Association Between Vertebral Fracture and Diffuse Idiopathic Skeletal Hyperostosis

Effect of Diffuse Idiopathic Skeletal Hyperostosis on the Occurrence of Thoracolumbar Vertebral Fragility Fractures at Different Ages

STUDY DESIGN

Retrospective Case control Study.

OBJECTIVES

To analyze the effect of diffuse idiopathic skeletal hyperostosis (DISH) on the occurrence of new thoracolumbar vertebral fragility fractures (VFFs) at different ages.

METHODS

A retrospective analysis of 564 patients, including 189 patients who presented with new-onset thoracolumbar VFFs and 375 patients without spinal fractures, was performed in 4 age groups (50-59 years, 60-69 years, 70-79 years, and 80+ years). DISH was diagnosed based on computed tomography findings, and the Mata score of each disc space level combined with the maximum number of consecutive ossified segments (MNCOS) for each patient was recorded. Data were compared between the fracture and control groups, and odds ratios (ORs) were calculated for each of the 4 age groups using logistic regression.

RESULTS

Both the crude ORs and the adjusted ORs of DISH for VFFs decreased with age, with statistical significance shown in the 50-59 years group (crude OR = 4.373, P = 0.017; adjusted OR = 7.111, P = 0.009) and the 80+ years group (crude OR = 0.462, P = 0.018; adjusted OR = 0.495, P = 0.045). The Mata scores and the MNCOS were significant risk factors for VFFs (P < 0.05) in the 50-59 years group, but they were protective factors in the 80+ years group, which was more significant in the T11/12-L5/S1 subsegment.

CONCLUSIONS

The effect of DISH on the occurrence of thoracolumbar VFFs is complex, and in patients above 50 years, it changes from a risk factor to a protective factor with increasing age.

Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) and early-phase DISH across the lifespan of an American population

OBJECTIVES

DISH is a common musculoskeletal disorder; however, the imaging features and disease continuum from early to advanced stages is poorly understood. The purpose of this study was to evaluate the prevalence of DISH and early-phase DISH in an American population and to assess the extent and pattern of ectopic mineralization across the thoracic spine.

METHODS

Data were retrieved in collaboration with the Rochester Epidemiology Project. We conducted a retrospective image evaluation of a sample of individuals over 19 years of age with CT of the thoracic spine from a Northern US catchment area. Stratified random sampling by age and sex was used to populate the study. We examined the prevalence and extent of ectopic mineralization along the thoracic spine using previously established criteria.

RESULTS

A total of 1536 unique images (766 female and 770 male individuals) including 16 710 motion segments were evaluated for imaging features of the continuum of DISH. Collectively, 40.5% of all motion segments evaluated displayed evidence of ectopic mineralization in the thoracic spine. The prevalence of early-phase DISH was 13.2% (10.4% of female and 15.8% of male individuals). The prevalence of established DISH was 14.2% (7.4% of female and 20.9% of male individuals). Remarkable heterogeneity was detected in individuals within each disease classification, based on the extent of the thoracic spine affected and degree of mineralization.

CONCLUSIONS

The continuum of imaging features associated with DISH is detected in more than one in four adults and both sexes in an American population.

Outcomes of Balloon Kyphoplasty for Vertebral Compression Fractures in Patients with Diffuse Idiopathic Skeletal Hyperostosis at the Distal End or Adjacent Vertebra of the Fused Segments

STUDY DESIGN

A retrospective cohort study.

PURPOSE

To investigate the outcomes of balloon kyphoplasty (BKP) for vertebral compression fractures (VCFs) at the distal end or adjacent vertebra of the fused segments in patients with diffuse idiopathic skeletal hyperostosis (DISH).

OVERVIEW OF LITERATURE

Vertebral fractures in the midportion of the fused segments in patients with DISH are generally unstable; thus, immobilization is recommended. However, VCFs classified as type A in the AO classification are observed at the distal end and adjacent vertebra of the fused segments, and treatment strategies for VCFs associated with DISH remain controversial.

METHODS

The outcomes of 72 patients who underwent BKP for VCFs between 2015 and 2021 were retrospectively investigated. Patients with DISH were assigned to group D (n=21), whereas those without DISH were assigned to group ND (n=51). Back pain, incidence of subsequent adjacent fractures, reoperation rates, and local kyphosis were statistically analyzed.

