Progress in the treatment of diffuse idiopathic skeletal hyperostosis combined with thoracolumbar fracture / 国际外科学杂志

Diffuse idiopathic skeletal hyperostosis(DISH) is a kind of ankylosing spinal disease, which usually occurs in the middle-aged and elderly. It is mainly manifested as ossification and calcification of ligaments and tendon attachment points. It is a bone disease that mainly involves the spine but is not accompanied by severe intervertebral disc degeneration or sacroiliac joint and intervertebral facet joint ankylosis. DISH combined with thoracolumbar fracture has a high rate of delayed diagnosis and neurological deterioration, so this kind of fracture should be diagnosed and treated in time. However, there are different conclusions on the choice of treatment methods and postoperative efficacy, and there are still disputes in some academic aspects.The author consulted the relevant literature and reviewed the treatment methods of DISH combined with thoracolumbar fracture in order to provide reference for the clinical treatment of this kind of fracture.

Clinical outcomes of transforaminal lumbar interbody fusion for patients with lumbar spinal stenosis and diffuse idiopathic skeletal hyperostosis / 中华骨科杂志

Objective:To evaluate the outcomes of transforaminal lumbar interbody fusion (TLIF) for patients with lumbar spinal stenosis (LSS) and diffuse idiopathic skeletal hyperostosis (DISH).Methods:This study recruited 33 patients (15 male and 18 female) with LSS and DISH who underwent TLIF surgery from January 2010 to July 2018. The mean age was 65.1±11.2 years old and the instrumented segments averaged 1.45±0.42 levels. Another group of LSS patients without DISH were well matched to the DISH group at a 1∶1 ratio in terms of age, sex, and instrumented levels. Lumbar lordosis, local lordosis as well as lowerlumbarlordosis were measured on X-ray taken before and after surgery. According to Pfirrmann's classification, the degree of preoperative disc degeneration was evaluated on preoperative MRI, and the incidence of postoperative fusion cage subsidence was recorded during follow-up. Oswestry disability index (ODI) was used to evaluate the lumbar function and visual analogue scale(VAS) scores for low back pain and leg pain were used to evaluate the quality of life.Results:There were no significant difference between two groups in terms of age, bone mineral density, operative time, postoperative bleeding volume, fusion levels and postoperative follow-up time. Compared with the non-DISH group (3.20±0.95), the DISH group had higher degeneration disc according to Pfirrmann's classification (3.82±0.64) ( t=3.109, P=0.002), lower lumbar lordosis(37.4°±8.5° vs. 45.2°±12.2°, t=3.013, P=0.003), and lower lower lumbar lordosis (18.3°±3.9° vs. 21.9°±5.4°, t=3.104, P=0.002). After TLIF surgery, lumbar lordosis was significantly improved in both groups. During follow-up, notable correction loss was noted in DISH group in terms of lumbar lordosis (43.6°±9.7° vs. 50.1°±10.2°, t=2.652, P=0.010), lower lumbar lordosis (19.1°±4.7° vs. 22.9°±5.2°, t=2.540, P=0.013) as well as local lumbar lordosis (17.4°±6.5° vs. 22.7°±7.2°, t=3.138, P=0.002). Moreover, these above value in the DISH group were significantly lower than those in the non-DISH group. At the latest follow-up, 12 patients in the DISH group were identified with cage subsidence, which were significantly higher than in the non-DISH group (36.3% vs. 12.1%, χ2=5.280, P=0.022). Till the latest follow-up, both groups had considerable improvement of the ODI score, back pain and leg pain VAS score. However, the back pain VAS scores in the DISH group were significantly higher than that in the non-DISH group ( t=2.862, P=0.005). Conclusion:Compared with LSS patients without DISH, LSS patients with DISH are more likely to have cage subsidence and loss of correction of lumbar lordosis angle after TLIF surgery. Moreover, the VAS score of low back pain in LSS patients with DISH was lower than those without DISH.

The diffuse idiopathic skeletal hyperostosis classification based on CT and the correlation of ossification and sagittal spinal morphology / 中华骨科杂志

