Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction

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.

Cervical spinal cord injury following osteophyte excision for respiratory distress caused by diffuse idiopathic skeletal hyperostosis associated with ossification of posterior longitudinal ligament: a case report and literature review

BACKGROUND

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic non-inflammatory disorder characterized by enthesopathy and osteophyte formation. DISH can also cause several other symptoms. Limited range of motion (ROM) is the most common symptom; however, dysphagia and respiratory distress are clinically important symptoms. Dysphagia caused by cervical DISH is initially treated conservatively, but surgical treatment is performed when conservative treatment is ineffective. Although there are many reports on the surgical excision of osteophytes for refractory dysphagia, only a few reports on surgery for dysphagia caused by DISH associated with ossification of the posterior longitudinal ligament (OPLL) exist. Here, we report a rare case of cervical spinal cord injury following osteophyte excision for a respiratory distress and dysphagia caused by DISH associated with OPLL.

CASE PRESENTATION

A 76-year-old male with hypertension and diabetes presented with dysphagia, respiratory insufficiency, and palpitations. Four months later, he experienced severe dyspnea and was hospitalized. His vital signs indicated respiratory distress, which led to intubation and tracheotomy due to his worsening condition. Imaging revealed massive anterior cervical osteophytes and multisegmental OPLL that caused spinal canal stenosis and tracheal compression. Surgical excision of the osteophytes was performed, but the patient later developed tetraplegia attributed to C5/C6 instability. Posterior fusion and laminoplasty were performed, resulting in neurological improvement but persistent dysphagia and motor deficits. He was transferred to another hospital for rehabilitation but died of aspiration pneumonia.

CONCLUSIONS

Patients with cervical OPLL and spinal cord compression may experience spinal cord injury when intervertebral mobility is slightly increased due to osteophyte excision. If dysphagia or respiratory distress occur in patients with DISH and OPLL, decompression and fusion surgery at the mobile segment is required, in addition to osteophyte excision surgery. Posterior decompression and fusion surgery should be performed before anterior osteophyte excision surgery to avoid implant infection, particularly in patients with respiratory distress who have undergone tracheostomy. Patients receiving long-term mechanical ventilation are less likely to recover their swallowing function and should undergo a total laryngectomy.

Dysphagia with recurrent severe aspiration due to cervical diffuse idiopathic skeletal hyperostosis (Forestier's disease)

Dysphagia is a common symptom in patients presenting to the gastroenterologist. However, extraluminal causes of dysphagia may be missed by endoluminal diagnosis alone. This case report presents a 72-year-old man with slowly progressive dysphagia that occurred with the ingestion of certain solid foods and was intermittently associated with severe aspiration. Esophagogastroduodenoscopy and barium swallow study were both normal. However, a conventional x-ray and computed tomography (CT) scan of the neck revealed diffuse idiopathic skeletal hyperostosis (Forestier's disease) of the anterior cervical spine (C2-C7). Fiber endoscopic evaluation of swallowing (FEES) revealed functionally incomplete emptying of the oral cavity during swallowing, and the patient reported dysphagia score (EAT-10) was 23 (normal < 3). Surgical removal of the hyperostosis (C3-C6) resulted in immediate and sustained improvement in dysphagia at 3 months.

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.

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.

Step-By-Step Surgery for Diffuse Idiopathic Skeletal Hyperostosis (DISH) of the Cervical Spine

Diffuse idiopathic skeletal hyperostosis (DISH) is a disease that can lead to relevant ENT symptoms such as dysphagia or dyspnea. Surgical treatment for this disease offers good results and outcomes, allowing patients to restore fundamental functions such as swallowing or phonation. Laryngoscope, 134:2787-2789, 2024.

A Case of Dysphagia Due to Large Osteophytic Lesions in the Cervical Spine: A Conservative Approach

Dysphagia is a common symptom with various underlying etiologies, making its management challenging even for experienced physicians. The presence of osteophytes in the cervical spine may often impede swallowing, displace the larynx, and cause a sore throat. We describe a case of an 85-year-old male who presented with a two-year history of progressive dysphagia, exacerbated over the last two months, especially with solid foods and liquids, prompting an ENT evaluation. Despite prior investigations, including normal gastroscopy and empirical pain management, further assessment revealed bulging masses in the hypopharynx indicative of cervical osteophytes. Conservative management, including speech and swallow therapy, dietary modifications, and pharmacological interventions, resulted in significant symptom improvement without surgical intervention. This case demonstrates the effectiveness of conservative treatment measures in treating dysphagia caused by cervical osteophytes, emphasizing the significance of a multidisciplinary approach for optimal patient care.

Long-term effects of diffuse idiopathic skeletal hyperostosis on physical function: A longitudinal analysis

BACKGROUND

Cross-sectional studies on diffuse idiopathic skeletal hyperostosis have focused on its incidence and related factors. However, the long-term changes caused by the disease remain unclear. This longitudinal cohort study aimed to elucidate the progression of diffuse idiopathic skeletal hyperostosis and its effects on physical function, health-related quality of life, and spinal alignment.

METHODS

We recruited 255 older adults (87 men and 168 women; average age, 71.3 years in 2014) who attended local health checkups in 2014 and 2020. Height, body weight, body mass index, blood pressure, grip strength, functional reach, and bone mineral density were measured. The prevalence, location, number of ossified contiguous vertebrae, and spinopelvic parameters were estimated using whole-spine standing radiographs. For health-related quality of life assessment, the Oswestry disability index and EuroQuol-5D were obtained. We performed a 1:1 case-control study with age and sex-matched patients with and without diffuse idiopathic skeletal hyperostosis and analyzed progression over a 6-year period.

RESULTS

In 2014, 39 (15.3%) of 255 patients were diagnosed with diffuse idiopathic skeletal hyperostosis (24 males and 15 females), which occurred more frequently in the elderly and males. In 2020, 12 (4.3%) patients were newly diagnosed with diffuse idiopathic skeletal hyperostosis, and 28 (71.7%) of 39 patients diagnosed in 2014 showed varying degrees of progression. Compared with age- and sex-matched patients without diffuse idiopathic skeletal hyperostosis, patients with the condition had higher body mass index and lumbar bone mineral density, larger sagittal vertical axis, and greater T1-pelvic angle. Changes in physical function and spinal-pelvic parameters during the 6-year period did not differ between the groups.

CONCLUSIONS

Over a 6-year period, the prevalence of diffuse idiopathic skeletal hyperostosis increased by 4.3%, and it progressed in 71.7% of patients. However, it had little effect on longitudinal physical function, health-related quality of life, and spinopelvic parameters in older adults.