RESULTS

VCFs in group D occurred at the distal end or adjacent vertebra of the fused segments, and no fractures occurred in the midportion of the fused segment. Back pain improved in both groups, with no significant differences between them. Subsequent adjacent fractures were observed in three of the 21 patients in group D and 11 of the 51 patients in group ND, with no significant difference between them. Reoperation was performed in one patient each in groups D and ND, with no significant difference between the groups. Postoperatively, local kyphosis progressed significantly in group D.

CONCLUSIONS

Although local kyphosis is more advanced in patients with DISH, BKP is effective for VCFs at the distal end or adjacent vertebra of the fused segments and may be useful in older patients with high complication rates.

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.

ENPP1 in Blood and Bone: Skeletal and Soft Tissue Diseases Induced by ENPP1 Deficiency

The enzyme ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) codes for a type 2 transmembrane glycoprotein that hydrolyzes extracellular ATP to generate pyrophosphate (PPi) and adenosine monophosphate, thereby contributing to downstream purinergic signaling pathways. The clinical phenotypes induced by ENPP1 deficiency are seemingly contradictory and include early-onset osteoporosis in middle-aged adults and life-threatening vascular calcifications in the large arteries of infants with generalized arterial calcification of infancy. The progressive overmineralization of soft tissue and concurrent undermineralization of skeleton also occur in the general medical population, where it is referred to as paradoxical mineralization to highlight the confusing pathophysiology. This review summarizes the clinical presentation and pathophysiology of paradoxical mineralization unveiled by ENPP1 deficiency and the bench-to-bedside development of a novel ENPP1 biologics designed to treat mineralization disorders in the rare disease and general medical population.

Examining the Association Between the Extent of Anterior Longitudinal Ligament Ossification Progression and Comorbidities in Diffuse Idiopathic Skeletal Hyperostosis

BACKGROUND

 It has been documented that diffuse idiopathic skeletal hyperostosis (DISH) exhibits a higher prevalence among elderly, male, and obese individuals. Additionally, diabetes mellitus and other comorbidities are more frequently observed in this patient population. However, there is a lack of reports exploring the correlation between the extent of ossification and these demographic and clinical characteristics.

OBJECTIVE

To examine the correlation between comorbidities and the severity of ossification of the anterior longitudinal ligament in patients with DISH.

MATERIALS AND METHODS

The study included 468 patients who visited our hospital in 2018-2022. They were divided into DISH and non-DISH groups based on computed tomography image evaluation according to the Resnick criteria. The patients in the two groups were matched for age and sex. We compared comorbidity-related factors including body mass index (BMI), serum markers for metabolic syndrome and renal function, and hemoglobin A1c (HbA1c) levels between the matched groups. Moreover, we examined the correlation between the number of fused vertebral bodies and comorbidity-related factors, age, and sex within the DISH group.

RESULTS

The DISH group included significantly more men and elderly patients than the non-DISH group. Furthermore, the average BMI and HbA1c levels were significantly higher in the matched-DISH group than in the matched-non-DISH group, whereas no differences were observed in other markers. In the DISH group, the number of fused vertebral bodies did not correlate with age, sex, BMI, or HbA1c levels.

DISCUSSION

BMI and HbA1c levels were significantly higher in patients with DISH than those without; however, the number of fused vertebral bodies and the possibility of having coexisting obesity or diabetes mellitus showed no correlation with the age or sex of the patient. Therefore, each patient should be carefully assessed for ossification severity regardless of age, sex, and the comorbidities they possess.

The Impact of Diffuse Idiopathic Skeletal Hyperostosis on Nutritional Status, Neurological Outcome, and Perioperative Complications in Patients with Cervical Spinal Cord Injury

This retrospective study aimed to investigate the characteristics of patients with cervical spinal cord injuries (CSCI) with diffuse idiopathic skeletal hyperostosis (DISH). We included 153 consecutive patients with CSCI who underwent posterior decompression and fusion surgery. The patients were divided into two groups based on the presence of DISH. Patient characteristics, neurological status on admission, nutritional status, perioperative laboratory variables, complications, neurological outcomes at discharge, and medical costs were compared between the groups. The DISH group (n = 24) had significantly older patients (72.1 vs. 65.9, p = 0.036), more patients with low-impact trauma (62.5% vs. 34.1%, p = 0.009), and a lower preoperative prognostic nutritional index on admission (39.8 vs. 42.5, p = 0.014) than the non-DISH group (n =129). Patients with DISH had significantly higher rates of ventilator management (16.7% vs. 3.1%, p = 0.022) and pneumonia (29.2% vs. 8.5%, p = 0.010). There was no significant difference in medical costs and neurological outcomes on discharge. Patients with CSCI and DISH were older, had poor nutritional status, and were prone to postoperative respiratory complications, while no differences were found between the neurological outcomes of patients with CSCI with and without DISH.

