Hyperostosis Frontalis Simulating Metastatic Deposits: Unmasked on SPECT-CT.

Skeletal scintigraphy has a pivotal role in detecting a number of bone pathologies, but it has its own limitations because of 2D image acquisition. Hybrid imaging acts as a savior in these cases where it is difficult to distinguish between benign and malignant lesions just on the basis of planar images. We present one such case of known breast carcinoma with abnormal increased radiotracer uptake in the skull which was difficult to characterize as benign lesion such as hyperostosis frontalis or metastatic osseous lesion. The importance of describing this case is to have a thorough understanding of hyperostosis patterns and to not confuse it with metastatic deposits in patients with known malignancies.

Esophageal perforation with near fatal mediastinitis secondary to Th3 fracture.

A 74-year-old male patient was referred with signs of sepsis 5 days after having been diagnosed with a rib fracture following a fall out of bed. Novel hypodensities were visible on thoracic X­rays and laboratory tests revealed elevated inflammatory parameters. Subsequently performed thoracic computed tomography (CT) scan showed burst fracture of the 3rd thoracic vertebra, posttraumatic esophageal rupture at the same level and mediastinitis. Furthermore, marked degenerative changes of the spinal column (diffuse idiopathic skeletal hyperostosis) were present. The patient underwent emergency thoracotomy and esophagectomy. Gastric pull-up with esophagogastrostomy was postponed for 3 days. After 14 days on the intensive care unit (ICU) and 12 days of i.v. antibiotics, the patient was transferred to the general ward and 7 weeks after trauma the patient was infection-free without difficulties in swallowing. Up to the latest follow-up 41 months following injury, several endoscopic dilations with a bougie due to constrictions at the anastomosis have been performed. Similar to previous cases in the literature, esophageal injury was diagnosed delayed, with the patient already having developed severe complications. This extremely seldom injury should be suspected in young patients following high-energy trauma, but also in older patients after low-energy trauma but known degenerative changes of the vertebral column.

TNF-alpha blockade in Primary Chronic Non-Bacterial Osteomyelitis of the Mandible.

OBJECTIVES: Primary chronic Non-Bacterial Osteomyelitis of the jaw is a rare auto-inflammatory disease of unknown aetiology that bears pathophysiological resemblance to both the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome in adults and chronic recurrent multifocal osteomyelitis (CRMO) in children. Both SAPHO and CRMO respond to TNF-alpha blockade. Previously reported treatment regimens in CNOM including non-steroidal anti-inflammatory drugs, corticosteroids, antibiotics, anti-resorptive therapy, and surgery all bear disappointing results. TNF- α blockade is suggested as a treatment option by some experts but this is not backed by any clinical data.We sought to retrospectively and exhaustively report our experience of anti-TNF alpha therapy in refractory CNOM. METHODS: Fifteen patients with refractory CNOM and high disease burden were referred to our centre. TNF- α blockade was attempted in 10 cases, given its efficacy in neighbouring diseases, its good tolerance profile and failure of previous treatment strategiesWe herein retrospectively report detailed outcomes for all patients having received anti-TNF alpha therapy for this indication in our centre. RESULTS: TNF-α-targeting therapy resulted in a rapid and sustained remission in a majority of patients with CNOM, without serious adverse events. Treatment was tapered and stopped without relapse in some patients despite a refractory course of several years. Male sex seems to be associated with a poorer outcome. CONCLUSION: Our results suggest that blocking TNF-α is efficient and safe in CNOM.

Prevalence and characteristics of osseous bridging between vertebral bodies in the cervical spine: A skeletal study.

Osseous bridging (OB) in three or more segments of motions (SOMs) of the mobile spine was initially defined as diffuse idiopathic skeletal hyperostosis (DISH), located particularly in the thoracic spine (T-spine). This pathological phenomenon is often characterized by calcification and ossification, which take place simultaneously or separately. The soft tissues, mainly ligaments and entheses, are calcified, with bone formation not originating from the anterior longitudinal ligament (ALL). DISH formation can involve osteophytes, which are created by the ossification process and can involve soft tissue such as the ALL. The ALL can also be calcified. Until recently, the prevalence of DISH in the general population was considered low (0%-5%) and rare in the cervical spine (C-spine). In a cross-sectional observational skeletal study, we investigated the prevalence and location of C-spine OB between vertebral bodies with fewer than three SOMs. We tested a large sample (n = 2779) of C-spines housed in the Cleveland Museum of Natural History (Ohio, USA). The human sources of the samples had died between the years 1912 and 1938 and represented both sexes and two different ethnic groups: Black Americans and White Americans. The process development can be seen on the ALLs as calcification, osteophytosis, and candle-shaped. Among all of the specimens, 139 (5%) were affected by OB, mostly in one SOM. Prevalence tended to be higher in women, White Americans, and the older age group. The levels most affected were C3-C4, followed by C2-C3 and subsequently, C5-C6. OB involving two consecutive SOMs was found only at C5-C7. We believe it is important to respond to the presence of a single SOM with a presumptive diagnosis of OB and to follow up, identify whether the diagnosis is correct, and take preventive action if possible. There is a need for updated diagnostic criteria and research approaches that reflect contemporary lifestyle factors and their impact on spine health.

