Surgical Challenges in the Management of Charcot Spinal Arthropathy with Progressive Spinal Deformity

Introduction: Charcot spinal arthropathy develops in approximately 1% of patients after spinal cord injury. Surgical stabilization is performed for sitting balance, prevention of decubitus ulcers, and restoration of intrathoracic/abdominal volume. Here, we present unique technical challenges and reconstruction considerations in a patient with spinopelvic dissociation due to Charcot spine, in the setting of prior pedicle screw instrumentation T2-L1 and anterior instrumentation T11-L5.

Methods: A 37 yo/male, paraplegic at birth due to spinal cord vascular event presented with progressive scoliosis, spinal shortening and recurring ischial decubitus ulcers from marked pelvic obliquity. Patient underwent lateral TSRH instrumentation at T11-L5 at age 8 followed by T2-L1 posterior fusion at age 16 for progressive thoracic scoliosis. He developed Charcot arthropathy at L5-S1 with complete dissociation and transection of thecal sac. Pelvic obliquity was more than 25 degrees.

Results: We performed revision of posterior instrumentation at T7-L5, pseudo-arthrosis repair at T10-T11, L5 three column osteotomy with an large structural titanium mesh cage done all posteriorly, L5-S1 posterior spinal fusion with six-point pelvic fixation- bilateral stacked S2-alar-iliac and iliac kickstand screws. Significant improvement in his ability to sit upright with spinal alignment was noted at 6-week follow-up. Sitting tolerance and transfer abilities have improved per patient and occupational therapy evaluations. He reports having to self-cath less often and improved bowel control.

Conclusion : Intraoperative navigation is challenging in spinopelvic dissociation. We performed temporary pelvic fixation with kickstand screws and then could navigate more robust pelvic fixation. Navigation facilitated pedicle screw placement around existing instrumentation. Placement of a large cage was done from posterior route in the setting of complete thecal sac transection. Targeting the right sagittal alignment for a paraplegic sitter is critical.