Objective:To investigate CT classification of diffuse idiopathic skeletal hyperostosis (DISH), and to analyze the correlation between the position of ossification in the anterolateral spine and the sagittal configuration of the spine.Methods:The medical records of 109 patients (70 male and 39 female) who underwent whole spine computerized tomography (CT) from October 2018 to October 2020 were retrospectively analyzed. The average age was 68.4±6.9 years old, ranging from 60 to 88 years old. High resolution CT volume rendering technique images were used to assess the degree of anterolateral spinal ossification in each vertebral space, and a CT grading system was established. Sagittal parameters such as thoracic kyphosis (TK), lumbar lordosis(LL), cervical lordosis (CL), sacral slope (SS), and thoracolumbar junction angle (TLJ) of the patients were measured. The sagittal morphology of the spine was divided into four types using the modified Abelin-Genevois (AG) sagittal classification. In AG type 1 patients, the kyphotic vertex was located in the middle of the thoracic spine (T 4-T 11). In AG type 2 patients, there was no significant kyphotic vertex. In AG type 3 patients, the kyphotic vertex was located in the thoracolumbar segment (T 12-L 2). In AG type 4 patients, the kyphotic vertex was located in the upper thoracic segment (T 1-T 3). Inter-observer and intra-observer reliability were calculated by intra-group correlation coefficient ( ICC). Statistical analysis was conducted to investigate the correlation between different AG types and ossification location and severity. Results:The new DISH grading system classifies the severity of anterolateral spinal ossification in each intervertebral space into grades 0 to 3 with an intra-observer ICC value of 0.871 and inter-observer ICC value of 0.874. Combined with Resnick's DISH diagnostic criteria, 97 patients (89.0%) in this study had four consecutive intervertebral spaces with ossification grade 1 or above. For these patients, in T 4-T 11, the standardized ossification grade of AG type 1 was 1.24±0.69, greater than that of AG type 2 (0.84±0.71) and AG type 3 (1.00±0.70), and the differences were statistically significant ( F=23.101, P<0.001). In T 12-L 2, the standardized ossification grade of AG type 3 was 1.44±0.87, which was higher than AG type 1 (1.06±0.84) and AG type 2 (0.72±0.63), the differences were statistically significant ( F=14.008, P<0.001). In this study, no patients with kyphosis apex in the cervicothoracic region (AG type4) were found. In T 1-T 3, there was no statistical difference between the three groups ( F=0.303, P=0.738); in the whole thoracic and lumbar spine (T 1-L 5), there was statistically significant difference in the total ossification grade ( F=14.374, P<0.001), there was no statistical difference between AG type 1 and AG type 3 ( P=0.254), both of which were higher than AG type 2 ( P<0.001). Conclusion:The new DISH ossification grading system proposed in this study has high credibility, which can be used in DISH's study. This study confirmed that the region where the apex of kyphosis is located is prone to anterolateral ossification of the spine.

Prevalence and distribution of diffuse idiopathic skeletal hyperostosis in patients with thoracic ossification of the ligamentum flavum / 中华骨科杂志

Objective:To analyze the prevalence and distribution characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in hospitalized patients with thoracic ossification of the ligamentum flavum (TOLF).Methods:The clinical records of 132 consecutive TOLF patients from January 2018 to June 2019 were retrospectively studied. DISH was identified by the preoperative X-ray and CT and its prevalence was calculated. The prevalence of patients with different genders, different age groups and different ossification types was compared. The segmental distribution of DISH and the distribution in the upper (T 1-T 4), middle (T 5-T 8), and lower thoracic spine (T 9-T 12) were analyzed. Ossification degree of DISH was evaluated based on the Meta scoring system. The demographic characteristics (age, gender, BMI, etc.) were compared between DISH and non-DISH group. Results:Forty-nine patients was diagnosed as DISH with the prevalence of 37.1% in all included cases. The prevalence was about twice as high in male (46.3%) than in female (23.1%) ( χ2=8.806, P=0.003). The prevalence in the age groups of <40, 40-49, 50-59, 60-69 and ≥70 years was 20.0%, 28.0%, 34.4%, 44.0%, and 66.7%, respectively. The prevalence in long-segment TOLF patients (45.1%) was significantly higher than that in short-segment TOLF patients (24.0%) ( χ2=5.937, P=0.015). DISH most frequently affected T 8,9 levels (91.8%). The total number and mean number of ossified segments were 365 and 7.4, respectively. Ossification lesions in the upper, middle, lower thoracic spine accounted for 26.03%, 40.54%, and 33.15%, respectively. Grade I, grade II, and grade III ossification accounted for 21.4%, 28.5% and 50.1%, respectively. The mean age of the DISH group was older than the non-DISH group ( t=2.024, P=0.045). The proportion of male patients in the DISH group was significantly higher than that in the non-DISH group ( χ2=8.806, P=0.003). The average height and weight in the DISH group were significantly greater than those in the non-DISH group ( t=2.564, P=0.012; t=2.191, P=0.030), whereas no significant differences in BMI and constituent ratio of concurrent diabetes, cardiac disease, hypertension between two groups were observed. Conclusion:The prevalence of DISH in patients with TOLF is 37.1%. Male, elderly and long-segment TOLF patients are associated with higher prevalence. DISH frequently occurs in the middle and lower thoracic spine, and T 8,9 is the common affected segment. Ossification lesions may develop with age. Demographic characteristics of DISH group differ, to some extent, from those of non-DISH group.

Hiperostosis esquelética difusa idiopática, una causa infrecuente de disfagia y disfonía

Resumen La hiperostosis esquelética difusa idiopática (DISH) es una enfermedad sistémica caracterizada por la osificación del ligamento longitudinal anterior de la columna. Los pacientes suelen ser asintomáticos o presentar dolor leve o rigidez, sin embargo, cuando afecta la región cervical puede ocasionar disfagia, disfonía o disnea. Presentamos el caso de un paciente de 63 años con disfonía y disfagia en quien los estudios demostraron desplazamiento del aritenoides y colapso del seno piriforme debido a un osteofito a nivel de C4. El paciente presentó mejoría con tratamiento conservador. Realizamos una discusión del caso y una revisión de la literatura sobre diagnóstico y tratamiento de esta patología.

Abstract Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic disease characterized by ossi- fication of the anterior longitudinal ligament of the spine. Patients are usually asympto- matic, or present mild pain or stiffness, however cervical compromise can cause dysphagia, dyspnea and dysphonia. We present the case of a 63-year-old patient with hoarseness and dysphagia. Studies revealed anterior displacement of the arytenoid cartilage and collapse of the pyriform sinus secondary to an osteophyte at C4 level. The patient showed improvement with conservative management. We present a discussion about this case and the available scientific evidence on the diagnosis and treatment of this pathology.

