Long-term follow-up of the surgical management of neuropathic arthropathy of the spine.

BACKGROUND CONTEXT: No studies have discussed the long-term surgical management and outcomes of Charcot arthropathy of the spine. This case series presents nine patients treated over 30 years. The study hypothesis was that surgery would reduce instability, pain, recurrence, and the need for revision surgery in the long-term, given previous study findings of successful fusion of Charcot spine in the short-term. PURPOSE: To evaluate the long-term outcomes of surgery for Charcot spine. STUDY DESIGN/SETTING: Retrospective case series. Cases took place at Stanford University Medical Center and Santa Clara Valley Medical Center. METHODS: All patients had either complete paraplegia or dense paraparesis with both major motor and sensory deficits. Seven patients developed Charcot spine after spinal instrumentation for trauma, one after scoliosis repair for meningomyelocele, and one after spinal instrumentation for neuromuscular scoliosis caused by birth injury resulting in C6-C7 quadraplegia. Average time between initial instrumentation and development of Charcot spine was 7.6 years. Two patients underwent posterior fusion alone, six had anterior-posterior fusion, and one was managed with thoracolumbar orthosis. RESULTS: Average follow-up was 14.3 years. Revisions were necessary in 75% (6 of 8) of patients for complications including nonunion, new Charcot joints, recurrent hardware failure, and osteomyelitis. Achieving fusion often required multiple operations, and there were no deaths or neurologic complications. CONCLUSIONS: Long-term follow-up showed a high rate of revision surgery. Solid fusions often resulted in late breakdown or new junctional Charcot arthropathies. Patients initially fused to the lumbar spine instead of the sacrum or pelvis had a higher rate of developing another Charcot joint. Fusion was often difficult with persistent nonunions and functional deficits because of decreased mobility. We recommend that Charcot spine well tolerated without skin, seating problems, or dysreflexia should be cautiously observed with conservative management. For surgical care, we recommend three-column stabilization with either combined anterior-posterior or all posterior approaches with anterior support to obtain and secure greater long-term stability.

Intracranial hypotension and recurrent pleural effusion after snow-boarding injury: a manifestation of cerebrospinal fluid-pleural fistula.

BACKGROUND DATA: Intracranial hypotension causing postural headaches has been described after occult and postsurgical cerebrospinal fluid (CSF) leaks and rarely isolated lumbar punctures. The occurrence of a CSF-pleural communication is much rarer, and a high level of suspicion aids in prompt recognition. PURPOSE: Early detection and anatomic delineation of the site of CSF-pleural fistula allows prompt intervention, results in resolution of symptoms and prevents the complication of meningitis. STUDY DESIGN: A case of intracranial hypotension with postural headaches is described after spinal surgery, with demonstration on computed tomography (CT) myelography of a rare CSF-pleural fistula. METHODS: The clinical presentation, postoperative intervention and imaging as well as laboratory data are presented. RESULTS: Chest X-ray showed recurrent pleural effusion after placement of chest tube, and serial head CT studies revealed decreasing ventricular size with development of severe headaches. Myelogram and CT postmyelogram demonstrate the CSF-pleural communication, allowing appropriate surgical repair. CONCLUSION: Severe headaches with a recurrent pleural effusion after thoracic spinal surgery may indicate presence of a CSF-pleural fistula, an unusual complication of thoracic spinal surgery.