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American Journal of Physical Medicine & Rehabilitation:
doi: 10.1097/PHM.0b013e31825a18dc
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Cephalad Sensory Loss as Clinical Manifestation of Charcot Spine in Spinal Cord Injury

Oni, Margaret B. MD; Dajoyag-Mejia, Maria Aurora MD

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From the Department of Physical Medicine and Rehabilitation (MBO, MAD-M), Baylor College of Medicine; and Spinal Cord Injury Care Line (MAD-M), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.

All correspondence and requests for reprints should be addressed to: Margaret B. Oni, MD, Baylor College of Medicine, 8735 Keegans Forest Lane, Houston, TX 77031.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

A 63-yr-old man with a history of T10 ASIA (American Spinal Injury Association) B spinal cord injury presented to the clinic with ascending sensory loss over a period of 2 yrs. Initial spinal injury occurred in 1969 after a motor vehicle accident, resulting in a laminectomy, followed by T5 to T12 Harrington rod placement for scoliosis in 1980. Before sensory changes, the patient was independent with activities of daily living, transfers, and manual wheelchair mobility.

The patient reported increased bilateral lower limb spasticity and difficulty maintaining an upright position in his wheelchair. On examination, the patient was noted to have ongoing ascending sensory loss; pinprick and crude touch remained intact through T1, impaired through T6, and absent distally. Rectal sensation remained intact and motor level unchanged with normal strength in the C5 to T1 distribution. The patient was ultimately classified as a T1 ASIA B. Computed tomography myelogram of the spine was significant for L2 to L3 diskitis and osteomyelitis (Fig. 1). Subsequent magnetic resonance imaging of the spine reiterated this finding (Fig. 2). Given concern for an infectious etiology, the patient underwent computed tomography–guided bone and soft tissue biopsies of involved vertebral levels, which were found to be negative for acute bacterial, fungal, viral, or neoplastic process.

Figure 1
Figure 1
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Figure 2
Figure 2
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In lieu of a diagnosis, the imaging studies were further reviewed with spinal cord and orthopedic colleagues, and it was noted that in addition to vertebral destruction, there were isolated areas of bony debris that could be consistent with Charcot spine rather than an infectious etiology. Furthermore, flexion and extension x-rays confirmed instability of the involved lumbar region.

Given above findings, a diagnosis of Charcot spinal arthropathy was made. It was hypothesized that spinal cord traction in the setting of vertebral destruction led to the above sensory deficits. The patient subsequently underwent anterior and posterior spinal stabilization via fusion and instrumentation of the involved vertebrae by orthopedic surgery.

Charcot spinal arthropathy is a destructive condition that affects the vertebral architecture in chronic spinal cord injury patients.1 The classic presentation includes back pain, kyphosis, and audible sounds with motion.2–4 The isolated symptom of cephalad sensory loss in this patient, although nonspecific, may aid in making the diagnosis with associated radiographic findings, particularly in the setting of benign infectious and neoplastic work-up. Such early recognition of Charcot spinal arthropathy may help expedite surgical intervention and subsequently improve patient functional status.

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REFERENCES

1. Bishop FS, Dailey AT, Schmidt MH: Massive Charcot spinal disease deformity in a patient presenting with increasing abdominal girth and discomfort. Neurosurg Focus 2010; 28: 17

2. Barrey C, Massourides H, Cotton F, et al.: Charcot spine: two new case reports and a systematic review of 109 clinical cases from the literature. Ann Phys Rehabil Med 2010; 53: 200–20

3. Vialle R, Mary P, Tassin JL, et al.: Charcot’s disease of the spine: diagnosis and treatment. Spine 2005; 30: 315–22

4. Standaert C, Cardenas DD, Anderson P: Charcot spine as a late complication of traumatic spinal cord injury. Arch Phys Med Rehabil 1997; 78: 221–5

© 2013 Lippincott Williams & Wilkins, Inc.

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