[Dysphagia as the main symptom in anterior cervical spine osteophytes (Forestier disease and cervical spondylosis deformans). Case reports and literature review]

Anterior cervical osteophytes are a fairly common X-ray finding in people over 50 years old. Incidence of dysphagia in patients with anterior osteophytes varies from 1% in those aged 40-60 years to 10.6% in patients over 60 years old. The most common causes of anterior cervical hyperosteophytosis causing dysphagia are cervical spondylosis deformans and Forestier disease. We present 2 clinical cases of spondylogenic dysphagia in cervical spondylosis deformans and Forestier disease. The review is devoted to the causes and diagnostic methods for dysphagia caused by anterior cervical osteophytes, as well as surgical options for this pathology.

CONCLUSION

Microsurgical resection of anterior osteophytes is an effective method for dysphagia after ineffective therapy for 3 months. Microsurgical osteophytectomy provides stable regression of dysphagia with low recurrence rate.

[Cervicogenic dysphagia: a case report]

The article presents a case of pharyngeal dysphagia and obstructive sleep apnea syndrome caused by degenerative-dystrophic changes in the cervical spine with the formation of large cervical osteophytes at the C3-C6 level. Osteophytes caused deformation of the posterior wall of the hypopharynx and narrowing of its lumen by 20-25% from the level of the arytenoid cartilages to the upper parts of the epiglottis. CT scan also showed the intervertebral disc heights lost, as well as osteophytes at the posterolateral margins of the vertebral bodies (disc osteophyte complex). Osteosclerosis in combination with facet arthrosis caused spinal and foraminal stenosis.

Cervical Spine Osteophyte: A Case Report of an Unusual Presentation

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition that causes abnormal bone growth at the sites of ligament insertion, mainly in the spine. It is of unknown etiology and usually affects older males. It is often asymptomatic, but it can sometimes cause dysphagia if it affects the anterior cervical spine. We report the case of a 50-year-old male patient with DISH who presented with chronic dysphagia and was diagnosed with a large cervical osteophyte compressing the esophagus. The patient had a history of several comorbidities, including diabetes, hypertension, stroke, and gout. He underwent surgical removal of the osteophyte and recovered well. We discuss the clinical features, diagnosis, and treatment options for this rare complication of DISH.

Anterior Cervical Huge Osteophyte Causing Dysphagia: A Case Report

The prevalence of anterior cervical osteophyte among elderly patients is high due to many causes such as trauma, degenerative changes, and diffuse idiopathic skeletal hyperostosis. Severe dysphagia is one of the main presenting symptoms for anterior cervical osteophytes. We describe a case of a patient with anterior cervical osteophyte with severe dysphagia and quadriparesis. The 83-year-old man presented to the emergency department following the incident of falling on his face. CT and X-ray were done in the emergency department, which showed huge anterior osteophytes at the level of C3-4 compressing the esophagus. The patient's consent was taken and shifted to the operation room and surgery was done. Anterior cervical osteophyte was removed, a discectomy was performed, and a peek cage and screws were inserted for fusion. In many cases of anterior cervical osteophyte, surgery is considered the ultimate treatment for patients to relieve symptoms, improve quality of life, and decrease mortality.

A Scoring System for Anterior Longitudinal Ligament Ossification of the Lumbar Spine in Diffuse Idiopathic Skeletal Hyperostosis: Relationship Between the Extent of Ligament Ossification and the Range of Motion

STUDY DESIGN

Retrospective observational study.

OBJECTIVE

To investigate the relationship between the extent of ligament ossification and the range of motion (ROM) of the lumbar spine and develop a new scoring system.

METHODS

Forty-three patients (30 men and 13 women) with lumbar spinal canal stenosis who underwent decompression from January to December 2018. Ligament ossification at L1/2 to L5/S was assessed on plain X-ray (Xp) and computed tomography (CT) using a modified Mata scoring system (0 point: no ossification, 1 point: ossification of less than half of the intervertebral disc height, 2 points: ossification of half or more of the intervertebral disc height, 3 points: complete bridging), and the intra-rater and inter-rater reliability of the scoring was assessed. The relationship of the scores with postoperative lumbar ROM was investigated.

RESULT

Intra-rater reliability was high (Cronbach's α was 0.74 for L5/S on Xp but 0.8 or above for other sections), as was inter-rater reliability (Cronbach's α was 0.8 or above for all the segments). ROM significantly decreased as the score increased (scores 1 to 2, and 2 to 3). A significant moderate negative correlation was found between the sum of the scores at L1/2-L5/S and the ROM at L1-S (ρ = - 0.4493, P = 0.025).

CONCLUSION

Our scoring system reflects lumbar mobility and is reproducible. It is effective for assessing DISH in fractures and spinal conditions, and monitoring effects on treatment outcomes and changes over time.

Imaging Characteristics of Diffuse Idiopathic Skeletal Hyperostosis: More Than Just Spinal Bony Bridges

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by new bone formation and enthesopathies of the axial and peripheral skeleton. The pathogenesis of DISH is not well understood, and it is currently considered a non-inflammatory condition with an underlying metabolic derangement. Currently, DISH diagnosis relies on the Resnick and Niwayama criteria, which encompass end-stage disease with an already ankylotic spine. Imaging characterization of the axial and peripheral skeleton in DISH subjects may potentially help identify earlier diagnostic criteria and provide further data for deciphering the general pathogenesis of DISH and new bone formation. In the current review, we aim to summarize and characterize axial and peripheral imaging findings of the skeleton related to DISH, along with their clinical and pathogenetic relevance.

Surgical Intervention of Dysphagia Caused by Ossification of Anterior Longitudinal Ligament: A Case Report

Ossification of the anterior longitudinal ligament (OALL) in the cervical spine is a common entity but rarely causes dysphagia, dyspnea, and dysphonia. We report an OALL case which causes such symptoms. A 47-year-old female patient had a complaint of progressive difficulty swallowing for 2 months. A cervical X-ray and computerized tomography scan were taken afterward, which showed OALL at the C3–7 level. She then had esophageal endoscopy to rule out other dysphagia-related disorders. The patient underwent anterior osteotomy via anterior cervical approach with significant relief of dysphagia postoperatively. Surgical management in symptomatic OALL improves dysphagia and prevents its secondary complications.

Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Involving the Cervical Spine: Technical Nuances and Outcome of a Multicenter Experience

STUDY DESIGN

Retrospective multicenter.

OBJECTIVES

diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH.