The challenging diagnosis of synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome: A rare case report.

Considered rare, the synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome is a distinct clinical entity, associating skin manifestations and osteoarticular symptoms. Anterior chest wall pain centered at sternoclavicular and sternocostal joints is an important and characteristic clinical finding that can lead to its diagnosis. Radiologists and clinicians must be aware of synovitis-acne-pustulosis-hyperostosis-osteitis syndrome as it can mimic some of the more common disease entities such as Paget's disease. We report the case of a 63-year-old male patient, with no significant medical history, who presented to the dermatology department, with severe palmar and plantar pustulosis associated with polyarthralgia. Computerized tomography scan showed sternoclavicular hyperostosis, in favor of SAPHO syndrome, with regression of clinical symptoms after non-steroidal anti-inflammatory drug treatment.

Thick Skin on the Dorsal Spine in Osteoproliferative Disease: Ossification of the Posterior Longitudinal Ligament and Diffuse Idiopathic Skeletal Hyperostosis.

Background Although the correlation between reduced skin thickness and reduced bone density has been investigated, no study has evaluated skin thickness and osteoproliferative diseases, including ossification of the posterior longitudinal ligament (OPLL) and diffuse idiopathic skeletal hyperostosis (DISH). Methodology This retrospective cohort study consisted of 99 consecutive patients aged ≥60 years treated for spinal surgery at our hospital between January 2022 and March 2023. Skin thickness was measured at the dorsal side of the cervical, thoracic, and lumbar vertebrae on the sagittal cross-section image of whole-spine CT. Based on the median value, skin thickness was categorized into two groups based on a median thickness of 4 mm. Bone mineral density (BMD) was assessed. The sum of the vertebral body and intervertebral bridging osteophytes of the anterior longitudinal and posterior longitudinal ligament were defined as the OALL index and OPLL index. Serum levels of bone metabolism-related markers, such as tartrate-resistant acid phosphatase type 5b, procollagen I N-propeptide, 25-hydroxyvitamin D, and periostin, were measured. To assess the association between skin thickness and imaging findings, we calculated the adjusted odds ratios, adjusting for age, sex, and body mass index (BMI) and using univariate and multivariate logistic regression analyses. Results No significant differences were found in skin thickness in the three dorsal regions of the cervical, thoracic, and lumbar spine (median = 3.3 mm versus 3.5 mm versus 3.4 mm, p = 0.357) and bone metabolism-related markers. Adjusting for age, sex, and BMI, cervical, thoracic, and lumbar skin thicknesses were related to DISH, the OPLL index, and the OPLL and OPLL index, respectively. Conclusions Skin thickness did not correlate with BMD but with the amount of spinal ossification. A correlation was found between skin thickness and vertebral and intervertebral ossification; vertebral osteophytes, OPLL, and DISH may be more common in thicker skin.

Guidance of clinical management for patients with tonsillar focal disease.

Tonsillar focal diseases (TFDs) are defined as "diseases caused by organic and/or functional damage in organs distant from tonsil, and the disease outcome is improved by tonsillectomy." Although several reports and reviews have shown the efficacy of tonsillectomy for TFDs, no guidelines for the clinical management of the diagnosis and treatment of TFDs have been reported. Therefore, the Society of Stomato-pharyngology established a committee to guide the clinical management of patients with TFDs, and the original guide was published in May 2023. This article summarizes the English version of the manuscript. We hope that the concept of TFDs will spread worldwide, and that one as many patients with TFDs will benefit from tonsillectomy.

Cervical spine fracture in diffuse idiopathic skeletal hyperostosis: A bibliometric analysis.

