Spontaneous symptomatic pseudoarthrosis at the T11-T12 intervertebral space with diffuse idiopathic skeletal hyperostosis: a case report

Spontaneous symptomatic lumbar intervertebral pseudoarthrosis associated with diffuse idiopathic skeletal hyperostosis treated with a combined posteroanterior fusion: a case report and review of literature

Although diffuse idiopathic skeletal hyperostosis (DISH) is generally asymptomatic, in rare cases it involves multiple segments and can present with intervertebral pseudoarthrosis which requires treatment. We report a case of a 47-year-old female patient with intervertebral pseudoarthrosis and severe dynamic instability in the L4-5 intervertebral disc due to DISH and provide a brief review of literature. The patient developed severe lower back pain and intermittent claudication due to the instability in the only mobile part between multiple fused vertebrae from C7 to L4 and fusion segment from L5 to the ilium. We performed long-range posterior spinal and two-stage 360° fusion with L4-5 lateral interbody fusion. After the surgery the pain and intermittent claudication were improved and bony fusion was successful. Reports of intervertebral pseudoarthrosis in DISH with no history of trauma are extremely rare. We have only been able to find 5 cases. Compared to the previous reports, the present case describes a youngest patient, first case of female, and had the longest fusion due to DISH. Therefore, the patient required long-range fusion from T10 to the iliac bone in order to achieve adequate stabilization. Moreover, the present case is the first example of choosing a lateral interbody fusion, which provides even more robust consolidation.

Progressive diffuse idiopathic spinal hyperostosis: a case report

Diffuse idiopathic spinal hyperostosis (DISH) causes various problems, such as adjacent disc dysfunction, pseudarthrosis, or reossification, when spinal surgery is performed or spinal fracture occurs. The authors herein describe a patient with DISH in whom ossification of the anterior longitudinal ligament progressively advanced from the thoracic to sacral vertebrae during a 14-year period. Surgery was performed three times to treat the characteristic problems associated with DISH: abnormal sagittal alignment of the spine, ossification of the posterior longitudinal ligament, reossification of the laminectomy-treated regions and accompanying spinal canal stenosis, pseudarthrosis after spinal fracture, and delayed palsy. DISH-associated problems after spinal fusion are not rare, but this patient developed a particularly large number of problems often seen in the long term after spinal fusion in patients with DISH. Clinicians must be aware of problems being likely to occur in ossification-discontinuous and fragile regions during the postoperative follow-up.

Prevalence of Diffuse Idiopathic Skeletal Hyperostosis in Patients with Spinal Disorders

Study Design

Retrospective cohort study.

Purpose

The purpose of this study was to evaluate the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in patients with spinal diseases determined by roentgen images of the whole spine.

Overview of Literature

Although several studies have investigated the prevalence of DISH in healthy subjects, no detailed data have been reported on the prevalence of DISH in patients with degenerative spinal disorders.

Methods

Standing whole-spine roentgen images of 345 consecutive patients who underwent surgery in our hospital were obtained. Patients aged <18 years or with congenital spinal disease, metastatic spinal tumors, or inflammatory spinal disease were excluded. In total, 281 patients were eligible for inclusion. The presence of DISH was assessed according to Resnick's criteria and Mata's scoring system. The prevalence, location, and numbers of fused vertebral bodies of DISH were recorded.

Results

DISH was present in 25.6% of patients (72/281). The prevalence of DISH in the 41–49, 50–59, 60–69, 70–79, and ≥80 year age groups was 8.3% (2/24), 9.8% (5/51), 16.0% (12/75), 49.5% (48/97), and 33.3% (4/12), respectively; the prevalence increased with age. The average number of fused vertebral bodies was 7.5. More than 80% of DISH was located from T7 to T11, and more than 95% of DISH was located at T9/10. Patients with DISH were significantly older (71.1 years vs. 60.9 years, p<0.05), and men were more likely to have DISH than women (p<0.05).

Conclusions

In patients with degenerative spinal diseases with DISH, fused vertebrae were found most frequently in the lower thoracic spine, and their prevalence increased with age. DISH may be an age-related skeletal disorder with a higher overall prevalence in patients with spinal disorders than that in healthy subjects.