METHODS

Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA.

RESULTS

24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel (P = 0.12) to the burr (P = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level (P = 0.15). Use of curved chisel reduced the surgical times (P = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more (P = 0.04) and shorter waiting times for surgery (P < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery.

CONCLUSION

The "age of DISH" counts more than patients' age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.

Diffuse idiopathic skeletal hyperostosis of the cervical spine causing dysphagia and airway obstruction: an updated systematic review

BACKGROUND AND CONTEXT

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by growing ossifications of spinal entheses and tendons, which may cause trachea and esophagus compression when located anteriorly in the cervical spine.

PURPOSE

Our previous systematic review on the epidemiological and clinical knowledge of dysphagia and airway obstruction caused by cervical DISH was updated, with a focus on (surgical) treatment and outcomes.

STUDY DESIGN

A systematic review of the literature was performed.

METHODS

Publications in Medline and EMBASE from July 2010 to June 2021 were searched. Two investigators performed data extraction and study specific quality assessment.

RESULTS

A total of 138 articles (112 case reports and 26 case series) were included, describing 419 patients with dysphagia and/or airway obstruction. The mean age of the patient group was 67.3 years (range: 35-91 years), and 85.4% was male. An evident increase of published cases was observed within the last decade. Surgical treatment was chosen for 66% of patients with the anterolateral approach most commonly used. The total complication rate after surgery was 22.1%, with 12.7% occurring within 1 month after intervention. Improvement of dysphagia was observed in 95.5% of operated patients. After a mean follow-up of 3.7 years (range: 0.4-9.0 years), dysphagia recurred in 12 surgically treated patients (4%), of which five patients had osteophyte regrowth.

CONCLUSIONS

The number of published cases of dysphagia in patients with DISH has doubled in the last decade compared to our previous review. Yet, randomized studies or guidelines on the treatment or prevention on recurrence are lacking. Surgical treatment is effective and has low (major) complication rates. Common trends established across the cases in our study may help improve our understanding and management of dysphagia and airway obstruction in cervical DISH.

Case Report: Diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament in the cervical spine: A rare case with dysphagia and neurological deficit and literature review

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by the calcification and ossification of ligaments and tendons. Progressive dysphagia caused by DISH-related anterior cervical osteophytes and deteriorating dysphagia caused by DISH combined with neurological dysfunction resulting from the posterior longitudinal ligament is rare. The initial diagnosis is misleading and patients often consult several specialists before spine surgeons. This study aims to provide a comprehensive review of the literature on this challenging pathological association. We also present a case illustration where a 53-year-old man presented with progressive dysphagia and foreign body sensation in the pharynx, accompanied by a neurological numbness defect in the right upper limb. Radiography and computed tomography confirmed the existence of osteophytes at the anterior edge of the C4–C7 pyramid and ossification of the posterior longitudinal ligament, in which the giant coracoid osteophyte could be seen at the anterior edge of the C4–C5 pyramid. The anterior cervical osteophyte was removed, and decompression and fusion were performed. The symptoms were relieved postoperatively. No recurrence of symptoms was found during the six-month follow-up. Spine surgeons should consider progressive dysphagia caused by DISH-related osteophytes at the anterior edge of the cervical spine as it is easily misdiagnosed and often missed on the first evaluation. When combined with ossification of the posterior longitudinal ligament, following cervical osteophyte resection it is necessary to consider stabilizing the corresponding segments via fusion.

Head rotation as an effective compensatory technique for dysphagia caused by unilateral cervical osteophytes

Objective

Dysphagia is common in patients with cervical osteophytes. We aimed to determine whether head rotation as a compensatory technique is effective for dysphagia caused by unilateral cervical osteophytes.

Methods

We retrospectively analyzed videofluoroscopic swallowing study (VFSS) data obtained in one university hospital. Patients whose VFSS showed pharyngeal stasis by mechanical obstruction due to cervical osteophytes were selected. They were divided into a unilateral skewed osteophyte group and a diffuse central osteophyte group as confirmed by laryngoscopy or computed tomography. The effect of head rotation on swallowing was investigated. Fisher’s exact test was used for statistical analysis.

Results

Among 2876 patients who underwent VFSSs, we identified 48 patients with osteophyte-induced dysphagia. The osteophytes were centrally located in 36 patients and unilateral in the remaining 12. Ten of the patients with unilateral osteophytes showed improvement when they swallowed with head rotation toward the osteophyte side, but none of the patients with central osteophytes showed effective swallowing. A statistically significant relationship was found between swallowing with head rotation and skewed cervical osteophytes.

Conclusion

Swallowing with head rotation was safe, easy, and effective for patients with dysphagia caused by unilateral cervical osteophytes. We advise attempting this method prior to considering surgical approaches.

Surgical Treatment of Dysphagia Secondary to Anterior Cervical Osteophytes Due to Diffuse Idiopathic Skeletal Hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is an ossifying and ankylosing skeletal condition that can be associated with DISH-related dysphagia in the case of cervical involvement. In contrast to most cases of dysphagia, which are managed conservatively, DISH-related dysphagia can be discouraging due to the progressive nature of DISH. We report two cases of DISH-related dysphagia that were treated with the surgical removal of osteophytes via an anterolateral approach. We were able to remove osteophytes using the bottleneck point as an anatomical landmark between the vertebral body and the bony excrescence. Patients’ symptoms improved following osteophyte removal, without recurrence. In cases of DISH-related dysphagia, osteophyte removal using an osteotome could improve dysphagia safely and quickly.

Combined Anterior Osteophytectomy and Cricopharyngeal Myotomy for Treatment of DISH-Associated Dysphagia

STUDY DESIGN

Retrospective observational case series.

OBJECTIVE

To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP).

METHODS

This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM.

RESULTS

A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures.

CONCLUSION

Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.

An unusual presentation of thoracic diffuse idiopathic skeletal hyperostosis (DISH) and video-assisted thoracoscopic surgery (VATS)

Introduction and importance

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease and Forestier and Rotes-Querol disease, is a systemic condition characterized by calcification and ossification of ligaments and entheses which often mainly affects the thoracic spine. Anterior osteophyte compression of the esophagus resulting in dysphagia and dyspepsia is extremely rare in symptomatic thoracic DISH.

Case presentation

A 72-year-old male presented with dyspepsia and dysphagia for 10 months. A large beak-like anterior osteophyte, detected by a radiographic study and by a Barium esophagogram test at the T9-T10 level of the thoracic spine, was established by gastrointestinal medicine specialists to be the cause of the symptoms. The large anterior osteophyte was removed using video-assisted thoracoscopic surgery (VATS). At the one-year follow-up, the patient's symptoms had significantly improved and there was no recurrence of the osteophyte or the dyspepsia and dysphagia.

