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.

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.

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.

Disfagia cervical espondilótica por hiperostosis esquelética difusa idiopática en un paciente joven / Diffuse idiopathic skeletal hyperostosis causing dysphagia in a young patient

Diffuse idiopathic skeletal hyperostosis (DISH) is an under-diagnosed condition producing flowing ossification of the antero-lateral ligaments of the spine. Affecting predominantly males over 65years old, it is an unusual cause of dysphagia and dysphonia. We report a 45-year-old mole with a three years history of dysphonia and three months of dysphagia. The initial diagnosis was gastroesophageal reflux, and an endoscopy ruled out esophageal luminal pathology. Cervical spine radiographs showed ossification of the cervical anterior longitudinal ligament with large, prominent osteophytes from C3 to C6, producing esophageal and upper airway compression; these images were compatible with DISH. Cervical osteophyte resection resulted in complete resolution of symptoms. DISH should be considered in the differential diagnosis of dysphagia and dysphonia.