Symptomatic pseudarthrosis in ochronotic spine: case report

In this study the authors report the first example of spinal pseudarthrosis in a patient with ochronosis, and they describe the application of posterior-only 360° surgery as an alternative approach to combined anterior-posterior surgery in the management of pseudarthrosis of an ankylosed spine, regardless of its etiology. Spinal involvement in ochronosis produces loss of flexibility and ankylosis of thoracic and lumbar segments. Pseudarthrosis is a serious complication of the diseases that present with ankylosis of the spine. However, its occurrence in ochronotic spine has not been reported previously. Evaluation of progressive paraparesis in a 68-year-old man with ochronosis revealed pseudarthrosis at the T11-12 level. Circumferential dural sac decompression, debridement of the disc space, interbody fusion, and screw-rod fixation were all done via a posterior-only approach. Postoperatively the patient exhibited a marked recovery in terms of pain and neurological status. At the 3-month follow-up, he was able to walk independently. Ochronosis should be included in the etiology of pseudarthrosis. With aggravation of back pain and the appearance of neurological deficits in an already stable patient with any ankylosing disease, pseudarthrosis should be suspected. Furthermore, single-stage, 360°, posterior-only surgery may obviate the need for single-stage or staged anterior-posterior surgical intervention in patients with pseudarthrosis of the thoracic and lumbar spine.

Spontaneous symptomatic pseudoarthrosis at the l2-l3 intervertebral space with diffuse idiopathic skeletal hyperostosis: a case report

Pseudoarthrosis at the intervertebral space in patients with ankylosing spondylitis has occasionally been reported, but symptomatic pseudoarthrosis at the intervertebral disc level is rare in patients with diffuse idiopathic skeletal hyperostosis (DISH). Here, we report a case of symptomatic pseudoarthrosis at the L2-L3 intervertebral space that was diagnosed based on clinical history. We first performed L1-L5 fixation, but back-out of the pedicle screw occurred in the early postoperative phase and may have been caused by a short fixation range and concomitant Parkinson's disease. However, the prognosis of the case was favorable after a second surgery. This case indicates that a fixation range of at least 3 above and 3 below is necessary for bone fracture of a thoracolumbar vertebra and pseudoarthrosis in patients with DISH.

Surgical outcomes of posterior thoracic interbody fusion for thoracic disc herniations

INTRODUCTION

Surgical strategy for thoracic disc herniation (TDH) remains controversial. We have performed posterior thoracic interbody fusion (PTIF) by bilateral total facetectomies with pedicle screw fixation. The objectives of this retrospective study are to demonstrate the surgical outcomes of PTIF for TDH.

MATERIALS AND METHODS

We enrolled 11 patients who underwent PTIF for myelopathy due to TDH and were followed for at least 1 year. The mean age at surgery was 55.2 years and the average period of follow-up was 4.3 years. The levels of operation were T10-T11 in three cases, T12-L1 in three, and T2-T3, T3-T4, T9-T10, T11-T12, and T10-T12 in one case, respectively. The pre- and postoperative clinical status was evaluated according to the modified Frankel grade and the Japanese Orthopaedic Association (JOA) score modified for thoracic myelopathy. Additionally, postoperative complications were assessed. Local kyphosis at the operated segment and status of fusion were evaluated using plain radiographs and computed tomography.

RESULTS

Improvement of at least one modified Frankel grade was observed in all but one patient. Average pre- and postoperative JOA scores were 4.9 and 8.8 points, respectively. The average recovery rate was 61%. Bony union was observed in ten cases. One patient's postsurgical outcome resulted in pseudoarthrosis, which required revision surgery due to kyphosis deterioration. Cerebrospinal fluid leakage was observed in one patient postoperatively with neither neurological deficit nor evidence of infection.

CONCLUSION

PTIF has produced satisfactory outcomes for myelopathy due to TDH. Therefore, PTIF is one of the surgical treatments of choice for patients with TDH causing myelopathy.

Prompt surgical management for spinal fracture in the elderly aged over 90 years with diffuse idiopathic skeletal hyperostosis to extend their healthy lifespan