Clinical discussion

Thoracic DISH rarely presents with dysphagia and dyspepsia due to the greater mobility of the esophagus in the area of the thoracic spine than in the area of the cervical spine. This is the first reported case of symptomatic thoracic DISH treated by anterior thoracic osteophytectomy with VATS. The treatment was effective with no post-operative complications.

Conclusion

Anterior thoracic osteophytectomy with VATS is an effective surgical treatment option for this condition.

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Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease and Forestier and Rotes-Querol disease, is an extremely rare form of symptomatic thoracic DISH.

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Secondary dysphagia and dyspepsia can be caused by a giant beak-like anterior osteophyte at the T9-T10 levels of the thoracic spine.

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Surgical management with video-assisted thoracoscopic surgery (VATS) provides results superior to non-surgical treatments.

SAPHO Syndrome Presenting With Atlo-Epistrophic Synovitis and Left Vocal Cord Paresis: A Challenging Diagnosis

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare syndrome mainly characterized by cutaneous and osteoarticular manifestations. The most typical osteoarticular manifestations are localized to the anterior chest wall and include a usually noninfectious osteitis, hyperostosis, and synovitis of the sternoclavicular joints. However, clinical presentation of SAPHO syndrome can be quite heterogeneous. Several clinical and radiological features are shared with other well-defined pathological entities, and clinical signs and symptoms often occur at different timepoints. Mainly due to this complexity and its rarity, there are currently no validated diagnostic criteria for SAPHO syndrome. Inflammation of the soft tissues around the bones and possible nerve compression could contribute to dysphagia, hypophonia, or obstruction of the airways. Neurologic manifestations could therefore be part of this multiorgan involvement. Here, we present a case of SAPHO syndrome with atypical onset symptoms, characterized by left vocal cord paralysis, acute neck pain due to osteolytic atlantoepistrophic lesion, and an unusual cutaneous manifestation, diagnosed as mid-dermal elastolysis. The latest two, to the best of our knowledge, have been here first described in a case of SAPHO syndrome.

Dysphagia due to anterior cervical osteophytosis: case report

Anterior cervical osteophytosis is a noninflammatory condition characterized by calcification or ossification of the anterolateral paravertebral ligaments of the cervical spine. It affects 20 to 30% of the elderly, being responsible for 1.6% of the identifiable etiologies of dysphagia in the senile population. In advanced states, dysphagia due to cervical osteophytosis can lead to complications such as malnutrition, weight loss and aspiration pneumonia. This study aims to alert to this diagnosis, enabling early treatment of the condition. The case of a 66-year-old male patient with choking dysphagia for solids and nasal food reflux for 1 year is reported. Fiberoptic Endoscopic Evaluation of Swallowing showed bulging of the posterior pharyngeal wall and, with solid food supply, restriction to the retroflexion of the epiglottis, nasal reflux of the food and a large amount of food residue on the lesion. Cervical spine Computed Tomography identified the presence of anterior cervical osteophytes between the C3 and C6 vertebrae, the largest with anteroposterior length of 12 millimeters, narrowing the air column at the level of the oro- and hypopharynx. The patient was adequately treated with swallowing therapy by speech-language pathologist. The initial treatment strategy for symptomatic osteophytosis should be conservative, usually with a good response to swallowing therapy. Although they are rarely implicated in the etiology of dysphagia, considering its high prevalence, it is important that otolaryngologists and speech-language pathologists are attentive to this diagnosis, allowing early and effective treatment for the assisted patient, better prognosis and fewer complications of oropharyngeal dysphagia in the elderly.

Pseudohypoparathyroidism mimicking cervical diffuse idiopathic skeletal hyperostosis with dysphagia: A case report and literature review

Dysphagia due to extensive ossification at anterior segments of the cervical spine is a rare occurrence and is usually attributable to diffuse idiopathic skeletal hyperostosis (DISH). We present the case of a 74-year-old female with dysphagia most likely due to ossification in pseudohypoparathyroidism type 1a (PHP1a). PHP1a is a rare, autosomal dominant disorder caused by mutations in the GNAS1 gene. Our patient had characteristic phenotype features of PHP1a, also known as Albright's hereditary osteodystrophy (AHO), which was diagnosed without genetic confirmation. She was conservatively treated with dietary measures and observation, and reported persisting symptoms of dysphagia at six-month follow-up. This is the first case to describe dysphagia in PHP1a with a similar presentation to DISH.

Increased risk of stroke in patients with diffuse idiopathic skeletal hyperostosis: a nationwide population-based cohort study

Diffuse idiopathic skeletal hyperostosis (DISH) is frequently an incidental finding during X-ray examination. Although it has been shown to be associated with several chronic diseases, the hazard of cerebrovascular disease has seldom been explored. Our study aimed at determining the risk of stroke conferred by DISH, which is a retrospective cohort study adopting the largest medical database in Taiwan. Patients with a diagnosis of DISH at least three times from 2005 to 2010 were identified as the study group, and those in the control group were selected by matching age and gender. Patients were followed up until the end of 2015 to trace the incidence of stroke. Cox regression analysis was performed to compute the hazard ratio of stroke. Among the included 5300 patients, 1060 had a diagnosis of DISH. Significantly higher prevalence rates of stroke, hypertension, diabetes, and hyperlipidemia were noted in these patients. Overall, DISH conferred a 1.68 times higher risk of developing stroke. The significantly higher hazard ratio could be identified in both genders whether hypertension existed or not. Even in those without comorbidities, DISH still conferred a significantly higher risk of cerebrovascular disease in the future, which should never be ignored when encountered during clinical practice.

DISHphagia – A Riddle Unwrapped a Clinical Case with Literature Review

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed systemic skeletal disease. It is characterized by calcifications affecting mainly the spinal anterior longitudinal ligament. In the majority of cases, the patients are asymptomatic, but cervical osteophytes can sometimes cause hoarseness, dysphagia (DISHphagia) and even dyspnea.

Case description: A 61-year-old man was admitted to our department with complaints of difficulty in swallowing and weight loss. Dysphagia had been increasing gradually for nine months. Barium swallow esophagram revealed asymmetric swallowing with expansion above the upper esophageal sphincter without other abnormalities. The extension was confirmed by esophago-gastro-duodenoscopy (EGD). Furthermore, CT scan of the thorax clearly demonstrated degenerative changes of the cervical and thoracic region, extensive ossification of the anterior longitudinal ligament, and osteophytes from C2-C7 with a forward displacement of the esophagus by 14 mm. The so-called “wax dripping down the candle” phenomenon was as well observed.

