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. 2021 Aug;15(4):752-762.
doi: 10.14444/8097. Epub 2021 Jul 27.

Surgical Management of Charcot Spinal Arthropathy in the Face of Possible Infection

Alexander Von Glinski  1   2   3   4 , Sven Frieler  1   2   3   4 , Christopher J Elia  1   2   5 , Darius Ansari  1   2 , Clifford Pierre  1   2 , Basem Ishak  1   2   6 , Ronen Blecher  1 , Bilal Qutteineh  1 , Sarah Strot  1 , Rod J Oskouian  1   2 , Jens R Chapman  1
Affiliations

Surgical Management of Charcot Spinal Arthropathy in the Face of Possible Infection

Alexander Von Glinski et al. Int J Spine Surg. 2021 Aug.

Abstract

Background: The design is a retrospective cohort study. Charcot spinal arthropathy (CSA) is a rare and poorly understood progressive destructive spine condition that usually affects patients with preexisting spinal cord injury. The complexity of this condition, especially when additionally burdened by superimposed infection in the CSA zone, can potentially lead to suboptimal management such as protracted antibiotic therapy, predisposition to hardware failure, and pseudarthrosis. While in noninfected CSA primary stabilization is the major goal, staged surgical management has not been stratified based upon presence of a superinfected CSA. We compare clinical and radiological outcomes of surgical treatment in CSA patients with and without concurrent spinal infections.

Methods: Our single-institution database was reviewed for all patients diagnosed with CSA and surgically treated, who were subsequently divided into 2 cohorts: spinal arthropathy with superimposed infection and those without. Those were comparatively studied for complications and reoperation rate.

Results: Fifteen patients with CSA underwent surgical intervention; mean follow up of 15.3 months (range, 0-43). Eleven patients received stabilization with a quadruple-rod thoracolumbopelvic construct, while 4 patients with superinfected CSA underwent a staged procedure. Patients treated with a staged approach experienced fewer intraoperative complications (0% versus 18%) and fewer revision surgeries (25% versus 36%). Both cohorts had the same eventual healing.

Conclusions: Surgical management in CSA patients with primary emphasis on stability and modified surgical treatment based on presence of an active infection in the zone of neuropathic destruction will lead to similar eventual successful results with relatively few and manageable complications in this challenging patient population.

Level of evidence: 4.

Clinical relevance: The proposed treatment algorithm including the use of a quadruple-rod construct with lumbopelivic fixation and a staged approach in patients with superinfected CSA represents a reasonable option in the surgical treatment of CSA.

Keywords: Hounsfield unit (HU); bone morphogenic protein (BMP); polymethylmethacrylate (PMMA); quadruple-rod construct.

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Conflict of interest statement

Disclosures and COI: The authors report no conflict of interest or financial support concerning the materials or methods used in this study or the findings specified in this paper. No relevant financial activities outside the submitted work. The manuscript submitted does not contain information about medical device(s)/drug(s). We certify that all applicable institutional and governmental regulations concerning the ethical use of clinical data were followed during this research. This study (IRB ID STUDY No. 2019000337) was approved by the Institutional Review Board at Swedish Neuroscience Institute. The data that support the findings of this study are available on request from the corresponding author (AvG). The data are not publicly available due to privacy restrictions. AvG was responsible for the study protocol, conducting the search, screening potentially eligible patients, extracting and analyzing data, interpreting results, and writing the paper. SF contributed to data evaluation, conception of the manuscript and writing the draft, and reviewed the manuscript. CE was responsible for reviewing and screening potentially eligible patients. He contributed to writing the report, extracting and analyzing data, interpreting results. DA contributed to the design of the review protocol, writing the study, and screening possible patients. CP contributed to data extraction and provided feedback on the study. BI contributed to data extraction and interpretations as well as drafting the manuscript. RB helped reviewing the script and reviewing all included patients regarding the diagnosis of Charcot spinal arthropathy (CSA). BQ helped screening patients, drafting the manuscript, and analyzing the radiographs. SH helped to identify all possible patients with CSA as well as drafting and revising the manuscript. RO helped with developing the study, drafting the manuscript, and revised it. Further he supervised the project. JC supervised the project, reviewed all included patients, and revised the manuscript.

Figures

Figure 1
Figure 1
Patient 2 (71F): Midthoracic (T4) spinal cord injury, unstable L5–S1 junction. (A) (left top) and (B) (right top) Anterior/posterior and lateral, (C) (left bottom) extension, and (D) (right bottom) flexion views.
Figure 2
Figure 2
Identification and exclusion of study cohort.
Figure 3
Figure 3
Patient 4: Second-stage surgery 21 days after polymethylmethacrylate strut insertion. One temporary rod broke caudally after transfer maneuver. Removal followed segmental instrumentation. Extensive aggressive debridement of spine and instrumentation tracks and completion L1–L3 vertebrectomies, pulsatile lavage, 9 L, remove antibiotic spacers. Anterior lumbar interbody fusion with expandable cage, Stryker AVS, and bone morphogenic protein (BMP) and allograft. Posterior spinal instrumentation and fusion T8 to ilium with quadruple-rod fixation and multiple crosslinks and posterolateral fusion, and posterior lamina fusion L4–S1, with BMP allograft.
Figure 4
Figure 4
Patient 2: Partial removal caudal end of Harrington rod, laminectomy, and epidural debridement, L5–S1. Posterior interbody fusion with bilateral expandable titanium cage with bone morphogenic protein (BMP) with local and allograft bone and posterior spinal instrumentation T10 to pelvis with quadruple-rod construct. L5–S1 fusion, posterolateral fusion and fusion to ilium using local bone and allograft BMP.
Figure 5
Figure 5
Distribution of spinal cord injury (SCI) and Charcot spinal arthropathy (CSA) incidence by vertebral level. Note CSA levels typically develop distal to level of SCI.
Figure 6
Figure 6
Patient 4: Extensive destructive Charcot arthropathy of L2 and L3 vertebral bodies and large paravertebral abscess. Wide decompressive laminectomies L1–L3, partial vertebrectomies L2 and L3, resection of abscess capsule, open reduction and internal fixation T11–L5, insertion polymethylmethacrylate strut graft (2 g of Simplex nontobramycin cement and 4 g vancomycin), 2 crosslinks.
See this image and copyright information in PMC

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