Percutaneous kyphoplasty for the treatment of diffuse idiopathic skeletal hyperostosis with vertebral fractures: A case report and treatment review

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic metabolic condition characterized by new bone formation mainly at the anterolateral spine. Surgery such as screw fixation is commonly used for DISH patients who also suffer from vertebral fractures. In this case report, we share a DISH case with lumbar vertebral fracture and osteoporosis who underwent percutaneous kyphoplasty plus braces and medication. Percutaneous kyphoplasty, considered as minimally invasive surgery, may be another treatment option with the advantages of less trauma and faster recovery. The clinical information and radiological findings are described and treatments for DISH with vertebral fractures are then briefly reviewed.

Can Diffuse Idiopathic Skeletal Hyperostosis Be Diagnosed by Plain Lumbar Spine X-Ray Findings Alone?

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

To determine whether diffuse idiopathic skeletal hyperostosis (DISH) can be diagnosed based on anterior longitudinal ligamental ossification in the lumbar spine using plain lumbar spine X-ray images.

METHODS

This study included 100 patients (59 men and 41 women; mean age, 64.8 ± 13.8 years; range, 27-89 years) who underwent computed tomography (CT) of the chest to the pelvis in our hospital and plain lumbar spine radiography within 6 months before and after CT scanning. DISH was diagnosed based on the thoracolumbar spine CT findings using Resnick's diagnostic criteria. The patients were grouped according to DISH diagnosis into the DISH (+) and DISH (-) groups. On the frontal and lateral lumbar spine X-ray images, each spinal level from Th11/12 to L5/S was scored based on the Mata scoring system. The distribution of the Mata scores was compared between the 2 groups.

RESULTS

Forty (40%) patients were diagnosed with DISH based on the CT findings. A cutoff value ≥8 provided a sensitivity of 75% and specificity of 100% for diagnosing DISH, thus, indicating the validity of the cutoff value. In the DISH (-) group, no patient had ≥3 consecutive spinal levels with a Mata score ≥2, suggesting that DISH can be diagnosed on the basis of at least 3 consecutive spinal levels with a Mata score ≥2.

CONCLUSION

On lumbar spine X-ray images of the T11/12 to L5/S levels, a Mata score ≥2 for at least 3 consecutive levels or a total score ≥8 strongly indicates the presence of DISH.

Unstable fracture of fusion mass in old healed tuberculous kyphosis: Case report

Introduction and importance

Old healed spinal tuberculosis sometimes makes bony ankylosis with kyphotic deformity. This bony ankylosis with adjacent vertebra is like ankylosing spinal disorders (ASDs) such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis. There is lots of report which revealed that conservative management might be failed in thoracolumbar fracture in ASDs. However, there is no report which shows surgical treatment was finally done because conservative management was failed in fracture healing of fusion mass caused by old spinal tuberculosis.

Case presentation

A 68 year-old male patient has suffered from spinal tuberculosis about fifty years ago and then has bony kyphotic ankylosis. He fell off a ladder and was conducted conservative treatment under diagnosis of a sprain at a doctor's office. He was diagnosed with fracture of fusion mass after computed tomography and magnetic resonance image scans in our hospital due to persistent back pain. At first, he refused operation strongly, but underwent eventually posterior fixation without anterior support and angle correction for persistent pain and fracture nonunion. We finally achieved bone union after postoperative nine months.

Clinical discussion

The characteristics of old healed spinal tuberculosis with kyphotic deformity is similar to that of ASDs. The spine fractures among the patients with ASDs can be easily missed. So, Checking whole spine CT or MRI is recommended for fracture screening to ASD patients with back or neck pain after trauma. For unstable AOSpine type B- or C-type injuries, conservative management is not recommended. This recommendations should also apply to patients with spinal tuberculosis.

Conclusion

In patients with bony kyphotic ankylosis due to spinal tuberculosis, minor trauma can cause unstable fracture. If there's found unstable fracture, surgery should be underwent as soon as possible for preventing neurologic deficits. Hence, we would like to report this case with literature reviews.