Conclusion: DISH is a systematic, musculo-skeletal disease of older adults with unknown etiology. Dysphagia is the most common symptom of the disease and might be caused by osteophytes of the cervical region. We presented a case of DISH with a rare localization of the osteophytes in the cervical region C2-C7. Due to the increasing incidence of the Forestier’s syndrome and its associated “DISHphagia”, the gastroenterologist should increase the awareness of this underestimated disease and improve the diagnostic approach.

Associations between Clinical Findings and Severity of Diffuse Idiopathic Skeletal Hyperostosis in Patients with Ossification of the Posterior Longitudinal Ligament

BACKGROUND

This study investigated how diffuse idiopathic skeletal hyperostosis (DISH) influences clinical characteristics in patients with cervical ossification of the posterior longitudinal ligament (OPLL). Although DISH is considered unlikely to promote neurologic dysfunction, this relationship remains unclear.

METHODS

Patient data were prospectively collected from 16 Japanese institutions. In total, 239 patients with cervical OPLL were enrolled who had whole-spine computed tomography images available. The primary outcomes were visual analog scale pain scores and the results of other self-reported clinical questionnaires. Correlations were sought between clinical symptoms and DISH using the following grading system: 1, DISH at T3-T10; 2, DISH at both T3-10 and C6-T2 and/or T11-L2; and 3, DISH beyond the C5 and/or L3 levels.

RESULTS

DISH was absent in 132 cases, grade 1 in 23, grade 2 in 65, and grade 3 in 19. There were no significant correlations between DISH grade and clinical scores. However, there was a significant difference in the prevalence of neck pain (but not in back pain or low back pain) among the three grades. Interestingly, DISH localized in the thoracic spine (grade 1) may create overload at the cervical spine and lead to neck pain in patients with cervical OPLL.

CONCLUSION

This study is the first prospective multicenter cross-sectional comparison of subjective outcomes in patients with cervical OPLL according to the presence or absence of DISH. The severity of DISH was partially associated with the prevalence of neck pain.

Outcomes and complications of surgical treatment of anterior osteophytes causing dysphagia: Single center experience

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To better understand the functional swallow outcomes, cervical balance, and surgical complications, we examined patients with anterior osteophytes and dysphagia who were treated operatively.

SUMMARY OF BACKGROUND DATA

Anterior osteophytes from diffuse idiopathic skeletal hyperostosis (DISH) or degenerative etiology of the cervical spine can cause dysphagia from mechanical compression of the esophagus. Osteophytectomy is generally accepted as a safe surgical treatment, but the risk of instability is unclear. The potential for associated complications must be considered.

METHODS

Patients who had anterior osteophytes and dysphagia from 2005 to 2020 were reviewed retrospectively. Demographics, radiographic parameters, functional swallow outcome, and complications were examined.

RESULTS

There were 15 patients identified treated surgically. Increased osteophyte height positively correlated with severity of dysphagia with Pearson coefficient of 0.53 (p = 0.042). Functional Outcome Swallowing Scale (FOSS) scores improved after surgical treatment from median of 2 to 0 (p = 0.002). C2-7 SVA did increase by 8 mm (p = 0.007) but was generally well tolerated. There was a 27% complication rate including a case of C5 lateral mass fracture with central cord syndrome after a fall 4 days following osteophytectomy. There was one patient who was preoperatively dependent on gastrostomy tube who required a tracheostomy and had continued reliance on the gastrostomy tube.

CONCLUSION

Surgical treatment of anterior osteophytes causing dysphagia with osteophytectomy can lead to overall improved FOSS scores for most patients. However, a high preoperative FOSS score may be a prognostic indicator of poor postoperative functional swallow outcome. It is important to consider the potential for instability when osteophytectomy is performed at 3 or more spinal segments.

Timing of Surgical Intervention for Dysphagia in Patients With Diffuse Idiopathic Skeletal Hyperostosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

This was a systematic review and meta-analysis.

OBJECTIVE

The objective was (1) to measure rates of successful resolution of dysphagia in patients after undergoing surgical intervention for diffuse idiopathic skeletal hyperostosis (DISH); and (2) to determine if older age, longer duration of preoperative symptoms, or increased severity of disease was correlated with unsuccessful surgical intervention.

SUMMARY OF BACKGROUND DATA

DISH, also known as Forestier disease, is an enthesopathy affecting up to 35% of the elderly population. Many patients develop osteophytes of the anterior cervical spine, which contribute to chronic symptoms of dysphagia causing debilitating weight loss and possibly resulting in the placement of a permanent gastrostomy feeding tube. For patients that fail conservative medical management, an increase in surgical interventions have been reported in the literature in the last 2 decades.

MATERIALS AND METHODS

A systematic search was performed on PubMed, Medline, Cochrane Library, and Embase. Studies measuring outcomes after surgical intervention for patients with dysphagia from DISH were selected for inclusion. Two independent reviewers screened and assessed all literature in accordance with Cochrane systematic reviewing standards.

RESULTS

In total, 22 studies reporting 119 patients were selected for inclusion. Successful relief of dysphagia was obtained in 89% of patients after surgical intervention. Failure to relieve dysphagia was associated with increased length of symptoms preoperatively (P<0.01) using logistic regression. Patients with more severe preoperative symptoms also seem to have an increased risk for treatment failure (risk ratio, 2.86; 95% confidence interval, 1.19-6.85; P=0.02). Treatment failure was not associated with patient age, use of intraoperative tracheostomy, implementation of additional fusion procedures, level of involved segments, or number of involved segments.

CONCLUSIONS

Patients undergoing surgical intervention have a higher likelihood of failing surgery with increasing preoperative symptom length and increased preoperative symptom severity.

LEVEL OF EVIDENCE

Level III.

Progression of Ossification of the Anterior Longitudinal Ligament Associated With Diffuse Idiopathic Skeletal Hyperostosis by Age: A Study of Computed Tomography Findings Over 5 Years

STUDY DESIGN

Observational study.

OBJECTIVE

To investigate whether the progression of anterior longitudinal ligament ossification varies by age among patients with diffuse idiopathic skeletal hyperostosis (DISH).

