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Extension of the posterior arthrodesis up to the T3 vertebra for T9–T10 relapse of spinal neuroarthropathy with vertebral numbering
Source publication
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-ol...
Context in source publication
Context 1
... years later, when the patient presented with a kyphosis associated with painless cracking sounds, a relapse of the spinal neuroarthropathy above the previous instrumentation was diagnosed. The spinal fusion had to be extended using a posterior approach and pedicular instru- mentation (Fig. 3). T10 screws of the previous construct Eur Spine J (2010) 19 (Suppl 2):S108-S113 ...
Citations
... Complications requiring re-instrumentation include failure of fixation [4] and new onset CSA [17], both seen in our patient which presented a refractory CSA within the instrumentation at T11-L1 levels and later on below at the L4-L5 disc space. Fusion down to the sacrum (and ilium) is recommended for CSA at or below the thoracolumbar junction to decrease the risk of new-onset CSA [26,27]. It is unknown whether a fusion to the sacrum would lead to stress fracture leading to a CSA in the sacrum. ...
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 fbrotic
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 sufcient to ensure perfect
stability of the construct and not to be very extensive from the frst surge. The risk would increase the fused levels which
limit the availability of mobile bufer 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
... In previous studies, limited cases of spinal syphilitic gumma have been reported, most of which underwent surgical treatment. Surgical decompression and fixation with a pedicle screw were usually required [14,15]. ...
Introduction and importance
Syphilis is a sexually transmitted disease that appears in various organs. Neurosyphilis in the spine is infrequent, and report of failed spinal arthrodesis surgery is rare. We report the first presentation of complete bone fusion in failed back surgery syndrome with teriparatide.
Case presentation
A 65-year-old man presented to the outpatient clinic after being admitted to the spine department. The patient visited the neurology department 30 years prior for syphilitic myelitis and had been walking with a cane. He underwent an L5–S1 stenosis operation earlier. Severe proximal adjacent L4–L5 level stenosis was observed due to syphilitic gumma with cauda equina syndrome. A posterior decompression and posterolateral fusion to S1 were performed. Four weeks post-surgery, bilateral lower extremity muscle weakness recurred, and a radiographic examination revealed bilateral posterior screw loosening and fracture of the fourth lumbar vertebrae body. After the stagnant fluid and metal removal, for the augmentation of bone union, teriparatide was used for six months, and a complete bone union was confirmed by radiography without pain.
Clinical discussion
Spinal syphilitic gumma has been rarely reported, most of which undergo surgical treatment. Surgical decompression and fixation with a pedicle screw are usually needed. There are complications after spinal surgery using a pedicle screw fixation, and parathyroid hormone (PTH) might be suitable for application in the prevention of nonunions or to augment bone fusion.
Conclusion
This case report is the first description of complete spinal bone fusion in failed back surgery syndrome using teriparatide in tertiary syphilis.
... 3,7,10,11,17,23,[35][36][37][38][39][40][41] Other less common conditions associated with CSA include diabetic neuropathy, syringomyelia, meningocele, myelomeningocele, anesthetic leprosy, congenital insensitivity to pain, medullary AV malformation, Parkinson's disease, transverse myelitis, Guillain-Barré syndrome, Friedreich ataxia, Charcot-Marie-Tooth disease, arachnoiditis, and others. 3,12,19,39,[42][43][44][45][46][47][48][49][50] Unfortunately, the incidence and prevalence of CSA are difficult to determine since CSA has been reported largely in case reports and small case series. The estimated prevalence of CSA developing after SCI is 1 in 220, and the incidence and prevalence of SCI in the United States (US) are 54 per 1 million (17,700 cases per year) and 288,000, respectively. ...
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.
... [7] To prevent relapse of CSA, some authors have proposed extension of posterior fusion from the first sacral vertebrae to at least the first level in a sensitive area. [27] Patients with construct extension to the ilium have a decreased risk of development of secondary CSA compared to patients with constructs ending in the lumbar spine. [26,29] Extension of instrumentation to the sacrum or ilium through a four-rod lumbopelvic construct may prevent development of new Charcot joints distal to the construct, as well as prevent hardware failure. ...