Características clínico-radiológicas de la hiperostosis esquelética idiopática difusa en 2 centros médicos de Cali, Colombia: reporte de 24 casos / Clinical and radiological characteristics of diffuse idiopathic skeletal hyperostosis in two medical centers in Cali, Colombia: Report of 24 cases

RESUMEN Introducción: La hiperostosis esquelética idiopática difusa (DISH, por sus siglas en inglés) es una afección caracterizada por la calcificación y la osificación progresiva de los ligamentos y las entesis. La mayoría de los pacientes permanecen asintomáticos hasta etapas avanzadas de la enfermedad, donde la limitación y el dolor son característicos. Objetivo: Describir las características demográficas, clínicas y radiológicas de los pacientes con DISH evaluados en el Centro Médico Imbanaco de Cali y en la Clínica de Artritis Temprana, en Cali, Colombia. Materiales y métodos: Es un estudio descriptivo, de corte transversal. Se revisaron los registros de pacientes diagnosticados con DISH, seguidos entre enero de 2000 y octubre de 2018. El diagnóstico se confirmó según los criterios de Resnick-Niwayama. Se encontraron 24 pacientes, todos se incluyeron para el análisis final. Resultados y discusión: En esta serie se encontraron 20 varones y 4 mujeres. La mediana de edad al diagnóstico fue de 70,5 arios (RIQ: 61,3-73,8 arios), siendo menor en las mujeres (71,5 versus 60 años; p = 0,04). La mediana de tiempo de evolución de los síntomas fue de 5 años (RIQ: 3-10 años), la duración fue menor en el grupo de las mujeres (5 versus 4 años; p = 0,20). El 54,2% tenían sobrepeso y el 20,8% eran diabéticos. El síntoma principal fue la limitación cervical. Los segmentos vertebrales (C: cervical; T: torácico; L: lumbar) más afectados por la osificación del ligamento longitudinal anterior (LLA) fueron C5-C6, T8-T10 y L1-L3. La afección periférica predominó en las crestas ilíacas. Todos los pacientes realizaron terapia física y 3 fueron sometidos a cirugía cervical. El grado de limitación funcional fue valorado en 19 pacientes a través de los cuestionarios modified Health Assessment Questionnaire (mHAQ) y Bath Ankylosing Spondylitis Functional Index (BASFI). La mediana del puntaje de ambos cuestionarios fue 2 veces más alta en las mujeres. Conclusión: La DISH fue más frecuente en varones mayores de 65 años y se asoció con enfermedades metabólicas como la obesidad y la diabetes. Aunque las diferencias no fueron significativas, los resultados sugieren que las mujeres presentan un fenotipo grave de la enfermedad explicado por el inicio temprano y curso progresivo de los síntomas, así como mayor limitación funcional medida por mHAQ y BASFI.

ABSTRACT Introduction: Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterised by calcification and progressive ossification of ligaments and entheses. Most patients remain asymptomatic until advanced stages of the disease, where limitation and pain are characteristic. Objective: To describe the demographic, clinical, and radiological characteristics of patients with DISH evaluated in the Centro Médico Imbanaco and Clínica de Artritis Temprana, in Cali, Colombia. Materials and methods: A descriptive, cross-sectional study was conducted by reviewing the records of patients diagnosed with DISH between January 2000 and October 2018. The diagnosis was confirmed according to the Resnick-Niwayama criteria. A total of 24 patients were found, and all were included for the final analysis. Results and discussion: The series included 20 men and 4 women, with a median age at diagnosis of 70.5 years (IQR 61.3-73.8 years), beinglower in women (71.5 versus 60 years; P=.04). The median time of onset of the symptoms was 5 years (IQR 3-10 years), and the duration was shorter in women (5 versus 4 years; P=.20). It was observed that 54% were overweight and 20% were diabetic. The main symptom was cervical limitation. The most affected vertebral segments due to the ossification of the anterior longitudinal ligament (ALL) were C5-C6, T8-T10 and L1-L3 (cervical C; thoracic T; lumbar L). The peripheral involvement was mainly in the iliac crests. All patients received physiotherapy, and three of them underwent cervical surgery. The degree of functional limitation was assessed in 19 patients using the mHAQ (Modified Health Assessment Questionnaire) and BASFI (Functional Ankylosing Spondylitis Functional (BASFI) questionnaires. The median score of both questionnaires was 2 times higher in women Conclusion: Diffuse idiopathic skeletal hyperostosis was more frequent in men over 65 years of age, and was associated with metabolic conditions such as obesity and diabetes. Although the differences were not significant, the results suggest that women have a more severe phenotype of the disease, explained by the early onset and progressive course of symptoms, as well as greater functional limitation measured by mHAQ and BASFI.