METHODS

Of the patients who underwent computed tomography (CT) of the thoracic to pelvic region at least twice from 2009 to 2018, 191 who underwent CT at an interval of 5 years and 0 months to 5 years and 2 months were enrolled (87 men and 104 women). Sex, age at the time of the first CT scan, the presence/absence of DISH, level of complete vertebral body fusion associated with DISH, and extent of ligament ossification using the modified Mata scoring system were investigated.

RESULTS

DISHs were detected in 53 (27.7%) of 191 patients. The score of ligament ossification increased over time in 35 (66%) of 53 patients; 93 intervertebral spaces were affected. The percentage of completely fused intervertebral spaces increased by 6.7% from 31.3% to 38.0% over time. The increase in score for all intervertebral spaces in individual patients was significantly greater in the ≤70 years old group (2.7 ± 2.8 points, n = 28) than in the ≥71 years old group (1.2 ± 1.4 points; n = 25; P = .028). The mean age of patients with a recorded score that increased by ≥1 point was 67.4 years and that of patients without any change in the score was 73.3 years (P = .036). Thus, patients with recorded changes in the score were younger.

CONCLUSION

During the approximately 5-year period, ossification progressed more in younger patients than in older patients.

Surgical Treatment of Ossifications of the Cervical Anterior Longitudinal Ligament: A Retrospective Cohort Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The study aims to evaluate anterior cervical discectomy and fusion (ACDF) in the treatment of patients with ossification of the anterior longitudinal ligament (OALL).

METHODS

We retrospectively reviewed cases performed at our institution between January 2015 and December 2018; adult (age ≥18 years) patients who underwent anterior cervical decompression and fusion in the presence of dysphagia and OALL. Ten patients (9 male, 1 female, mean age 64.4 years) with OALL who underwent ACDF were included. Charts were reviewed for demographics and comorbidities. Primary outcomes assessed were intra- and postoperative complications. Secondary outcomes were fusion rates, instrumentation failure, postsurgical instability/deformity, and readmission rates.

RESULTS

The average duration of symptoms prior to surgery was 12.3 months. All patients presented with dysphagia (mean Bazaz score 2.0). The average number of levels with OALL was 4.7 (±1.67). All patients underwent ACDF and 3 patients underwent additional posterior cervical fusion for kyphotic deformity correction or when extensive laminectomy was required. We did not encounter any intraoperative complications. Eight patients (72%) had solid fusion demonstrated on the lateral x-rays and no evidence of progressive kyphotic deformity. We did not encounter any instrumentation failure or loosening. Two patients developed recurrence of dysphagia (Bazaz scores 2 and 3 respectively).

CONCLUSION

ACDF for OALL with dysphagia and concomitant myelopathy in our small series of 10 patients demonstrate good fusion and clinical outcomes. Larger studies will be necessary to determine the optimal treatment for patients with dysphagia due to OALL.

Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis (Forestier's disease): A systematic review of the literature

OBJECTIVES

Forestier's disease or diffuse idiopathic skeletal hyperostosis (DISH) is a common, yet underreported, disease affecting the elderly population. From an otolaryngologic perspective, DISH may manifest with dysphagia, dysphonia, or even dyspnea. The purpose of this study was to identify all published cases of dysphagia and other associated upper airway symptoms resulting from DISH in the last decade and to establish subsequently a management algorithm.

METHODS

A comprehensive review of the literature was conducted in May 2020 on Medline and Embase databases following the PRISMA statement for systematic reviews and meta-analysis.

RESULTS

Sixty-three articles, consisting of 50 case-reports and 13 case-series, met the inclusion criteria. A total of 236 cases of DISH were reported from 2010 to date. Otolaryngology instrumental evaluation, by fiberoptic laryngoscopy and fiberoptic endoscopic evaluation of swallowing, was frequently reported. Surgery was the most common treatment strategy for the management of dysphagia in 58.9% of patients, while conservative treatment was used in 41.1%. Tracheotomy for acute airway obstruction relief was performed in 6% of patients. No correlation was found between the type of treatment and dysphagia improvement.

CONCLUSIONS

Forestier's disease is currently a growing source of complications in elderly, mostly dysphagia and less commonly upper airway obstruction. The management of these complications requires a multidisciplinary team and a thorough approach, where the otolaryngologist plays a pivotal role.

Anterior Cervical Osteophyte Resection for Treatment of Dysphagia

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVES

When anterior cervical osteophytes become large enough, they may cause dysphagia. There is a paucity of work examining outcomes and complications of anterior cervical osteophyte resection for dysphagia.

METHODS

Retrospective review identified 19 patients who underwent anterior cervical osteophyte resection for a diagnosis of dysphagia. The mean age was 71 years and follow-up, 4.7 years. The most common level operated on was C3-C4 (13, 69%).

RESULTS

Following anterior cervical osteophyte resection, 79% of patients had improvement in dysphagia. Five patients underwent cervical fusion; there were no episodes of delayed or iatrogenic instability requiring fusion. Fusion patients were younger (64 vs 71 years, P = .05) and had longer operative times (315 vs 121 minutes, P = .01). Age of 75 years or less trended toward improvement in dysphagia (P = .09; OR = 18.8; 95% CI 0.7-478.0), whereas severe dysphagia trended toward increased complications (P = .07; OR = 11.3; 95% CI = 0.8-158.5). Body mass index, use of an exposure surgeon, diffuse idiopathic skeletal hyperostosis diagnosis, surgery at 3 or more levels, prior neck surgery, and fusion were not predictive of improvement or complication.

CONCLUSIONS

Anterior cervical osteophyte resection improves swallowing function in the majority of patients with symptomatic osteophytes. Spinal fusion can be added to address stenosis and other underlying cervical disease and help prevent osteophyte recurrence, whereas intraoperative navigation can be used to ensure complete osteophyte resection without breaching the cortex or entering the disc space. Because of the relatively high complication rate, patients should undergo thorough multidisciplinary workup with swallow evaluation to confirm that anterior cervical osteophytes are the primary cause of dysphagia prior to surgery.

Anterior cervical osteophytes causing dysphagia: Choice of the approach and surgical problems

Background

Anterior cervical osteophytes (ACOs) may rarely cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly located between C3 and C7, whereas those at higher cervical (C1-C2) levels are rarer. We report a case series of 4 patients and discuss the best surgical approach according to the ostheophyte location and size, mainly for those located at C1-C2, and the related surgical problems.

Materials and Methods

Four patients (two males and two females) aged from 57 to 72 years were operated on for ACOs, causing variable dysphagia (and dyspnea with respiratory arrest in one). Three patients with osteophytes between C3 and C5 were approached through antero-lateral cervical approach, and one with a large osteophyte between C1 and C3-C4 level underwent a two-stage transcervical and transoral approach. All had significant postoperative improvement of dysphagia.

