143. IS SURGERY INDICATED FOR ALL SPINAL NEUROARTHROPATHIES?

Abstract

Purpose of the study: Management of the spinal neuroarthropathy of Charcot’s disease is recommended. Vertebral fusion should be extensive and often circumferential. The natural history of this disease, often diagnosed late, is poorly understood and the results of functional treatments not well studied. The purpose of this study was to describe the elements motivating surgical abstention and to analyse the natural course of the vertebral lesions.

Material and methods: The diagnosis of spinal neuroarthropathy was established in seven patients from 1997 to 2007. Six has paraplegia and one female patient Friedrich ataxia. The initial neurological disease was known for 18 years on average before diagnosis of the spinal neuroarthropathy. The management decision was based on patient motivation, comorbid conditions, and successive functional, clinical and imaging assessments. The patients were classed by the progression of vertebral destruction. Four patients had a non-evolving destruction, two with a stable spine and two with spinal hypermobility.

Results: The spinal stability, the absence of progression of the spinal neuroarthropathy, and in certain cases the presence of an ossification process were determining in deciding to abstain from surgery. Despite the collapse of the trunk, surgical abstention was decided for two patients basically because of the loss of spinal mobility resulting from the arthrodesis. For three other patients with progressing spinal lesions, the presence of comorbid factors (major risk of infection), patient refusal of the risk of temporary or definitive loss of function were the reasons surgery was decided against.

Discussion: According to the literature, it is assumed that abstention from surgery will invariably lead to neurological or infectious complications and even patient death. We did not observe these events in our series. The major surgery exposes to a risk of failure; certain authors have reported a complication rate of 60% and others have had 40% repeat operations. The instability induced by the spinal neuroarthropathy can be considered providential by the patient. The fact that several patients declined surgery because of the fear of worsening their handicap after arthrodesis is noteworthy. Simulation with a rigid corset was determining. The spinal neuroarthropathy does not appear to be a continuous destructive process but its natural history is not well known. Predictive elements were not identified in this study.

Conclusion: Charcot’s spinal neuroarthropathy is a challenging condition in frail patients. Disease progression, comorbid conditions, and multidisciplinary functional assessments are needed for adequate management and decision making.