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\begin{document}

\title{Infected charcot spine}



\author[1]{Hiromu Yoshizato}%
\author[1]{Tadatsugu Morimoto}%
\author[1]{Toshihiro Nonaka}%
\author[1]{Hirohito Hirata}%
\affil[1]{Saga University Faculty of Medicine Graduate School of Medical Sciences Department of Orthopaedic Surgery}%


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  \date{May 25, 2024}


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Infected charcot spine

Hiromu Yoshizato (MD)

Department of Orthopaedic Surgery, Faculty of Medicine, Saga University,
Saga, Japan

5-1-1 Nabeshima, Saga, 849-8501, Japan

22624011@edu.cc.saga-u.ac.jp

Tadatsugu Morimoto (MD, PHD)

Department of Orthopaedic Surgery, Faculty of Medicine, Saga University,
Saga, Japan

5-1-1 Nabeshima, Saga, 849-8501, Japan

morimot3@cc.saga-u.ac.jp

Toshihiro Nonaka (MD)

Department of Orthopaedic Surgery, Faculty of Medicine, Saga University,
Saga, Japan

5-1-1 Nabeshima, Saga, 849-8501, Japan

nohcanon.2@gmail.com

Hirohito Hirata (MD, PHD)

Department of Orthopaedic Surgery, Faculty of Medicine, Saga University,
Saga, Japan

5-1-1 Nabeshima, Saga, 849-8501, Japan

h.hirata.saga@gmail.com

Corresponding Author's Information

Tadatsugu Morimoto

\emph{morimot3@cc.saga-u.ac.jp}

Statements relating to ethics and integrity policies

We declare that we follow the ethical policies of the journal, including
patient consent, disclosure of funding information, and data
availability.

Manuscript Type: Case Images

Key words: Pain-Free, Low Back Pain, Spondylitis, Diagnosis,
Differential, Stphilis

Introduction.

Low back pain is an often encountered complaint among clinical
physicians. Although it can be caused by various conditions, there may
be diseases that, if overlooked, could lead to serious consequences.
Examples include aortic aneurysm, pyogenic spondylitis, metastatic
spinal tumors, etc. Charcot spine, which occurs as a result of syphilis
or spinal cord injury, exhibits severe deformity despite mild lower back
pain. Infected Charcot spine (ICS), even if accompanied by fever, may
not present lower back pain or only exhibit mild symptoms. As a result,
the diagnosis may not be accurately made until the vertebral destruction
progress severely and neurological paralysis emerges.

Case

A 44-year-old man was admitted with complaints of weakness in the lower
extremities. He had no low back pain and walked unaided. Although he had
no history of diabetes or spinal trauma, he had positive syphilis was
serology. A physical examination revealed right tibialis anterior muscle
weakness, decreased pain sensation in the lateral thigh, decreased
vibration sensation in both medial calves, and bladder dysfunction.
There was no heat or redness in the lumbar region. Blood tests showed
C-reactive protein (CRP) 30 mg/\selectlanguage{greek}µ\selectlanguage{english}L. X-rays showed severe destruction of
the L4 vertebra (figure1, arrow) and angulated kyphosis, and magnetic
resonance imaging revealed fluid retention in the destroyed L4 vertebra
(figure2, arrow). The severe spinal destruction without back pain was
diagnosed as an infected Charcot spine (ICS) , and an anterior-posterior
lumbar fusion was performed.

Discussion

Tabes dorsalis occurs 20 to 30 years after the initial infection of
syphilis, causing progressive degeneration of the posterior columns and
posterior nerve roots. As a result, proprioception and vibratory
sensation are lost, contributing to the development of Charcot spine and
Charcot joints. In this case, the patient had no low back pain, despite
a paralyzing severe spinal deformity. The reason for facing difficulty
in diagnosing such a condition lies in the pathophysiology of ICS, which
results in few complaints of back pain due to diminished sensation, and
the rapid progression of vertebral destruction due to concurrent
infection. Due to the paucity of symptoms, comprehensive examination by
a physician may not be performed, resulting in a delayed diagnosis until
there is evidence of progressive vertebral destruction or the onset of
nerve palsy. What points should be noted when diagnosing ICS? First, it
is crucial to understand the symptoms of Charcot spine. Churruca et al.
reported that 92\% of Charcot spine cases exhibit any symptoms.
Specifically, these include increased spasticity, reflex disorders,
autonomic nervous system symptoms, and pain (2). Second, having
knowledge of differential diagnosis is essential. Differential diagnoses
should include pyogenic vertebrates, osteomyelitis, Paget's disease of
bone, and destructive tumors. While ICS is rare, it should be included
in the differential diagnoses for febrile patients with a history of
syphilis or spinal cord injury. Early diagnosis allows prompt initiation
of suitable treatments, preventing severe spinal damage and nerve
paralysis.

Author Contribution

\textbf{Hiromu Yoshizato} : Writing-original draft. \textbf{Tadatsugu
Morimoto} : Writing- review and editing.

\textbf{Toshihiro Nonaka} : Writing-original draft. \textbf{Hirohito
Hirata} : Writing -- review and editing.

Funding Information

The authors have no current financial arrangement or affiliation with
any organization that could directly influence their work.

Conflict of Interest Statement

We do not have any conflict of interest.

Data Availability statement

Additional data related to this patient case, beyond what is presented
in this publication, is

not publicly available to maintain patient consent, confidentiality, and
anonymity.

Consent

The patient provided written informed consent to publish this report in
compliance with the

journal's patient consent policy.

ORCID

Hiromu Yoshizato\emph{https://orcid.org/0009-0004-7933-3744}

Refferences

\begin{enumerate}
\tightlist
\item
  karthik Yelamarthy P krishna, Rustagi T, Mahajan R, Singh V, Das K,
  Bansal ML, et al. Infected charcot spine arthropathy. Spinal Cord Ser
  Cases. 2018;4:73.
\item
  Arco Churruca AD, V\selectlanguage{ngerman}ázquez Bravo JC, Álvarez SG, Donat SM, Llona MJ.
  Charcot arthropathy in the spine. Experience in our centre. About 13
  cases. Review of the literature. Rev Esp Cir Ortop Traumatol. 2021
  S1888-4415(21)00014-X.
\item
  Suda Y, Saito M, Shioda M, Kato H, Shibasaki K. Infected Charcot
  spine. Spinal Cord. 2005;43:256--259.
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