Results

The patient operated on though the transoral approach experienced postoperative flogosis of the prevertebral tissues and occipital muscles and thrombosis of the right jugular vein and transverse-sigmoid sinuses (Lemierre syndrome).

Conclusion

The transoral approach is the best surgical route to resect C1 and C2 ACOs, whereas the endoscopic endonasal approach is not indicated. The anterior transcervical approach is easier to resect osteophytes at C3, as well as those located below C3. A combined transoral and anterior cervical approach may be necessary for multilevel osteophytes.

Fusion for subaxial bow hunter's syndrome results in remote osseous remodeling of the hyperostotic growth responsible for vertebral artery compression

Background:

The authors present a previously unreported case of a patient with diffuse idiopathic skeletal hyperostosis (DISH) who developed bow hunter’s syndrome (BHS) or positional vertebrobasilar insufficiency. In addition, the authors demonstrate angiographic evidence of remote osseous remodeling after segmental fusion without direct decompression of the offending bony growth. BHS is a rare, yet well established, cause of posterior circulation ischemia and ischemic stroke. Several etiologies such as segmental instability and spondylosis have been described as causes, however, DISH has not been associated with BHS before this publication.

Case Description:

A 77-year-old man who presented with BHS was found to have cervical spine changes consistent with DISH, and angiography confirmed right vertebral artery (VA) stenosis at C4–5 from a large pathological elongation of the right C5 lateral mass. Head rotation resulted in occlusion of the VA. The patient underwent an anterior cervical discectomy and fusion and reported complete resolution of his symptoms. A delayed angiogram and CT of the cervical spine demonstrated complete resolution of the baseline stenosis, no dynamic compression, and remote osseous remodeling of the growth, respectively.

Conclusion:

This case represents the first publication in the literature of DISH as a causative etiology of BHS and of angiographic data demonstrating resolution of a compressive osseous pathology without direct decompression in BHS.

Two Cases of Severe Type 2 Respiratory Failure Associated with Diffuse Idiopathic Skeletal Hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory process characterized by hyperostosis at tendon insertions and around joint capsules and ossification of the anterior longitudinal ligament of the spine. The flexibility of the spinal column is reduced in DISH and affects the movement of the thorax, leading to restrictive ventilatory function. In this report, we describe the first two cases of severe type 2 (hypercapnic) respiratory failure associated with DISH. Two older men presented with histories of shortness of breath. Radiography of the spine revealed DISH with coexisting ankylosis of the costovertebral joints. The patients’ thoracic motion was severely restricted, reducing the mechanism of lung expansion to diaphragm contraction only. Both patients required non-invasive positive-pressure ventilation therapy to cope with their conditions. Our report sheds light on the risk of potentially life-threatening respiratory manifestations of DISH among older adults.

Sarcopenic Dysphagia After Occipito-Cervical Fusion Surgery in an Elderly Patient With High-Cervical Myelopathy Caused by Retro-Odontoid Pseudotumor: A Case Report

Occipito-cervical fusion surgery may cause dysphagia due to inadequate occipito-cervical alignment. However, little is known about any other mechanisms behind postoperative dysphagia. We present a rare case of severe sarcopenic dysphagia despite appropriate occipito-cervical alignment after occipito-cervical fusion surgery. An 85-year-old man who presented with high-cervical myelopathy due to a retro-odontoid pseudotumor underwent occipito-cervical fusion surgery and developed severe dysphagia immediately after the surgery. Swallowing videoendoscopy revealed stagnation of thick fluid at the larynx. Oral intake was prohibited and swallowing rehabilitation was performed. Subsequently, he showed a gradual improvement in swallowing function. He was allowed to start oral intake in the fourth week after surgery and was able to swallow solid foods in the sixth week after surgery. In this case, several parameters of occipito-cervical alignment such as the occipito-C2 angle (O-C2 angle), swallowing line (S-line), C2-C7 angle, and pharyngeal inlet angle, which are recognized as predictors of postoperative dysphagia after occipito-cervical fusion surgery, were adequate to prevent postoperative dysphagia. However, the patient had sarcopenia and cervical hyperlordosis to compensate for thoracic hyperkyphosis, which induces the hypertonicity of hyoid muscles. These findings led to a diagnosis of sarcopenic dysphagia after surgical invasion. Sarcopenic dysphagia is considered to be associated with skeletal and swallowing muscle weakness, apart from thinness, malnutrition, and surgical invasion. Elderly patients with sarcopenia may present with sarcopenic dysphagia because of surgical invasion after occipito-cervical fusion surgery. In such cases, it is important not only to control intraoperative occipito-cervical alignment but also to evaluate preoperative swallowing function.

Diffuse idiopathic skeletal hyperostosis (DISH) with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine without neurological deficit - A Case report

Introduction

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier disease, is a condition characterized by calcification and ossification of ligaments and enthuses (ligament and tendon insertion sites), which mainly affect the vertebral column. The clinical manifestation of DISH is variable. Some patients can be completely asymptomatic, whereas others can complain of painful stiffness, decreased range of movement, and myelopathy symptoms. OPLL usually produce myelopathy symptoms. Combined of OPLL and DISH are rare case.

Illustration

A 59 years old woman patient complained of neck and shoulder pain in the last 20 years ago, with decreased neck range of motion and dysphagia. There was no gross abnormality on patient's neck and back. Cervical x ray was showing a continuous ossification extending from the anterior surface of C2 to C7 in lateral radiograph. A similar ossification was also noticed on the posterior surface of the vertebral bodies from C2 to C6 abutting the spinal canal.

Discussion

Despite striking abnormal appearance of cervical DISH and OPLL seen on radiologic examinations, absence of myelopathy is an indication to non-operative treatment. Presence of dysphagia was not an indication of surgery in this patient, as dysphagia was not severe and myelopathy was absent. Patient was observed during her clinical course to document the progression of myelopathy. Prophylactic surgery was not indicated for this patient, and progression of myelopathy during observation is an indication for surgical intervention.

Conclusion

Diffuse and large abnormalities in cervical area with normal neurological function is not indication for surgery. Selective treatment based on individual case.