Objective: The study aimed to assess and investigate cervical spine fracture in diffuse idiopathic skeletal hyperostosis and to identify research trends in cervical spine fracture in diffuse idiopathic skeletal hyperostosis in countries around the world using bibliometric analysis. Method: We examined bibliometric data obtained from the Scopus database collection for the periods 1 January 2000 and 1 January 2022. Authors, institutions, nations, publications, keywords, and references were noted and analyzed. The total number of research articles published on the subject of diffuse idiopathic skeletal hyperostosis was used to calculate the amount of research on that subject undertaken in the study period. A sample of the publication data collected from the Scopus database was then analyzed using the Bibliometric program and used to develop a relationship chart using the Bibliometrix and VOSviewer programs. Results: The number of citations was assumed to be a qualitative measure of the publication. We estimated the impact of the research using several metrics, including the H-index, in the bibliometric analysis of authors, geographic areas, institutes, and references. A total of 52 studies related to cervical spine fractures in diffuse idiopathic skeletal hyperostosis were identified. Only 5.12% of those studies were cited in other publications, for a total of 1410 citations in publications by 342 authors, of whom only two authors had published a single study. Co-authorships occurred at 7.273%. Diseases common in elderly males were often studied retrospectively, and "Diffuse Idiopathic Skeletal Hyperostosis" was a frequently mentioned keyword. Conclusion: The findings of this study provide insights into authors, institutions, key publications, and research trends related to diffuse idiopathic skeletal hyperostosis and can potentially serve as a guide for further studies in the field. The bibliometric analysis of cervical spine fractures in patients with diffuse idiopathic skeletal hyperostosis highlights important contributors, influential papers, geographical trends, and study characteristics in this area of research.

Pathological caudal skeleton of an ichthyodectiform fish from the Upper Cretaceous Niobrara Formation of western Kansas, USA.

A series of 12 contiguous caudal vertebrae of an ichthyodectiform fish from the Smoky Hill Chalk Member of the Niobrara Formation is described. The vertebral centra exhibit extensive overgrowth of pathological bone and there is additional pathological bone within the centra and intervertebral spaces, which together resulted in the coossification of most centra. The extent of the pathology is greatest on preural vertebrae 1-3 and decreases anteriorly, which suggests that the pathology began posteriorly and progressed anteriorly. In addition to the pathological overgrowth on bones, the specimen preserves features interpreted as calcified and/or ossified soft tissues associated with the neural and haemal canals. The pathologies are unlike previously described examples of bony pathologies in fish, and it is suggested that they resulted from combined bacterial and fungal infections. As the pathologies developed, they would have adversely impacted the fish's swimming and feeding abilities, and presumably eventually led to the fish's death.

Diffuse idiopathic skeletal hyperostosis (DISH): Detection on dental radiologic examinations in two older adults and overview of the literature.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is a potentially serious osteopathic disorder associated with coalescing ossifications of the anterior vertebrae and may be concomitant with a constellation of symptomatology and systemic comorbidities. There is limited dental literature describing this finding on panoramic radiographs and cone beam computed tomography (CBCT) scans. CASE PRESENTATIONS: Two case reports of DISH are provided. One patient manifested extensive ossifications along the cervical vertebrae and consequent episodes of dysphagia and hoarseness. The other affected patient's cervical ossification was found at an earlier stage of formation and without symptomatology. Panoramic radiography, cervical spine radiography, and CBCT examinations have been provided. CONCLUSION: Attending dental healthcare practitioners should carefully evaluate all areas of interest and surrounding fields of view when taking panoramic radiographs and CBCT scans for manifestations of DISH and other potential disorders of the cervical vertebrae. A suspected radiologic finding of DISH should prompt timely referral for comprehensive medical assessment to mitigate neurologic deficits and other comorbidities.

A rare case of bilateral en plaque meningioma presenting as a bilateral exophthalmos. A case report.

En plaque meningioma is a rare type of meningioma characterized by an infiltrative nature, sheet-like growth, and at times invading the bone. We report here a case of en plaque meningioma. The patient was a 66-year-old woman presenting with headache and painful bilateral proptosis. Cerebral magnetic resonance imaging revealed a bilateral en plaque meningioma showed as a bilateral hyperostotic of greater wing sphenoid bone associated with bilateral thickening and enhancement of the dura in the anterior temporal area and the retroclival region invading bilaterally the cavernous sinus, the prechiasmatic portion of the optic nerve, and the lateral rectus muscle of the orbit through the superior orbital fissure causing bilateral exophthalmia. Due to invasion of the cavernous sinus and the orbital apex, a subtotal but extensive removal combined with bony decompression of the cranial nerves at the superior orbital fissure and optic canal followed by adjuvant radiotherapy frequently produces good functional and cosmetic results, and over a 3-year period, follow-up magnetic resonance imaging scans showed no obvious signs of recurrence.

