Surgical management of Charcot spinal arthropathy: a single-center retrospective series highlighting the evolution of management.

OBJECT: Charcot spinal arthropathy (CSA) is an uncommon disorder that occurs in the setting of conditions with decreased protective sensation of the vertebral column, resulting in vertebral joint degeneration, pain, and deformity. Historically, CSA treatment has been fraught with high failure rates. Over time, the authors' institution has trended toward a CSA treatment paradigm of intralesional debridement, circumferential fusion, and four-rod lumbopelvic fixation. As such, the overall objectives of this study were to define the specific clinical characteristics of this rare condition and to determine whether the authors' treatment paradigm has decreased the incidence of revision due to hardware failure/presumed pseudarthrosis or the development of a new CSA over the course of the study and in comparison with historical controls.
METHODS: The authors performed a retrospective review of the clinical and radiographic records for all patients with CSA treated by the Spine Service at the University of Washington between 1997 and 2009.
RESULTS: Twenty-three patients with CSA were identified. The mean age at presentation was 43.1 years, and the mean latency between spinal cord injury and CSA diagnosis was 19.6 years. The mean follow-up was 33.1 months. Pain and progressive deformity were the major presenting symptoms. Concomitant infection was identified in 17% of patients. Patients with CSA were noted to have long initial fusion constructs spanning an average of 8.4 vertebral levels. Charcot spinal arthropathy did not occur above the level of neurological injury. The vast majority of CSA cases occurred caudally along the spinal axis, with 65% occurring within 1 level of the caudal end of the index fusion construct and 35% occurring even farther distally. Revision due to hardware failure or the development of a new CSA level occurred in 35% of patients. Rates of treatment failure requiring revision significantly decreased over the course of the study, with revision occurring in 6 (66%) of 9 patients who underwent surgery before 2002, in comparison with only 2 (14%) of 14 treated between 2002 and 2009. During a mean follow-up period of 34 months, no treatment revision occurred in the subgroup of 9 patients who underwent four-rod lumbopelvic fixation.
CONCLUSIONS: This study represents the largest reported modern surgical series of CSA patients. While revision rates were initially high and comparable to previous reports, the authors' multimodal treatment paradigm, which includes the use of bone morphogenetic protein and four-rod lumbopelvic fixation, dramatically reduced the incidence of treatment failure requiring revision over the course of the study period and represents a significant improvement in the treatment of CSA.