Charcot Spine Treated Using a Single Staged Posterolateral Costotransversectomy Approach in a Patient with Traumatic Spinal Cord Injury
The patient was a 57-year-old man with a 26 year history of complete T8 paraplegia. He suffered a T7, 8 burst fracture in a motor vehicle accident. At that time, he was treated at another institution. In 2010, 26 years after the injury, the patient presented to our institution because of a crunching noise inside his back when transferring from the wheelchair to the bed. He was unable to maintain the sitting posture.\nPhysical examination showed a kyphotic deformity of the thoracolumbar junction. He had flaccid, areflexic lower extremities. He had no significant contractures at the hips and knees. Laboratory analysis revealed no signs of infectious spondylitis or urinary tract infection.\nOn thoracolumbar spine radiographs, there was old fracture of T7, 8 by trauma, and deformity at the T11, 12 segments : right ward translation of T11 with respect to the distal segments; marked destruction of the T11, 12 vertebral body; productive bony changes including sclerosis and bulky osteophytes; and destruction of the posterior elements ().\nCT scan confirmed the radiographic findings of an extensive destructive. Additionally, CT revealed a large complex paraspinal soft tissue process with areas of fluid attenuation, ossifications, and peripheral bony debris extending as far as the posterior paraspinal soft tissues ().\nMRI further demonstrated the complexity of the vertebral destruction and paraspinal mass with associated fluid collections. The mass was intermediate signal intensity on T1 weighted images, complex with mildly hyperintense areas on T2 weighted images, and demonstrated peripheral enhancement ().\nIn view of this radiological evidence, the possibility of a chronic infection or a cancerous process was nevertheless envisaged and prompted us to perform a surgical exploration and biopsy for ruling out these differential diagnoses. Cultures of liquid samples were negative. Histological examination revealed the presence of fibrous tissue with sequestered bone but no signs of malignancy (). The findings were typical of Charcot spine. Therefore, the authors could make a diagnosis Charcot spine.\nOne week after a surgical exploration and biopsy, the authors performed a circumferential arthrodesis via a single staged posterolateral costotransversectomy approach for correction T11, 12 severe deformities. The thoracolumbar spine was exposed and pedicle screws were inserted into T8-T10 and L1-L3. Because of gross instability and collapse across the Charcot segment, a unilateral rod was used for temporary stability and distraction. Laminectomy was performed at T10 and L1 to gain access to the normal epidural space above and below. Next, the scar and hypertrophic reactive tissue around the left T11, 12 roots and the residual T11, 12 posterior elements was removed. The left T11, 12 roots were then ligated and divided to give access to the lateral and anterior aspects of the destroyed vertebral bodies (). Bony resection of the residual T11, 12 bodies and adjacent disc was then carried out, taking care to keep within the confines of the anterior pseudocapsule of the Charcot joint. The end plates of T10 and L1 were then prepared. A mesh case with auto-iliac bone graft, placed within the concavity of the endplates. The lateral posterior elements of T10 (inferior facet) and L1 (superior facet) were decorticated and packed with morselized local bone and allograft. The patient tolerated the surgical procedure well, there were no intraoperative complications, and estimated blood loss was 500 mL. After surgery, the patient was mobilized as tolerated without brace. A prophylactic antibiotic was used for 48 hours after surgery. There were no postoperative complications.\nTwo year after surgery, the patient returned to independent life including driving to work. And the fusion appeared solid without evidence of hardware loosening or change in spinal alignment on the plain radiographs (). However, the follow-up CT imagies revealed inadequate preparation of T10 lower and L1 upper end plate, and incorrect placement of a mesh cage. A floating mesh cage (not placed within the concavity of the endplates) generally cannot guarant solid fusion. We thought that causes of inadequate endplate preparation were limited visualization of posterior approach and vague boundary between bone and disc by the scar and hypertrophic reactive tissue around the Charcot segment. Instead of getting fusion between T10 and L1, we luckily got solid fusion between the residual T11, 12 bodies by a mesh cage with auto-iliac bone graft ().