Charcot spinal arthropathy (CSA) is a rare progressive disorder of vertebral joint degeneration that occurs in the setting of any condition characterized by decreased afferent innervation with loss of deep pain and proprioceptive sensation in the vertebral column. While surgical circumferential arthrodesis remains the most effective treatment modality, it is associated with multiple complications, including hardware construct failure. This manuscript represents an up-to-date narrative review of the treatment of CSA, its associated complications, and complication prevention.
... Late-stage SNA closely mimics several other spinal conditions, most importantly spinal infection. The overlap of imaging and clinical features with those of other spinal pathologic conditions, particularly spinal infection, creates a diagnostic disease, Guillain-Barré syndrome, transverse myelitis, and Friedreich ataxia (10)(11)(12)(13)(14)(15)(16). ...
Die Neuroarthropathie der Wirbelsäule oder Charcot-Wirbelsäule ist eine progredient verlaufende, destruierende Gelenkerkrankung, die nach Verlust der neuroprotektiven Sensibilität und der propriozeptiven Reflexe auftritt. Die klinische Diagnose ist wegen der unterschiedlich langen Zeit zwischen der initialen neurologischen Schädigung und dem Auftreten der Arthropathie und wegen der infolge der vorbestehenden neurologischen Ausfälle eingeschränkten Symptomatik schwierig. Die spinale Neuroarthropathie stellt auch deshalb eine diagnostische Herausforderung dar, weil ihre Bildgebungsmerkmale denen bei anderen Erkrankungen der Wirbelsäule, wie z. B. Diszitis/Osteomyelitis, Knochentuberkulose, hämodialysebedingte Spondylarthropathie und Pseudarthrose, ähneln. Das für die Diagnose einer spinalen Neuroarthropathie wichtigste Bildgebungskennzeichen ist die Beteiligung sowohl der anterioren als auch der posterioren Elemente der thorakolumbalen bzw. lumbosakralen Gelenke. Als zusätzliche Hinweise finden sich im Bildgebungsbefund das Vakuumphänomen innerhalb der Bandscheibe (ein Zeichen abnorm erhöhter Beweglichkeit), Malalignment und paraspinale Weichgeweberaumforderungen oder Flüssigkeitsansammlungen, die Knochendebris enthalten. In manchen Fällen kann sich jedoch der Befund trotz dieser Zeichen mit dem einer Infektion überschneiden oder es liegt eine spinale Neuroarthropathie mit Superinfektion vor. In diesen Fällen kann eine Biopsie erforderlich sein. Voraussetzung für die Entwicklung einer spinalen Neuroarthropathie ist eine vorbestehende neurologische Erkrankung, in den meisten Fällen eine traumatische Rückenmarkschädigung. In den Bereichen der empfindungslos gewordenen Wirbelsäule, die die größte Beweglichkeit aufweisen und gleichzeitig der stärksten Gewichtsbelastung ausgesetzt sind, kommt es wiederholt zu Mikrotraumata und unkontrollierter Hyperämie mit der Folge einer Destruktion der Intervertebralgelenke. Der progressive und destruierende Charakter der spinalen Neuroarthropathie verursacht erhebliche Deformitäten, Funktionsverlust und häufig weitere neurologische Ausfälle. Die Patienten stellen sich mit Deformitäten, Rückenschmerzen, hörbaren Geräuschen bei Bewegung oder neu aufgetretenen neurologischen Symptomen vor. Die Behandlung besteht hauptsächlich aus chirurgischem Débridement, Reposition und Fusion. Der Radiologe kann zur Einleitung einer frühen Intervention dadurch beitragen, dass er anhand der wichtigsten Bildgebungsmerkmale zwischen spinaler Neuroarthropathie und ähnlich aussehenden Bildgebungsbefunden unterscheidet und eine weitere neurologische Verschlechterung verhindert.
... [13,14] Limited reports are available on neuromuscular scoliosis. [15][16][17] In this study, we reported this case of a 14-yearold GBS case with scoliosis. In our case, lower limb pain occurred first, followed by weakness in the lower limbs, unsteady gait, and the inability to stand up from squatting position unassisted. ...