Stress fracture of the clavicle associated with sternocostoclavicular hyperostosis combined with bony ankylosis of the acromioclavicular joint and ossification of the coracoclavicular ligament.

Sternocostoclavicular hyperostosis (SCCH) has been reported in patients with pustulotic arthro-osteitis, but there are few reports of marked ossification of the lateral part of the clavicle. Here, we report a case of stress fracture in a patient with SCCH with marked ossification of the lateral part of the clavicle. In this case, the clavicular fracture was proximal and no dislocation. Conservative treatment with a clavicle band and the administration of corticosteroids resulted in rapid symptom improvement. Eight months later, the patient had no difficulty in daily life, but X-rays showed that bone fusion was not complete. Therefore, it is necessary to carefully follow-up such patients for any recurrence of symptoms and radiographic changes.

Significant Reduction in Bone Density as Measured by Hounsfield Units in Patients with Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis.

Background: Multisegmental pathologic autofusion occurs in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH). It may lead to reduced vertebral bone density due to stress shielding. Methods: This study aimed to determine the effects of autofusion on bone density by measuring Hounsfield units (HU) in the mobile and immobile spinal segments of patients with AS and DISH treated at a tertiary care center. The mean HU was calculated for five distinct regions-cranial adjacent mobile segment, cranial fused segment, mid-construct fused segment, caudal fused segment, and caudal adjacent mobile segment. Means for each region were compared using paired-sample t-tests. Multivariable regression was used to determine independent predictors of mid-fused segment HUs. Results: One hundred patients were included (mean age 76 ± 11 years, 74% male). The mean HU for the mid-construct fused segment (100, 95% CI [86, 113]) was significantly lower than both cranial and caudal fused segments (174 and 108, respectively; both p < 0.001), and cranial and caudal adjacent mobile segments (195 and 115, respectively; both p < 0.001). Multivariable regression showed the mid-construct HUs were predicted by history of smoking (-30 HU, p = 0.009). Conclusions: HUs were significantly reduced in the middle of long-segment autofusion, which was consistent with stress shielding. Such shielding may contribute to the diminution of vertebral bone integrity in AS/DISH patients and potentially increased fracture risk.

Pelvic Roll Back Can Trigger Functional Psoas Impingement in Total Hip Arthroplasty.

In most cases, impingement of the iliopsoas tendon after total hip arthroplasty is caused by acetabular component retroversion. The present case report describes a patient with functional iliopsoas impingement following total hip arthroplasty. With increasing flexibility of the hip joint after surgery, the functional adjustment to the stiff thoracolumbar spine in this patient with diffuse idiopathic skeletal hyperostosis resulted in progressive pelvic roll back. This roll back resulted in a functional iliopsoas impingement as the psoas tendon travels over the front of the pecten ossis pubis. Since excessive roll back is usually also addressed in primary total hip arthroplasty by decreasing anteversion of the acetabular component, surgeons should be aware to avoid the combination of roll back and decreased anteversion and their potential impact on iliopsoas impingement.

Spinal Deformity Manifested by Urinary Tract Infection: A Case of Acute-on-Chronic Mobility Dysfunction.

A 53-year-old man with diabetes mellitus presented to the emergency department with a fever and impaired mobility. A preliminary diagnosis of urinary tract infection was made based on dysuria and pyuria. History-taking revealed a history of gait disturbance and difficult urination. A thorough physical examination suggested a spinal abnormality. MRI scan revealed a narrow spinal canal due to ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. Throughout the diagnostic process, we employed both vertical tracing to investigate the causes of urinary tract infection and horizontal tracing to explore comorbidities such as diabetes. Additionally, we introduced appropriate social security and support systems under the name of diagnostic excellence.

Defining the imaging diagnostic criteria for adult chronic non-bacterial osteitis.