Surgical treatment of fractures of the ankylosed spine / Tratamento cirúrgico de fraturas da coluna anquilosada / Tratamiento quirúrgico de las fracturas en la columna anquilosada

ABSTRACT Objective We aim to identify retrospectively surgically treated patients with an ankylosed spine who sustained a vertebral fracture. Our goal is to evaluate the main outcomes and complications. Methods We selected patients through the database of surgical interventions in the setting of fractures of an ankylosed spine segment between January 1st 2008 and June 30th 2018. We collected data from digital medical records. The parameters analyzed include hospital length of stay, Intensive Care Unit (ICU) admission, perioperative and postoperative complications as well as neurological evolution. Results Fractures occurred in 14 patients with ankylosing spondylitis (82%) and 3 patients with diffuse idiopathic skeletal hyperostosis (18%). All patients were male and the mean age was 69 years. Fourteen fractures occurred after minor trauma (83%), of which 11 were due to falls from standing height or lower (65%). The cervical spine represents the majority of the levels involved (65%). Seven patients were admitted to the ICU (41%) and 11 suffered neurological damage. There was improvement of neurological status in less than 50% and there were high percentages of post-operative complications. Conclusion Patients with ankylosed spine diseases are at higher risk for vertebral fracture, even after minor trauma, and these are located predominantly in the cervical spine. The surgical treatment of these conditions is effective as it allows improvement of the patient's neurological status. However, they still present higher morbidity and mortality, as well as increased post-op complications. Prevention of falls may drastically change patients' outcome, neurological function and independence in activities of daily living. Level of evidence IV; A case series therapeutic study.

RESUMO Objetivo Identificar retrospetivamente casos de tratamento cirúrgico de fraturas vertebrais em pacientes com coluna anquilosada. O nosso propósito consiste em avaliar os principais desfechos e respectivas complicações. Métodos Selecionamos pacientes através do banco de dados de intervenções cirúrgicas no quadro de fraturas de um segmento da coluna anquilosada entre 1 de janeiro de 2008 a 30 de junho de 2018. Coletamos os dados a partir dos prontuários médicos digitais. Os parâmetros analisados incluem período de internação hospitalar, admissão na Unidade de Tratamento Intensivo (UTI), complicações pré- e pós-operatórias, assim como evolução neurológica. Resultados As fraturas ocorreram em 14 pacientes com espondilite snquilosante (82%) e em 3 pacientes com hiperostose esquelética difusa idiopática (18%). Todos os pacientes eram do sexo masculino e a idade média era de 69 anos. Quatorze fraturas ocorreram devido a trauma menor (83%), das quais 11 eram devido a quedas da própria altura ou inferiores (65%). A coluna cervical representa a maioria dos níveis envolvidos (65%). Sete pacientes foram admitidos na UTI (41%) e 11 sofreram lesão neurológica. Houve melhoria do estado neurológico em menos de metade dos pacientes e altas porcentagens de complicações pós-operatórias. Conclusão Os pacientes com doenças da coluna anquilosada têm maior risco de fraturas vertebrais, mesmo após trauma menor, localizando-se predominantemente na coluna cervical. O tratamento cirúrgico dessas condições é eficaz, uma vez que permite melhora do estado neurológico do paciente. Entretanto, ainda apresentam altos índices de morbilidade e mortalidade, assim como maior incidência de complicações pós-operatórias. A prevenção de quedas pode alterar drasticamente o desfecho, função neurológica e independência nas atividades diárias do paciente. Nível de evidência IV; Estudo terapêutico de série de casos.

RESUMEN Objetivo Identificar retrospectivamente casos de tratamiento quirúrgico de fracturas vertebrales en pacientes con columna anquilosada. Nuestro propósito consiste en evaluar sus principales resultados y respectivas complicaciones. Métodos Seleccionamos pacientes mediante banco de datos de intervenciones quirúrgicas en el cuadro de fracturas de un segmento de la columna anquilosada entre el 1 de enero de 2008 al 30 de junio de 2018. Recolectamos los datos a partir de los prontuarios médicos digitales. Los parámetros analizados incluyen período de internación hospitalaria, admisión en la Unidad de Tratamiento Intensivo (UTI), complicaciones pre y postoperatorias, así como evolución neurológica. Resultados Las fracturas ocurrieron en 14 pacientes con espondilitis anquilosante (82%) y en 3 pacientes con hiperostosis esquelética difusa idiopática (18%). Todos los pacientes eran del sexo masculino y la edad promedio era de 69 años. Catorce fracturas ocurrieron debido a trauma menor (83%), de las cuales 11 eran debido a caídas de la propia altura o inferiores (65%). La columna cervical representa la mayoría de los niveles implicados (65%). Siete pacientes fueron admitidos en la UTI (41%) y 11 sufrieron lesión neurológica. Hubo mejora del estado neurológico en menos de la mitad de los pacientes y altos porcentajes de complicaciones postoperatorias. Conclusión Los pacientes con enfermedades de la columna anquilosada tienen mayor riesgo de fracturas vertebrales, incluso después de trauma menor, localizándose predominantemente en la columna cervical. El tratamiento quirúrgico de esas condiciones es eficaz, ya que permite mejora del estado neurológico del paciente. Entretanto, aún presentan altos índices de morbilidad y mortalidad, así como mayor incidencia de complicaciones postoperatorias. La prevención de caídas puede alterar drásticamente los resultados, función neurológica e independencia en las actividades diarias del paciente. Nivel de evidencia IV; Estudio terapéutico de serie de casos.

