the inferior endplate of T10.
Figures 2A and 2B: Coned down radiographs showing destruction of the T10-T11 disc space with anterior subluxation. There’s destruction of the superior end plate of T11 and the inferior endplate of T10.
Figures 3A and 3B: T1 (Figure 3A) and T2 (Figure 3B) sagittal MRIs showing destruction of T10-T11 disc space with canal compromise. There’s significant destruction of the superior portion of the T11 vertebra and the inferior portion of T10. There is evidence of the healed trauma at T5 and T6.
Figure 4: T2 axial MRIs showing destruction of the T10-T11 disc space and facets with canal compromise. There’s no soft tissue mass.
Charcot spine and differential diagnosis of discitis.
With her imaging and history of paraplegia and a negative serum infection profile, diagnosis of Charcot spine was made.
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Because of the difficulty in achieving fusion in Charcot spine, a posterior three column transdiscal osteotomy was performed with a posterior long stabilization to the pelvis. The complete posterior elements of T11 were removed along with the T11 pedicles and proximal body. The osteotomy was extended proximally to remove the T10-T11 disc and the distal body of T10. The remaining T10 body was then reduced onto the distal remaining half of T11 with osteotomy closure to facilitate fusion. The transdiscal technique has been described in Spine (2010:35(13) pp. 1316-1322).
Figures 5A and 5B: Post-operative AP (left) and lateral (right) radiographs showing long stabilization to the pelvis.
The patient has done extremely well and has resumed her full activities as tolerated.
Charcot spine is a complex pathology and as noted requires as part of the differential diagnosis that infection is ruled out. Serum markers can be normal in the setting of indolent or atypical infections and biopsy can be considered, although even that approach often does not yield definitive answers in some cases. In either instance, the bone destruction and stability concerns warrant surgical stabilization (and intra-operative cultures/biopsy).
In order to obtain a solid fusion in this setting it is important to consider anterior and posterior bone grafting and long instrumentation given the lever arm across this level of the spine as well as the neurological compromise of the patient (insensate). A formal anterior approach at the thoracolumbar junction is a rather safe approach, would permit complete corpectomies and grafting with autologous rib, as well as placement of structural support. The decision to proceed with an all posterior approach is a valid consideration although there is a neurological risk (bladder control is present despite sensory and motor loss, an incomplete injury). However, if well executed such an approach spares the risks and morbidity of a transthoracic approach.