There is a possibility that the patients with diffuse idiopathic skeletal hyperostosis (DISH) increase with aging of the population and progressive lengthening of life expectancy in developed countries. In the patients with DISH, even a trivial vertebral fracture may actually turn out to be a three-column injury because mechanical stress is applied to the fracture site due to the lever arm effect. Under these circumstances, even a prolonged strict immobilization often results in failure. Recently, elderly people increasingly wish to maintain physical abilities. We present three patients aged over 90 years with DISH sustaining lower thoracic vertebral fracture after minor trauma. Long fusion involving three vertebral levels above and below the fracture site was performed with pedicle screw system, and vertebroplasty was carried out by transpedicular filling with hydroxyapatite blocks. The patients' activities of daily living were maintained close to the pre-injury level 1 year and 9 months, 2 years and 3 months, and 1 year after surgery, respectively. Many reports have recommended surgery over conservative treatments at vertebral fracture complicating DISH; however, there has been no report of vertebral fracture in patients aged over 90 years with DISH. Satisfactory results were obtained by surgical treatment in our three patients despite their age. We recommend posterior fusion with vertebroplasty just after injury for vertebral fracture in the elderly patients of advanced age with DISH to extend their healthy lifespan.

Symptomatic lumbar mobile segment with spinal canal stenosis in a fused spine associated with diffused idiopathic skeletal hyperostosis

BACKGROUND CONTEXT

Chronic, continuous stress at the junction of a stable/unstable site of the spine in diffuse idiopathic skeletal hyperostosis (DISH) has been reported to cause a nonunion. Back pain resulting from the nonunion has been rarely reported and few operative treatments have been suggested.

PURPOSE

To report and discuss the pathogenesis, treatment, and surgical outcome of a rare cause of back pain.

STUDY DESIGN

Case report of back pain caused by a single lumbar segment is lacking bony union at the caudal end of a fused spine associated with diffuse idiopathic skeletal hyperostosis.

METHODS

Back pain in a 66-year-old man who had suffered for 10 years worsened. The back pain and thigh pain became intolerable, and the left buttock and thigh became numb. Radiographs and computed tomography images showed continuous hyperostosis in the anterior aspect of the vertebral bodies from C2 to L2. At the caudal adjacent level of these fused segments, L2/3 level was mobile and had canal stenosis. Decompression and posterior lumbar interbody fusion (PLIF) were performed.

RESULTS

The pain disappeared soon after the operation. The nonunited segment showed bony union at the 5-year follow-up.

CONCLUSIONS

PLIF may be an option for surgically treating symptomatic nonunited lumbar segments at the caudal end of a fused spine with DISH in cases unresponsive to conservative treatment.

Charcot spinal disease after spinal cord injury

Object

The authors investigated the background, risk factors, and treatment strategies for Charcot spinal disease (CSD) after spinal cord injury (SCI).

Methods

The authors retrospectively examined the clinical and radiological findings in 9 patients with a total of 10 Charcot spine lesions that occurred after SCI. The mean age of the 9 patients was 54 years, and all patients presented with complete SCIs. In all but 1 patient, symptoms did not develop until 10 years postinjury. All 10 Charcot spine lesions were located below the thoracolumbar junction. Surgical treatment was performed in 7 patients (7 lesions), and the mean duration of postoperative follow-up was 84 months.

Results

All patients reported audible noises when changing posture, 5 of 9 patients reported low-back pain, and 7 patients displayed increasing instability while sitting. In 8 patients, spasticity disappeared and limbs became flaccid several years after SCI. Two patients had associated bacterial infections in the Charcot spine lesions, and 1 patient complained of autonomic dysreflexic symptoms associated with trunk movements. Although postoperative complications occurred in 3 patients, all patients who underwent surgical treatment made a good recovery and were able to return to daily life in a wheelchair. On lateral radiography, the mean range of motion at the lesion site was 43°, and fluid collections between the involved vertebrae were observed in 8 patients on MR images; ankylosing spinal hyperostosis was observed in 7 patients. Charcot spine lesions tended to occur at the junction between or at the end of an ankylosing spinal hyperostotic lesion. Postoperatively, solid arthrodesis was obtained within 6 months in all surgically treated lesions.

Conclusions

Disappearance of spasticity in the lower extremities is thought to be an important physical sign suggestive of CSD after SCI. Sitting imbalance and the fluid volume of the Charcot spinal lesions are related to range of motion at the lesion site. In addition to a combined approach, a single posterior approach with acquisition of anterior support is an option for surgical treatment even in cases of infected CSD.

Diffuse idiopathic skeletal hyperostosis: Forestier's disease

Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier's disease is characterized by calcification and ossification of soft tissue entheses of ligaments and tendons. DISH is believed to be a variant of osteoarthritis (OA) without the degenerative intervertebral disc and joint degenerative qualities seen in classic OA. The likely pathoetiologic causes of DISH are presented.