Surgical Outcomes of Dysphagia Provoked by Diffuse Idiopathic Skeletal Hyperostosis in the Cervical Spine

PURPOSE: This study aimed to predict the surgical outcomes of diffuse idiopathic skeletal hyperostosis (DISH)-related dysphagia (DISH-phagia) and to evaluate the importance of prevertebral soft tissue thickness (PVST).MATERIALS AND METHODS: In total, 21 surgeries (anterior osteophytectomy or anterior cervical decompression and fixation) were included in this study for DISH-phagia from 2003 to 2019. Clinical outcomes were assessed using the Dysphagia Outcome and Severity Scale (DOSS) preoperatively, at 1 month postoperatively, and last follow up (mean 29.5 months). PVST was measured using lateral plain radiographs. Paired t-test and Spearman's correlation test was used to identify relationships between various PVST indices and DOSS.RESULTS: Comparisons were made from 17 patients out of 21, in which the record had all of three measurements. The narrowest PVST preoperatively was 2.55±0.90 mm, with a DOSS score of 4.47±1.61, and that at 1 month after surgery was 5.02±2.33 mm, with a DOSS score of 6.12±1.32. At last follow up, PVST and DOSS values were 3.78±0.92 mm and 5.82±1.34, and three patients experienced symptom relapse. Significant relationships were found between PVST and DOSS at all time points: before surgery (R=0.702, p<0.001), 1 month after surgery (R=0.539, p=0.012), and last follow up (R=0.566, p=0.020).CONCLUSION: Surgical removal of anterior osteophytes is an effective treatment option for DISH-phagia, and PVST is a useful parameter in DISH-phagia. The goal of DISH surgery should be to remove DISH as much as possible to ensure sufficient PVST postoperatively.

Ossification Of The Anterior Longitudinal Ligament: Clinical And Embryological Aspect

Normal anatomy of vertebral column is extremely vital for weight transmission as well as normal day to dayactivities. Osteogenic outgrowths and ossifications are commonly reported in literature; however, extensiveossification of the anterior longitudinal ligament (ALL) is a rare finding. During routine undergraduate teachingin the Department of Anatomy, Hamdard Institute of Medical Sciences, New Delhi, we came across ossification inthe ALL of an elderly male skeleton, extending from T9 to L2, with complete bridging between vertebrae T11 -T12as well as L1- L2 and broken (possibly due to bone processing) in region between T9-T10, T10- T11, T12-L1.Ossification was extensive on the right side as compared to the left. Knowledge of such ossification will aid asurgeon during lateral transpsoas approach of vertebral column and prevent complications while performingsurgeries in this region such as lordiosis restoration with ALL release and in placement of hyperlordotic cage etc.

Arthroscopic Treatment for Femoroacetabular Impingement with Extraspinal Diffuse Idiopathic Skeletal Hyperostosis

BACKGROUND: Patients with extraspinal diffuse idiopathic skeletal hyperostosis (DISH) involving the hip joint have symptoms like femoroacetabular impingement (FAI). To date, no reported study has determined the clinical outcomes of arthroscopic treatment in extraspinal DISH involving the hip joint. METHODS: A total of 421 hips with FAI that underwent arthroscopic treatment were reviewed retrospectively. We determined the extraspinal involvement of DISH with three-dimensional computed tomography (3D-CT) and simple radiography of the pelvis and hip joint. Clinical outcomes were evaluated at a minimum of 2 years postoperatively. The visual analog scale score (VAS), modified Harris hip score (MHHS), and hip outcome score–activity of daily living scale (HOS-ADL) were used, and hip range of motion (ROM) was evaluated pre- and postoperatively and at the time of the final follow-up. RESULTS: Among the 421 hips (372 patients) with FAI that underwent arthroscopic treatment, 17 hips (12 patients, 4.04%) had extraspinal DISH on the hip joints. The mean age of the patients was 51.5 years. The 3D-CT scans and simple radiographs showed extraspinal DISH on multiple points around the pelvis and hip joint. Nine of the 17 hips (seven of 12 patients) had spinal DISH. At the final follow-up, VAS, MHHS, and HOS-ADL improved significantly from 6.5, 65.3, and 66.6, respectively, to 1.2, 87.8, and 89.5, respectively, and hip flexion and internal rotation improved significantly from 97.7° and 7.9°, respectively, to 117.1° and 18.2°, respectively. CONCLUSIONS: This study has demonstrated that extraspinal DISH involving the hip joint could lead to FAI, and arthroscopic treatment could result in relief of symptoms, including pain and ROM limitation, in extraspinal DISH patients.

Enfermedad de Forestier en paciente mayor de 65 años: reporte de caso con seguimiento a 6 años de manejo conservador / Diffuse idiopathic skeletal hyperostosis (DISH): report of one case

Forestier Disease, or Diffuse Idiopathic Skeletal Hyperostosis (DISH), causes a considerable ossification of the anterior longitudinal ligament of the spine. When it involves cervical segments, it can be accompanied by dysphagia, dysphonia and/or dyspnea. This entity usually has a benign course. Surgical treatment is required for progressive cases. We report a 72-year-old male with a history of chronic cervical pain and slight neck stiffness. On the imaging studies, there was an exuberant ossification of the anterior longitudinal ligament, at the cervical spine level, between C2 and C7. He was managed conservatively without clinical deterioration in a six-year follow-up.

