Complex Charcot Spine Reconstruction in a Young Paraplegic Patient: A Case Report

Spinal Charcot arthropathy (SCA) is a rare, progressive, and destructive neurogenic joint disorder that develops in the setting of impaired sensory and autonomic innervation. Although once associated primarily with tabes dorsalis, spinal cord injury (SCI) is now the leading cause. The condition arises through a combination of autonomic dysregulation, bone resorption, and loss of proprioceptive feedback, resulting in progressive joint destruction and spinal instability. Diagnosis is often delayed, as symptoms such as deformity, instability, or autonomic dysreflexia (AD) may develop insidiously over the years. We report the case of a 28-year-old female patient with paraplegia secondary to a chronic T5 SCI who presented with progressive thoracic deformity due to a severe Charcot joint at T12, associated with fracture-dislocation and a large pseudomeningocele. Despite complete thecal sac transection, her neurological function remained stable. Surgical management involved T5-pelvis posterior fusion with vertebrectomy, expandable cage placement, and a four-rod construct for maximal biomechanical stability. Intraoperative neuromonitoring was utilized throughout the procedure. The thecal sac was ligated to control cerebrospinal fluid (CSF) leakage. Postoperatively, the patient experienced transient hypotension consistent with autonomic dysfunction, but otherwise recovered well, achieving stable spinal alignment and resolution of her spinal deformity at three-month follow-up. This case highlights several critical considerations in managing SCA, including the need for long-segment fixation extending to the pelvis to reduce recurrence, the advantages of multirod constructs for enhanced mechanical durability, and the importance of addressing CSF leaks from thecal sac injury. AD and hemodynamic instability must also be anticipated in this patient population. SCA should be suspected in paraplegic patients presenting with new deformity or instability, even at a young age. Early recognition and individualized surgical planning, including long-segment fusion, anterior column support, and definitive dural management, are essential to achieve durable stabilization and prevent recurrence. This case also highlights the importance of considering SCA among the differential diagnoses for progressive deformity in chronically paraplegic patients, while also recognizing alternative etiologies such as prior destabilizing surgery. This case contributes to the limited literature on SCA in young patients and offers practical insights for complex spinal reconstruction in neurologically impaired patients.