After Charcot described the neuropathic joint in 1868 [
1] and Charcot spinal arthropathy was reported in a patient with tabes dorsalis in 1884 [
2], the first report of Charcot spinal arthropathy in a patient with post-traumatic paraplegia appeared in 1978 [
3]. Since then, traumatic spinal cord injury has become the commonest cause of Charcot spinal arthropathy, however, this condition is rare with less than 90 cases reported [
4]. The mean time of development of Charcot spine after the initial spinal injury is usually greater than 10 years [
5]. The destructive process is triggered by loss of protective pain and proprioceptive sensation in the post-traumatic spinal cord-injured spine, resulting in abnormal motion and instability, leading to disc degeneration, facet joint destruction, and eventually causing vertebral destruction and fracture, subluxation, deformity, and dislocation. Symptoms include pain, further neurological deterioration, progressive deformity and impairment of sitting balance. There have been rare case reports of patients presenting with autonomic dysreflexia, an imbalance in reflex sympathetic discharge resulting in hypertension, headache and profuse sweating [
4,
6]. Surgery is often indicated upon failure of non-operative management, although it is associated with high risk of complications, including infection, failure of fixation and need for revision surgery [
7,
8]. The goals of surgery are to achieve a painless well-balanced spine, maintain sitting balance and obtain a solid fusion, thus restoring stability. Dual anterior and posterior surgery is usually recommended to obtain circumferential stabilization and fusion, especially in severe cases [
7,
8]. Occasionally, patients may have a long pre-existing fusion mass with the Charcot arthropathy distal to this, and the posterior instrumentation needs to be extended to the sacrum or pelvis [
5].
Long multisegmental posterior thoracolumbar fusions to the sacrum and pelvis are challenging operations associated with high complication rates including instrumentation prominence and failure and pseudarthrosis [
9]. However, successful fusion results in stiffening of the spine and leads to increased motion and biomechanical strain at caudal or rostral levels of the axial skeleton adjacent to the fusion [
10]. This in turn may cause degeneration, instability and insufficiency fracture, especially in patients with poor bone quality and longer fusion segments [
11]. Although uncommon, sacral insufficiency fractures just distal to S1 screws after multisegmental lumbosacral fusion have been reported in several case series [
12]. If symptoms do not improve with non-operative management, extension of instrumentation to the iliac wings is an effective salvage procedure. However, the biomechanical effects of long fusions and instrumentation to the ilium are unknown. To the best of our knowledge, no previous case of bony fracture immediately distal to iliac fixation has been reported. When the fusion ends in the ilium, the hip joint becomes the adjacent distal joint. We present a patient who sustained a comminuted intertrochanteric femoral neck fracture after a long multisegment spinopelvic fixation to the ilium for Charcot spine.