Prevalence of Diffuse Idiopathic Skeletal Hyperostosis Diagnosed by Whole Spine Computed Tomography: A Preliminary Study

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of the enthesis. The diagnosis has been mainly based on the chest or whole spine lateral plain film. Recently, chest or thoracolumbar computed tomography (CT) has been reported to be more reliable for the diagnosis of DISH. The purposes of this study were to investigate the prevalence and location of DISH and evaluate the prevalence of comorbidities, such as ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF), using whole spine CT. METHODS: Whole spine CT scans of patients over 16 years of age who were examined at Cheju Halla General Hospital between February 2011 and December 2016 were reviewed for this study. The diagnosis of DISH was made according to the modified Resnick criteria. The prevalence of DISH in each age decade and its location were evaluated. Also, the prevalence of OPLL and OLF in DISH patients was investigated. RESULTS: The overall incidence of DISH was 24.4% (40 of 164 cases). There was no case of DISH in patients in their 40s and younger. The percentile incidences of DISH in patients in their fifth, sixth, seventh, eighth, and ninth decades were 20.0% (4 of 20 cases), 32.3% (10 of 31 cases), 40.0% (10 of 25 cases), 34.5% (10 of 29 cases), and 27.3% (6 of 22 cases), respectively. A strong positive correlation between the age decade and the incidence of DISH was noted (r = 0.853, p = 0.007). DISH patients had higher incidences of OLF (22.5%) and OPLL (37.5%). The most common location of DISH was the middle thoracic spine (90.0%) followed by the lower thoracic spine (87.5%). There was one case of DISH involving only the cervical spine. CONCLUSIONS: The incidence of DISH diagnosed by CT was higher than we expected. Whole spine CT can be a valuable modality to evaluate the location of DISH in the cervical and lumbar spine and the comorbidity rates of OLF and OPLL.

Prevalence of diffuse idiopathic skeletal hyperostosis among elderly subjects referred for radiological investigation in tertiary hospital at Oman / 대한해부학회지

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by calcification of different entheseal sites including the anterior longitudinal ligament of the spine. There is no documented information about DISH in Oman. This study determined the prevalence of DISH and associated factors among elderly subjects in a national tertiary care referral hospital in Oman. This retrospective study reviewed chest X-rays of all patients aged more than 50 years, referred to the radiology department of Sultan Qaboos University Hospital in the year 2016, based on the Resnick's criteria. The prevalence was expressed as proportions across age groups and sex. Chi-square test and logistic regression analysis was done to determine the association of the age and sex with DISH. A total of 1305 chest X-rays of patients were reviewed. The overall prevalence of DISH was 10%, with male to female ratio of 1.56:1. The odds ratio for males and increasing age were 1.63 (95% confidence interval [CI], 1.12–2.3; P<0.05) and 1.34 (95% CI, 1.14–1.58; P<0.001) respectively. The prevalence increased with age to maximum of 13% in the age group of ≤80. The pre-stage DISH prevalence was 9.3% and more frequently observed among males. Prevalence of DISH in the national tertiary care referral center in Oman is lower than in Jewish population, almost similar to Japanese, but higher than in Koreans. DISH prevalence is positively associated with age and sex. It is necessary to take appropriate precautionary measures to target the ageing population in Oman, especially elderly males.

Prevalence of Diffuse Idiopathic Skeletal Hyperostosis in Patients with Spinal Disorders

STUDY DESIGN: Retrospective cohort study. PURPOSE: The purpose of this study was to evaluate the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in patients with spinal diseases determined by roentgen images of the whole spine. OVERVIEW OF LITERATURE: Although several studies have investigated the prevalence of DISH in healthy subjects, no detailed data have been reported on the prevalence of DISH in patients with degenerative spinal disorders. METHODS: Standing whole-spine roentgen images of 345 consecutive patients who underwent surgery in our hospital were obtained. Patients aged <18 years or with congenital spinal disease, metastatic spinal tumors, or inflammatory spinal disease were excluded. In total, 281 patients were eligible for inclusion. The presence of DISH was assessed according to Resnick's criteria and Mata's scoring system. The prevalence, location, and numbers of fused vertebral bodies of DISH were recorded. RESULTS: DISH was present in 25.6% of patients (72/281). The prevalence of DISH in the 41–49, 50–59, 60–69, 70–79, and ≥80 year age groups was 8.3% (2/24), 9.8% (5/51), 16.0% (12/75), 49.5% (48/97), and 33.3% (4/12), respectively; the prevalence increased with age. The average number of fused vertebral bodies was 7.5. More than 80% of DISH was located from T7 to T11, and more than 95% of DISH was located at T9/10. Patients with DISH were significantly older (71.1 years vs. 60.9 years, p<0.05), and men were more likely to have DISH than women (p<0.05). CONCLUSIONS: In patients with degenerative spinal diseases with DISH, fused vertebrae were found most frequently in the lower thoracic spine, and their prevalence increased with age. DISH may be an age-related skeletal disorder with a higher overall prevalence in patients with spinal disorders than that in healthy subjects.

Kyphotic Deformity after Spinal Fusion in a Patient with Diffuse Idiopathic Skeletal Hyperostosis: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: To report a case of progressive kyphotic deformity after spinal fusion in a patient with diffuse idiopathic skeletal hyperostosis (DISH). SUMMARY OF LITERATURE REVIEW: DISH is characterized by spinal and peripheral enthesopathy, and is a completely different disease from ankylosing spondylitis (AS). Though DISH can be associated with thoracic kyphosis, no reports have described a progressive thoracolumbar kyphotic deformity after spinal fusion surgery in a DISH patient. MATERIALS AND METHODS: A 47-year-old male presented with pain in the thoracolumbar region. After excluding the possibility of AS and confirming the diagnosis of DISH, we performed spinal fusion for the treatment of a T11-T12 flexion-distraction injury. The kyphotic deformity was found to be aggravated after the first operation, and we then performed corrective osteotomy and additional spinal fusion. Results: The kyphotic deformity of the patient was corrected after the second operation. RESULTS: The kyphotic deformity of the patient was corrected after the second operation. CONCLUSIONS: In DISH patients in whom AS must be excluded in the differential diagnosis, a kyphotic deformity can become aggravated despite spinal fusion surgery, so regular and continuous follow-up is required.

