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

Abstract

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.

Keywords: Charcot spine; complications; long-term spinal cord injury; neuropathic spinal arthropathy; spinal neuroarthropathy.

Figure 1

Preoperative imaging in patient with new-onset autonomic dysreflexia and long history of complete C7 quadriplegia. CT imaging in axial (a), sagittal (b), and coronal (c) views showing sclerosis, joint erosion and effusion, paraspinal osseous fluid collection, T8–9 vertebral body destruction with air spaces, and intervertebral disc destruction at the T8–9 interspace. T2-weighted noncontrast MRIs in sagittal view (d and e) shows debris and disorganized fluid within the disc space of T8–9, significant vertebral body erosion of T8–9, complete loss of intervertebral disc integrity at the T8–9 interspace, inflammation and erosion of posterior elements, and proximal syrinx formation from C4–5 to mid-body T2. formation from C4–5 to mid-body T2

Figure 2

Postoperative plain thoracic X-ray (lateral view) showing vertebral body cage placement and posterior construct with fixation at T6–T7 and T10–T11

Figure 3

At 1-year follow-up, imaging of thoracic spine. Plain lateral X-ray (a) and (b) sagittal T2-weighted non-contrast MRI (b) showing stable construct, cord decompression, restoration of lordosis, and syrinx resolution