Charcot's arthropathy of the spine



Illustration 1.

The patient, a 67-year-old man with a 19-year history of posttraumatic D9 sensorimotor paraplegia, was referred to our hospital for progressive fatigue. Physical examination revealed deep sacral and lumbar decubitus ulcers, but findings were otherwise normal. Blood tests revealed a modestly elevated C-reactive protein level and erythrocyte sedimentation rate. Blood cultures yielded negative results. Based on the hypothesis that the symptoms were the result of a cancerous process or chronic osteomyelitis associated with decubitus ulcers, a computed tomography scan (left) and plain radiographs (right) of the spine were obtained. A proliferative, hypertrophic L4 vertebral lesion with bone destruction and a pseudotumoral appearance was observed. Several percutaneous vertebral biopsies were performed; however, histologic and bacteriologic examination revealed nonspecific bone fibrosis. Charcot's arthropathy of the spine was diagnosed based on the findings of hypertrophic vertebral deformity with bone destruction in the absence of an infectious or neoplastic disease, in a patient with a predisposing neurologic condition. First described by Jean Charcot in patients with tertiary syphilis, Charcot's arthropathy of the spine, also known as spinal neuropathic arthropathy, is a destructive, degenerative condition affecting the intervertebral disc and the contiguous vertebral bodies, which develops secondary to a neurologic lesion. Today, it predominantly affects patients with traumatic paraplegias or congenital insensitivity to pain. Impaired proprioception and loss of pain sensation result in the lack of retraction reflexes and other protective mechanisms. The resulting unopposed, cumulative mechanical damage eventually leads to dislocation, destruction, and deformity of the affected joint (1). In imaging studies, extensive bone destruction and disorganization associated with productive hypertrophic changes, osteophytosis, peripheral bony debris, and inflammation of the paraspinal soft tissues are seen (2). The resulting pseudotumoral appearance is often misdiagnosed as infective spondylitis or as a cancerous condition. Management options comprise observation, immobilization with a body jacket, and surgery (3). This patient refused therapeutic management of the lesions.