Compression Fractures in the Setting of Diffuse Idiopathic Skeletal Hyperostosis

Compression fractures are the most common vertebral fractures. They involve the anterior column of the spine, and are considered stable fractures due to the presence of intact posterior ligaments that aid in resisting further collapse and deformity. They are thus often managed conservatively. We describe a series of 3 cases that were initially diagnosed as compression fractures and managed conservatively. With the abundance of compression fractures and increase in preference for conservative management of compression fractures, it is of utmost importance to recognize the possibility of other spinal co-pathologies, especially that of hyperostosis of the spine, both by clinical judgment as well as radiological analysis before embarking on conservative management, should there be under-treatment and development of complications that could have otherwise been avoided, as in the cases presented in this series.

Iatrogenic Lumbar Vertebral Fracture during Osteosynthesis for a Trochanteric Fracture of the Femur in Diffuse Idiopathic Skeletal Hyperostosis

Vertebral fractures occur with only slight trauma in patients with diffuse idiopathic skeletal hyperostosis (DISH). However, a lumbar vertebra fracture, due to an intraoperative body position has not been previously reported. An 87-year-old woman with kyphosis sustained a left trochanteric fracture of her femur. The patient was placed in a supine position during the operation. Postoperatively, the patient experienced severe right thigh pain. Magnetic resonance imaging revealed an L4 vertebral fracture. Computed tomography revealed ankylosis from the upper thoracic spine to the sacrum. While in a supine position under general anesthesia, the contact of the patient's lower back with operating table likely created a fulcrum at her lumbosacral spine acting as a long lever arm, bearing the mass of her upper body. We performed L1-S2 posterior stabilization. DISH patients with kyphosis placed in a supine position have an increased risk for lumbar vertebral fracture.

Association of diffuse idiopathic skeletal hyperostosis and aortic valve sclerosis / Asociación de hiperostosis esquelética idiopática difusa y esclerosis valvular aórtica

The principal objective of this investigation was to analyze the association between diffuse idiopathic skeletal hyperostosis (DISH) and the presence of aortic valve sclerosis (AVS). For this study we used results from 1000 consecutive outpatients (473 males), older than 50 years of age (average 67.6 years), that had been examined with Doppler echocardiogram and anterior and lateral chest radiographs. Overall, 195 patients (19.5%) were diagnosed with DISH and 283 (28.3%) with AVS. DISH was more prevalent than AVS in males (66.7% vs. 42.6%, p< 0.0001) and in older patients (73.6 ± 9 years vs. 66.1 ± 9 years, p < 0.0001). Furthermore, 55.4% of patients with dorsal DISH presented aortic sclerosis calcification vs. 21.7% of patients free of DISH (OR = 4.47; 95% CI = 3.22-6.21). The adjusted odds ratio (OR) was calculated by sex and age resulting in 3.04 (95% CI = 2.12-4.36; p < .0001). A statistically significant association was found between DISH and AVS in accordance to age and sex. The biological plausibility of this association is based on similar risk factors, pathogenic mechanisms and vascular complications.

El objetivo principal fue analizar la asociación entre la hiperostosis esquelética idiopática difusa (DISH) y la presencia de esclerosis valvular aórtica (AVS). Se evaluaron los resultados de 1000 pacientes ambulatorios consecutivos (473 varones), mayores de 50 años (promedio, 67.6 años), que habían sido examinados con un ecocardiograma Doppler y radiología torácica anterior y lateral. Globalmente, 195 pacientes (19.5%) tuvieron diagnóstico de DISH y 283 (28.3%) de AVS. DISH fue más prevalente que AVS en varones (66.7% vs. 42.6%, p < 0.0001) y en pacientes de mayor edad (73.6 ± 9 años vs. 66.1 ± 9 años, p < 0.0001). Además, 55.4% de los pacientes con DISH dorsal presentaron AVS vs. 21.7% de los pacientes sin DISH (OR = 4.47; 95% CI = 3.22-6.21). El odds ratio (OR) ajustado por sexo y edad fue 3.04 (95% CI = 2.12-4.36; p < 0.0001). Se encontró una asociación estadísticamente significativa entre DISH y AVS, que se mantuvo después de ajustar por sexo y edad. La plausibilidad biológica de esta asociación se basa en los factores de riesgo, mecanismos patogénicos y complicaciones vasculares compartidos.