Osteitis of the sternocostoclavicular (SCC) region, referred to as sternocostoclavicular hyperostosis (SCCH), is the clinical expression of chronic non-bacterial osteitis (CNO) in adults with this rare chronic auto-inflammatory disorder of the axial skeleton. The diagnosis is based on distinctive computerized tomography (CT) features of sclerosis and hyperostosis of the SCC region, and local increases in osteoid formation visualized by high radiopharmacon uptake on skeletal scintigraphy but clear radiologic diagnostic criteria are lacking. In a cross-sectional study, CT scans and whole-body skeletal scintigraphy images obtained in 169 patients seen at the Center for Bone Quality of the Leiden University Medical Center between 2008 and 2018 with a suspected diagnosis of CNO of the SCC region were re-evaluated by 2 skeletal radiologists and 2 nuclear physicians. The diagnosis was confirmed in 118 (70%) predominantly female patients (n = 103, 89.2%); median age at first symptoms 45 years (range 20-73). The diagnosis was excluded in the remaining 51 "non-CNO" patients. Increased radiopharmacon uptake at the SCC region was observed in 82% CNO patients, with the manubrium sterni having the highest predictive ability to discriminate on both imaging modalities. The prevalence of sclerosis of the clavicles, manubrium and first ribs was significantly higher in CNO patients (P < 0.001). Hyperostosis was not observed in non-CNO patients. 46 CNO versus only 2 non-CNO patients had costoclavicular ligament calcification. Our findings identify CT scan features of sclerosis and hyperostosis of manubrium sterni, medial end of clavicles and first ribs, and calcification of costoclavicular ligaments, associated with increased tracer uptake on skeletal scintigraphy at the SCC region, specifically manubrium sterni, as well-defined imaging diagnostic criteria for adult CNO. Pitfalls encountered in the diagnosis of CNO are highlighted. These defined imaging diagnostic criteria for adult CNO should facilitate the diagnosis of this rare auto-inflammatory bone disease across the spectrum of its early to late stages.

Osteosynthesis of an intertrochanteric fracture on osteopetrosis A case report.

INTRODUCTION: Osteopetrosis is a rare hereditary disease that can be transmitted in an autosomal recessive or autosomal dominant. CASE REPORT: Here, we report a case of trochanteric fracture in an 18-year-old boy with an anatomical plate. At the last follow-up, 24 months after surgery, the fracture had healed well, and the patient was not restricted in his activities. DISCUSSION: Osteopetrosis is a rare bone disease that is mainly caused by osteoclast dysfunction. It results from a remodelling defect that leads to hypermineralization of the skeleton, resulting in bone fragility. Both surgical and nonsurgical management have advantages and disadvantages. Thus, open reduction and anatomic plate fixation remain effective management modalities for trochanteric fractures in osteopetrosis patients. CONCLUSION: For our patient and as described in the literature, the complication rate decreases as some principles are respected with better consolidation of the osteoporotic fracture.

Benign Hyperostosis of the Rib.

Teaching point: Benign hyperostosis of the rib is a benign entity consisting of a stress phenomenon that should not be confused with Paget, fibrous dysplasia, or osteoblastic metastasis.

Space invaders: Reassessing the histology of hyperostosis frontalis interna.

Hyperostosis frontalis interna (HFI) is a human skeletal lesion characterized by nodules of hyperplastic bone and thickening of the frontal bone's inner surface. Despite its prevalence in the general population and its long history of observation-it is one of the most frequently observed pathologies in gross anatomy laboratories-HFI's etiology and pathogenesis remain poorly understood. This is largely due to the lack of a thorough survey of its histology across the various stages of its development. Our study has three major aims: (1) assess HFI histology from incipient to advanced lesions; (2) elucidate lamellar and trabecular structure in HFI; and (3) clarify impacts/roles of the dura mater in HFI. Sections of nondecalcified bone provide evidence for two different categories of lesions: (1) stratum lesions, characterized by lamellar-based overall thickening of the internal table, and (2) eruptive lesions, characterized by nodular formations of initially lamellar bone that appear to form the bulk of bone mass in advanced stages. Sections of nondecalcified bone also suggest that for both lesion types, HFI growths begin as deposits of lamellar bone, which are later remodeled into woven bone deposits; our data do not support the hypothesis that lesions begin as a "diploization" of cortical bone as suggested by prior studies. Trichrome-stained sections provide evidence that growing lesions erode through and engulf the dura mater, effectively destroying this tissue layer as they grow laterally and inwardly. Our results indicate possible avenues of research to better understand the root causes of this disorder.