Dysphonia, Stridor, and Dysphagia Caused By Diffuse Idiopathic Skeletal Hyperostosis: Case Report and Review of Literature

Diffuse idiopathic skeletal hyperostosis (DISH) also known as Forestier disease is a noninflammatory, systemic skeletal disease of unknown etiology. DISH is usually asymptomatic but may compress the posterior wall of the aero digestive tract and lead to dysphagia, globus, hoarseness, stridor, dyspnea, and neurological problems. Although dysphagia is not uncommon among the presenting symptoms of DISH but dysphonia and stridor are rarely reported. We report a 68-year-old man who presented with a history of progressive dysphagia over 1 year and recent dysphonia and stridor secondary to cervical osteophytes. We discuss the symptoms, radiological features, and management of this uncommon case of DISH in conjunction with review of literature.

Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic bone-forming condition characterized by the presence of at least three bony bridges at the anterolateral spine. The aim of this review was to address the present state of pathophysiological knowledge, the clinical relevance, and diagnosis of DISH. The pathogenesis of DISH is currently unknown. The presence of DISH has been associated with older age, male sex, obesity, hypertension, atherosclerosis, and diabetes mellitus. Because the new bone forms mainly at entheseal sites, local fibroblasts, chondrocytes, collagen fibers, and calcified matrix are probably influenced by genetic, vascular, metabolic, and mechanical factors. Diagnosing the presence of DISH is of clinical importance, because the risk of a spinal fracture increases and associations with the metabolic syndrome, coronary and aortic disease, and respiratory effects are strong. Unravelling the pathogenesis of DISH can impact the field of regenerative medicine and bone tissue regeneration.

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.

Anterior Cervical Idiopathic Hyperostosis and Dysphagia: The Impact of Surgical Management-Study of a Series of 11 Cases

OBJECTIVE

To assess the efficacy and safety of surgery for dysphagia in anterior cervical idiopathic hyperostosis.

METHODS

This retrospective study included 11 consecutive patients presenting with dysphagia and anterior cervical idiopathic hyperostosis. Computed tomography scans and dynamic swallowing fluoroscopies were performed. The site of compression and the size and position of osteophytes were measured. The clinical outcomes and complications were recorded.

RESULTS

Two patients with anterior esophageal compression were found to have dysphagia caused by lower esophageal sphincter dysfunction. In the remaining 9 patients, the level of maximal compression was between C3 and C5 with the size of the osteophytes ranging from 8 to 17 mm. Intubation was challenging in 7 patients. Postoperative transient worsening of dysphagia was encountered in 3 patients. Two patients experienced severe complications including aphagia and respiratory compromise. Within 2 months of the operation, all patients reported satisfactory improvement of symptoms and a considerable gain in quality of life. No recurrence had occurred at final follow-up.

CONCLUSIONS

Anterior cervical hyperostosis causing dysphagia typically affects older men and results from compression between C3 and C5 from osteophytes of variable sizes. Operative intervention can provide long-lasting resolution of symptoms but is complicated by difficulty in endotracheal intubation, postoperative dysphagia, and rarely respiratory compromise. A systematic preoperative ear, nose, and throat consultation is recommended to reduce these complications.

CT-Based Evaluation of Diffuse Idiopathic Skeletal Hyperostosis in Adult Population; Prevalence, Associations and Interobserver Agreement

Diffuse idiopathic skeletal hyperostosis (DISH), being an asymptomatic condition, is generally discovered incidentally on imaging and it has not received much attention for research on clinical grounds. We assessed the prevalence of DISH, its associated factors, and interobserver agreement for computed tomography (CT)-based diagnosis of DISH. CT scans of chest, abdomen, and pelvis performed for various clinical indications were retrospectively reviewed. Resnick criteria were used for the diagnosis of DISH. Moreover, enthesopathy along with comorbidities was assessed. CT scans were observed by 3 observers having different experience levels. Out of total 416 patients, the prevalence of DISH was 30.8%. Strong positive agreement was observed between observer 1 and 2 (k = 0.89), observer 1 and 3 (k = 0.91), and observer 2 and 3 (k = 0.94). Reporting rate of DISH was 59.3%. Regression analyses showed that enthesopathy was 2.45 times (adjusted odds ratio [AOR]: 2.45, 95% confidence intervals [CI]: 1.48-4.05), diabetic patients were 4.74 times (AOR: 4.74, 95% CI: 2.89-7.78) while hypertensive patients were 2.17 times (AOR: 2.17, 95% CI: 1.30-3.62) more likely to have DISH in comparison to those who do not have DISH. A high prevalence of DISH was observed in our cohort. Enthesopathy and comorbidities like diabetes and hypertension were significant factors associated with DISH. Moreover, excellent agreement was observed in defining DISH on CT according to Resnick criteria.

Respiratory presentation of diffuse idiopathic skeletal hyperostosis (DISH): Management and review of the literature

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by the ossification of entheses. When localized in the cervical paravertebral region, typical signs and symptoms include stiffness, pain, loss of range of motion, and difficulty swallowing. Clinical Presentation: The authors present two less typical respiratory manifestations of DISH due to cervical osteophytes protrusion and obstruction of the upper airway. The first patient was treated conservatively (application of CPAP during nighttime), while the second required emergency intubation and a combined ENT-neurosurgical operation for the removal of osteophytes. Clinical Relevance: Even though dysphagic symptoms are more frequent, DISH may be a cause of airway obstruction and should be included in the differential diagnosis of respiratory distress and OSA.

Improvement of Swallowing Function After Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis: Our Experience

OBJECTIVE

To investigate the swallowing improvement in patients who underwent a transcervical prevascular retrovisceral approach for symptomatic cervical diffuse idiopathic skeletal hyperostosis (DISH), by means of the 10-item Eating Assessment Tool (EAT-10) questionnaire.

METHODS

Retrospective observational study of 21 patients treated with a transcervical anterior prevascular retrovisceral approach for symptomatic DISH with dysphagia as the primary symptom. All patients underwent videofluoroscopic study of swallowing before surgery and the EAT-10 questionnaire before and after the surgical procedure.

RESULTS

A statistically significant (P < 0.001) improvement in the postoperative EAT-10 score was reported. Sixteen out of 21 patients (76.2%) had their symptoms completely resolved, with an EAT-10 score less than 3. These results were not influenced by age and sex nor by presence of tracheostomy. The preoperative EAT-10 score was consistently related to postoperative outcome. Patients with mild and moderate dysphagia had better Δ in EAT-10 scores than patients with severe and very severe dysphagia (P = 0.02).

CONCLUSIONS

Surgical management seems to be effective in resolving swallowing disorders related to this disease in a consistent percentage of patients. This evidence is supported by the statistically significant improvement in EAT-10 scores after treatment. Moreover, it might be postulated that early intervention can guarantee a higher success rate because patients with severe and very severe dysphagia had significantly smaller improvement.