Doença de Forestier e suas implicações otorrinolaringológicas: revisão de literatura / Forestier's disease and its implications in otolaryngology: literature review

Introdução: A Doença de Forestier afeta a coluna vertebral, preferencialmente em homens Coluna vertebral; idosos. Não é rara, mas é frequentemente não reconhecida e pode levar a relevante morbimortalidade. Quando acomete a coluna cervical, pode gerar importantes manifestações otorrino-Transtornos de laringológicas. Objetivo: Destacar os sintomas faringolaríngeos da doença de Forestier. Método: Revisão da literatura nas bases de dados Web of Knowledge, PubMed e SciELO e entre os dez periódicos de maior número de citações na área de otorrinolaringologia e também busca manual por publicações nas listas de referências dos artigos selecionados, principalmente os de cunho histórico. Resultados: A doença não tem etiologia clara. Os sintomas das complicações são mais exuberantes que os da doença propriamente dita. A disfagia é o sintoma cervical mais conhecido. Outros sintomas discutidos são a apneia do sono, globus faríngeo, tosse, disfonia, dispneia, otalgia reflexa e sintomas medulares compressivos. O diagnóstico é efetuado com apropriado estudo radiológico. O tratamento é baseado em estratégia conservadora. Pacientes com disfagia refratária e comprometimento respiratório podem ser submetidos a tratamento cirúrgico. Conclusão: A doença de Forestier deve ser suspeitada em pacientes idosos com os principais sintomas das complicações, os quais são comuns na prática otorrinolaringológica, para o início precoce de acompanhamento multidisciplinar. .

Introduction: Forestier's disease affects the spinal column of primarily elderly men. It is not rare, but it is often undiagnosed and can lead to significant morbidity and mortality. When it affects the cervical spine, it can result in important otorhinolaryngological manifestations. Objective: To analyze the pharyngeal and laryngeal symptoms of the Forestier's disease. Methods: Literature review of the Web of Knowledge, PubMed, and SciELO databases and of the ten most frequently cited journals in the field of otorhinolaryngology. Additionally, a manual search was performed for publications in the reference lists of selected articles, mostly those of a historical nature. Results: The etiology of the disease is still unclear. Symptoms of complications are more significant than the disease itself. Dysphagia is the most common cervical symptom and has several involved mechanisms. Other symptoms are sleep apnea, pharyngeal globus, coughing, dysphonia, dyspnea, otalgia, and medullary compression. The diagnosis is verified by appropriate radiological study. Treatment is based on a conservative strategy. Patients with refractory dysphagia and respiratory impairment can be surgically treated. Conclusion: Forestier's disease should be suspected in elderly patients with the major symptoms of complications, which are common in otorhinolaryngology practice and when identified, a multidisciplinary approach should be instituted as soon as possible. .

Síndrome de Forestier: Reporte de un caso y revisión de la literatura / Forestier syndrome: Case report and literature review

Introducción: El síndrome de Forestier, también conocido como hiperostosis esquelética idiopática difusa, es una enfermedad de etiología desconocida, caracterizada por aumento en la masa ósea de diferentes partes del cuerpo, responsable de cervicalgia y dorsalgia crónicas. Métodos: Se presenta el caso de un paciente masculino de 40 años con diagnóstico mediante estudios de imagen de síndrome de Forestier desde el 2006. Inició su cuadro clínico con lumbalgia de intensidad progresiva irradiada a miembro pélvico derecho asociado a rigidez matutina de espalda. Se le realizó cirugía de columna lumbar en Junio de 2005 (laminotomía y disquectomía L4-L5, espaciadores intersomáticos rellenos de hueso y colocación de espaciador interespinoso dinámico L4-L5) con poca mejoría postquirúrgica, nosotros iniciamos tratamiento médico antiinflamatorio como se describe en la literatura presentando una evolución satisfactoria. Discusión: Este padecimiento se reporta como una entidad poco frecuente, por lo cual el médico no lo tiene presente dentro de sus diagnósticos diferenciales; se presenta con disfagia como síntoma principal además de condicionar cervicalgia o lumbalgia debido a hipertrofia y osificación ligamentaria, aumento de la masa ósea con la consiguiente formación de puentes óseos. El dolor lumbar o cervical es una causa frecuente de consulta médica neuroquirúrgica. Conclusiones: La finalidad de este trabajo es presentar un caso poco habitual de dolor lumbar aumentando la sensibilidad diagnóstica de este padecimiento y evitar así una posible cirugía innecesaria; se complementó además con una revisión de la literatura.

Introduction: Forestier syndrome, also known as diffuse idiopathic skeletal hyperostosis, is a disease of unknown etiology, characterized by an increase in the bone mass in different parts of the body, which results in chronic cervical and back pain. Methods: We report the case of a male 40 year-old patient with a diagnosis of Forestier syndrome in 2006 based on imaging studies. The clinical picture began with lumbar pain of progressive intensity irradiating to the right pelvic limb and associated with morning spine stiffness. Lumbar spine surgery was performed in June 2005 (laminotomy and L4-L5 diskectomy, interbody spaces filled with bone, and a dynamic interspinous spacer in L4-L5), but there was little postoperative improvement. We instituted antiinflammatory medical treatment as described in the literature and the patient did fine. Discussion: This condition is reported as an infrequent entity leading to physicians not considering it within their initial differential diagnoses. It presents with dysphagia as the main symptom, together with neck or lumbar pain due to ligament hypertrophy and ossification, and increased bone mass leading to the formation of bone bridges. Lumbar or cervical pain is a frequent cause for visiting the neurosurgeon. Conclusions: The purpose of this paper is to present an unusual case of lumbar pain, which increases the diagnostic sensitivity of this disease, and may contribute to avoid unnecessary surgery. This was complemented with literature review.