Guillain–Barré syndrome (GBS) is an acute autoimmune inflammatory demyelinating polyneuropathy that mostly affects the peripheral nervous system. Little is reported about spinal deformity associated with GBS. This study aims to present a case of scoliosis occurring in the setting of GBS.
Case report and literature review.
The patient was a 14-year-old male with scoliosis. His spinal plain radiographs showed that the Cobb angle of thoracic scoliosis was 114°. History review revealed that he developed profound lower extremity pain, weakness, and numbness after catching a cold 5 years ago. These symptoms progressed to unsteady gait and inability to stand up from squatting position. The diagnosis of GBS was confirmed based on these symptoms. He underwent a posterior correction at Thoracic 5–Lumbar 5 (T5–L12) levels using the (LEGACY, USA) spinal system. The Cobb angle was corrected from 114° to 45° (correction rate 60.5%). His follow-up was symptomatic, well balanced in the coronal planes, with solid fusion 12 months after the operation.
Neuromuscular scoliosis could develop secondary to GBS. When evaluating patients with acute inflammatory polyneuropathy, clinical examination of the spine is essential to identify patients with rare neuromuscular scoliosis.
... Late-stage SNA closely mimics several other spinal conditions, most importantly spinal infection. The overlap of imaging and clinical features with those of other spinal pathologic conditions, particularly spinal infection, creates a diagnostic disease, Guillain-Barré syndrome, transverse myelitis, and Friedreich ataxia (10)(11)(12)(13)(14)(15)(16). ...
Spinal neuroarthropathy (SNA), or Charcot spine, is a progressive destructive arthropathy occurring after loss of neuroprotective sensation and proprioceptive reflexes. Clinical diagnosis is difficult because of the variable length to presentation after initial neurologic damage and the limited symptoms given preexisting neurologic deficits. SNA is also a diagnostic challenge because its imaging features are similar to those of spinal conditions such as discitis-osteomyelitis, osseous tuberculosis, hemodialysis-related spondyloarthropathy, and pseudarthrosis. The most important imaging clues for diagnosis of SNA are involvement of both anterior and posterior elements at the thoracolumbar and lumbosacral junctions. Additional imaging clues include vacuum phenomenon within the disk (indicating excessive motion), malalignment, and paraspinal soft-tissue masses or fluid collections containing bone debris. Despite these imaging signs, findings may overlap in some cases with those of infection, or SNA can be superinfected, and biopsy may be necessary. Development of SNA requires a preexisting neurologic condition, most commonly traumatic spinal cord injury. Areas of greatest mobility and weight bearing within the desensate spine experience repetitive microtrauma and unregulated hyperemia, leading to destruction of the intervertebral articulations. The progressive and destructive nature of SNA causes substantial deformity, loss of function, and often further neurologic deficits. Patients present with deformity, back pain, audible noises during movement, or new neurologic symptoms. The mainstay of treatment is surgical débridement, reduction, and fusion. The radiologist can help initiate early intervention by using key imaging features to distinguish SNA from imaging mimics and prevent further neurologic deterioration. (©)RSNA, 2016.
... [65] Neuroarthropathy, heterotopic ossification, neuromuscular scoliosis, and Issacs' syndrome were also reported to be stepped by GBS in rare conditions, though these casually associations need to be further explored. [66][67][68][69] Neuroarthropathy may develop after months or years after acute phase of GBS. A 47-yearold GBS patient firstly developed peripheral neuroarthropathy of both knees 5 months after the resolution of GBS and further suffered from a spinal involvement 4 years later. ...
... Multiple surgeries were performed to manage her peripheral Charcot arthropathy and Charcot spine. [66] Heterotopic ossification is defined as abnormal formation of bone within soft tissue. It occurred several years after GBS and severely injured the motor function of the patients. ...
Guillain-Barré syndrome (GBS) is an immune-mediated disorder in the peripheral nervous system with a wide spectrum of complications. A good understanding of the complications of GBS assists clinicians to recognize and manage the complications properly thereby reducing the mortality and morbidity of GBS patients. Herein, we systemically review the literature on complications of GBS, including short-term complications and long-term complications. We summarize the frequency, severity, clinical manifestations, managements and possible mechanisms of different kinds of complications, and point out the flaws of current studies as well as demonstrate the further investigations needed.
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.
