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Neuroradiologie Scan 2016; 06(03): 215-238
DOI: 10.1055/s-0042-109937
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© Georg Thieme Verlag KG Stuttgart · New York

Neuroarthropathie der Wirbelsäule: Pathophysiologie, klinisches Bild, Bildgebungsmerkmale und Differenzialdiagnose[1]

Spinal neuroarthropathy: pathophysiology, clinical and imaging features, and differential diagnosis
Luke N. Ledbetter
,
Karen L. Salzman
,
R. Kent Sanders
,
Lubdha M. Shah
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Publikationsverlauf

Publikationsdatum:
01. August 2016 (online)

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Zusammenfassung

Die Neuroarthropathie der Wirbelsäule oder Charcot-Wirbelsäule ist eine progredient verlaufende, destruierende Gelenkerkrankung, die nach Verlust der neuroprotektiven Sensibilität und der propriozeptiven Reflexe auftritt. Die klinische Diagnose ist wegen der unterschiedlich langen Zeit zwischen der initialen neurologischen Schädigung und dem Auftreten der Arthropathie und wegen der infolge der vorbestehenden neurologischen Ausfälle eingeschränkten Symptomatik schwierig. Die spinale Neuroarthropathie stellt auch deshalb eine diagnostische Herausforderung dar, weil ihre Bildgebungsmerkmale denen bei anderen Erkrankungen der Wirbelsäule, wie z. B. Diszitis/Osteomyelitis, Knochentuberkulose, hämodialysebedingte Spondylarthropathie und Pseudarthrose, ähneln. Das für die Diagnose einer spinalen Neuroarthropathie wichtigste Bildgebungskennzeichen ist die Beteiligung sowohl der anterioren als auch der posterioren Elemente der thorakolumbalen bzw. lumbosakralen Gelenke. Als zusätzliche Hinweise finden sich im Bildgebungsbefund das Vakuumphänomen innerhalb der Bandscheibe (ein Zeichen abnorm erhöhter Beweglichkeit), Malalignment und paraspinale Weichgeweberaumforderungen oder Flüssigkeitsansammlungen, die Knochendebris enthalten. In manchen Fällen kann sich jedoch der Befund trotz dieser Zeichen mit dem einer Infektion überschneiden oder es liegt eine spinale Neuroarthropathie mit Superinfektion vor. In diesen Fällen kann eine Biopsie erforderlich sein. Voraussetzung für die Entwicklung einer spinalen Neuroarthropathie ist eine vorbestehende neurologische Erkrankung, in den meisten Fällen eine traumatische Rückenmarkschädigung. In den Bereichen der empfindungslos gewordenen Wirbelsäule, die die größte Beweglichkeit aufweisen und gleichzeitig der stärksten Gewichtsbelastung ausgesetzt sind, kommt es wiederholt zu Mikrotraumata und unkontrollierter Hyperämie mit der Folge einer Destruktion der Intervertebralgelenke. Der progressive und destruierende Charakter der spinalen Neuroarthropathie verursacht erhebliche Deformitäten, Funktionsverlust und häufig weitere neurologische Ausfälle. Die Patienten stellen sich mit Deformitäten, Rückenschmerzen, hörbaren Geräuschen bei Bewegung oder neu aufgetretenen neurologischen Symptomen vor. Die Behandlung besteht hauptsächlich aus chirurgischem Débridement, Reposition und Fusion. Der Radiologe kann zur Einleitung einer frühen Intervention dadurch beitragen, dass er anhand der wichtigsten Bildgebungsmerkmale zwischen spinaler Neuroarthropathie und ähnlich aussehenden Bildgebungsbefunden unterscheidet und eine weitere neurologische Verschlechterung verhindert.

Abstract

Spinal neuroarthropathy (SNA), or Charcot spine, is a progressive destructive arthropathy occurring after loss of neuroprotective sensation and proprioceptive reflexes. Clinical diagnosis is difficult because of the variable length to presentation after initial neurologic damage and the limited symptoms given preexisting neurologic deficits. SNA is also a diagnostic challenge because its imaging features are similar to those of spinal conditions such as discitis-osteomyelitis, osseous tuberculosis, hemodialysis-related spondyloarthropathy, and pseudarthrosis. The most important imaging clues for diagnosis of SNA are involvement of both anterior and posterior elements at the thoracolumbar and lumbosacral junctions. Additional imaging clues include vacuum phenomenon within the disk (indicating excessive motion), malalignment, and paraspinal soft-tissue masses or fluid collections containing bone debris. Despite these imaging signs, findings may overlap in some cases with those of infection, or SNA can be superinfected, and biopsy may be necessary. Development of SNA requires a preexisting neurologic condition, most commonly traumatic spinal cord injury. Areas of greatest mobility and weight bearing within the desensate spine experience repetitive microtrauma and unregulated hyperemia, leading to destruction of the intervertebral articulations. The progressive and destructive nature of SNA causes substantial deformity, loss of function, and often further neurologic deficits. Patients present with deformity, back pain, audible noises during movement, or new neurologic symptoms. The mainstay of treatment is surgical débridement, reduction, and fusion. The radiologist can help initiate early intervention by using key imaging features to distinguish SNA from imaging mimics and prevent further neurologic deterioration.

1 © 2016 The Radiological Society of North America. All rights reserved. Originally published in English in RadioGraphics 2016; 36: 783 – 799. Online published in 10.1148 /rg.2016150121. Translated and reprinted with permission of RSNA. RSNA is not responsible for any inaccuracy or error arising from the translation from English to German.


 

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