Q. I am 52 and in my 25th year as a T6-7 complete para. I have Harrington rods from T3 to T10. About a year ago I noticed I was leaning to the left side of my chair and couldn’t seem to sit straight. I also started hearing a grinding sound in my lower back, and my leg spasms increased to the point where it was interfering with my daily life.
My doctor ordered a set of spine X-rays and then a CT scan. She said the results showed that I had “Charcot’s arthropathy” and showed me my X-ray. It looked like half of my T12 and L1 vertebrae had disappeared — just vanished. Two weeks later I had surgery that included cutting and removing the lower part of my rods at T8 and adding new rods from T8 to L3. It was a big surgery — and so far so good, I’m sitting straight, and the grinding noise and muscle spasms are gone.
Prior to my diagnosis I had never heard of Charcot’s arthropathy and I’m still trying to wrap my head around what it is. How common is it among people with SCI? A year after I was injured I was going to have my rods removed. Would it have made any difference?
A. Charcot’s arthropathy (also called “Charcot joint”) is the progressive destruction caused by repeated trauma to a joint that doesn’t have sensation. When it occurs in the spine, often referred to as “Charcot spine,” it causes one or more vertebrae — below the level of fusion — to become progressively reabsorbed (disappear), which creates a false joint that often causes instability, scoliosis (sideways curve) or kyphosis (outward curve of the spine).
Charcot joint was initially coined by Jean-Martin Charcot, a neurologist in the 1800s, to describe degenerative changes in a joint that had lost sensation due to diseases of the day like leprosy and syphilis. These days the term Charcot is usually associated with diabetes, as in “Charcot foot,” which describes progressive joint damage that a person is unaware of due to sensation loss. The person then keeps walking on the foot until the joint is destroyed and the body absorbs the bone.
To get the lowdown on how Charcot’s happens in the spine, I turned to Dr. Douglas Garland, an orthopedic surgeon and former director of neurotrauma at Rancho Los Amigos Rehab Center. Garland explains that Charcot Spine is caused by a combination of spinal fusion, loss of sensation below the fusion, and repeated, excess stress on the vertebrae below the fusion.
The spine has 24 articulating vertebrae (joints) that enable us to bend and twist. A fusion reduces the number of joints and the bending/twisting load is transferred to the remaining vertebrae. Garland explains that a fusion, whether done with rods, a cage, or other device, becomes a lever arm, just like the arm of a tire iron. The longer the fusion, the greater the lever arm force, which places a higher bending and twisting demand on the fewer remaining vertebrae. “When I was at Rancho I would warn those with SCIs about doing impact sports, because part of the spine is now fused and it puts more stress on the discs and vertebrae below,” says Garland. “Plus you can’t feel if you are stressing it too much. If you could feel it, you would self-limit. The pain would cause you to stop.”
“It is the fused vertebrae, not the rods, that change the dynamic of the spine,” explains Garland. “Unless they are bothering you, there is no evidence that removing rods is any better than leaving them in. In general rods should not be removed because it is difficult to tell if a proper fusion has occurred, and it is a difficult surgery.”
“Charcot spine is caused by wear and tear in the vertebrae below the base of the fusion — the vertebrae that don’t have sensation,” says Garland. “Repeated trauma causes micro fractures and the body starts to absorb the vertebrae, leading to a false joint. The trauma also causes huge amounts of bone deposit, almost like heterotopic ossification.” Charcot joint usually forms one to two segments below the spinal fusion.
A web search of Charcot spine pulled up seven journal articles on the subject published between the years of 1997 and 2015 that show corresponding findings. Symptoms of Charcot spine varied and included one or more of the following: localized low back pain, loss or increase of spasticity, audible noise (grinding or clicking) with motion of the spine, change in seating position — leaning to one side, or leaning forward with a rounding of the back (kyphosis). Also, episodes of severe sweating and autonomic dysreflexia. The average onset of Charcot spine symptoms was 27 years post-injury and ranged from 10 to 41 years, according to a five-patient case study in the September 2005 issue of The Bone and Joint Journal.
Early diagnosis and treatment of symptomatic Charcot spine is important, says Garland, especially if it is causing scoliosis or kyphosis, because it is a progressive disorder. The more it progresses, the more difficult it becomes to straighten out. Diagnosis is made with an X-ray and followed up by an MRI or CT scan to rule out osteomyelitis (bone infection). Treatment usually consists of using rods and screws to fuse the vertebrae together and straighten the spine.
All five of the Charcot spine subjects in The Bone and Joint article underwent fusion at a three year follow-up. They all reported good relief of their symptoms and were able to return to their previous level of activity.
“Just as important as knowing when to treat Charcot spine, is knowing when to leave it be,” explains Garland. “If a Charcot joint is present in the spine, but there are no symptoms and the spinal column remains lined up, it should be left alone. In those cases it helps with flexibility. It should be monitored with a yearly X-ray, and as long as things remain stable and there isn’t a big gap and no deformity, it should be left alone.”
The main takeaway of all of this is awareness and risk analysis. “If you have a long fusion and are doing impact sports, you put yourself at risk of having Charcot spine,” says Garland. It is a balancing act of knowing the risks of certain sports and activities and making informed decisions.
How common is Charcot spine? A common thread among several journal articles on Charcot spine is that although it is rarely reported in journals up to now, Charcot spine will probably be seen more frequently because those of us with SCI are living longer and have active lives. This makes it important for physicians to be aware of the condition. It is even more important to us to be aware, since we know our bodies better than anybody.
• Characteristics and surgical management of neuropathic (Charcot) spinal arthropathy after spinal cord injury: www.thespinejournalonline.com/article/S1529-9430(13)01362-4/abstract?cc=y=
• Charcot’s Arthropathy of the Spine: A Late Complication of Spinal Instrumentation: www.bjjprocs.boneandjoint.org.uk/content/87-B/SUPP_III/401.3
• Charcot Joint in a Paraplegic History: www.spineuniverse.com/professional/case-studies/sekhon/charcot-joint-paraplegic
• Charcot Spine after Remote Cervical Spine Injury: www.omicsgroup.org/journals/charcot-spine-after-remote-cervical-spine-injury-2167-1222.1000191.pdf
• Charcot spinal arthropathy: an increasing long-term sequel after spinal cord injury with no straightforward management: www.nature.com/articles/scsandc201522