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Old healed spinal tuberculosis sometimes makes bony ankylosis with kyphotic deformity

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patients with kyphotic deformity due to old healed spinal tuberculosis have an even minor trauma, CT or MRI should be recommended

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If there’s found unstable fracture, surgery should be underwent as soon as possible for preventing neurologic deficits

Penetrating Endplate Screw Fixation for Thoracolumbar Pathological Fracture of Diffuse Idiopathic Skeletal Hyperostosis

With the advancement of cancer treatment and minimally invasive surgery, the indications for surgery for metastatic spinal tumors are expanding. Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory skeletal disease characterized by calcification and ossification of ligaments and entheses. In Japan, the prevalence of DISH is increasing with its superaging society. The purpose of this article is to report a case of applying a novel screw technique for pathological fracture in a patient with DISH and spinal metastasis. An 80-year-old man with spinal metastasis presented with acute onset of severe back pain, and investigations revealed a fracture of a metastatic lesion in T10–T12 in the range of DISH. We performed posterior fixation with a percutaneous pedicle screw system using a penetrating endplate technique. The patient's back pain improved, and he was able to mobilize with minimal assistance and survived for 8 months with a good quality of life. Spinal fracture accompanied by DISH sometimes occurs with severe instability because of injury across 3-column injury and its long lever arm. Spinal instability neoplastic score indicates instability of pathological fractures of spinal metastases but needs to be evaluated carefully when DISH is present. The prevalence of DISH is increasing in the elderly, and penetrating endplate screws can be an effective option in posterior fusion surgery for patients with DISH and spinal metastases.

Urinary Retention as the Presenting Clinical Manifestation of Unstable Thoracic Spinal Fracture with Diffuse Idiopathic Skeletal Hyperostosis

Patients with diffuse idiopathic skeletal hyperostosis (DISH) are at high risk for unstable vertebral fracture, which can be frequently missed. An 80-year-old man with pre-existing muscle lower limb weakness due to frailty was referred from another hospital, presenting with progressive urinary retention and its related symptoms, which had been treated as a urinary tract infection at previous hospital. One week prior to our visit, he had fallen. On arrival, he appeared lethargic and unable to follow commands. He denied any back pain. Computed tomography identified a T10 fracture and dislocation associated with DISH. Although immediate surgical fixation was performed, the patient did not recover from the neurological deficits. Diagnostic delay of DISH-associated vertebral fracture can occur due to both patients' and clinicians' delayed action. We believe this case report can help clinicians recognize this potentially devastating condition.

Posterior spinal fixation using penetrating endplate screws in patients with diffuse idiopathic skeletal hyperostosis-related thoracolumbar fractures

OBJECTIVE

Diffuse idiopathic skeletal hyperostosis (DISH)-related vertebral fractures essentially require operative treatment due to severe fracture site instability and high potential risk of posttraumatic neurological deficit. However, the optimal surgical procedure remains unclear. The purpose of this study was to assess the efficacy of posterior spinal fixation with penetrating endplate screws (PESs) for DISH-related thoracolumbar fractures.

METHODS

The authors conducted a retrospective, single-center, observational study. They included data from 26 consecutive patients with DISH-related thoracolumbar fractures who were treated with posterior spinal fixation using either conventional pedicle screws (PS group, n = 8) or a combined PES technique (PES group, n = 18) between 2013 and 2019. Age, sex, BMI, bone mineral density, fracture level, use of antithrombotic drug, blood loss, operation time, fixation range, perioperative American Spinal Injury Association Impairment Scale score, implant failure, revision surgery, complications, and mortality were compared. The authors also evaluated screw loosening and bone healing on radiographs and CT scans.

RESULTS

More patients had vertebral fractures in the lumbar spine in the PS group than in the PES group (3 vs 0; p = 0.019). Patients in the PES group had less blood loss (63 vs 173 ml; p = 0.048) and shorter range of fixation (5 vs 5.5 levels; p = 0.041). The screw loosening rate was significantly lower in the PES group than in the PS group (3% vs 49%; p < 0.001).

CONCLUSIONS

Posterior spinal fixation using a PES technique may be an ideal surgical procedure for thoracolumbar fractures with DISH, providing more rigid and less invasive fixation than PS.

The relationship of diffuse idiopathic skeletal hyperostosis, visceral fat accumulation, and other age-related diseases with the prevalent vertebral fractures in elderly men with castration-naïve prostate cancer

The prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in prostate cancer patients and its relationship with prevalent vertebral fractures (PVF) has not yet been demonstrated. This study aimed to investigate the relationship of DISH, visceral fat accumulation, and other age-related diseases to PVF in elderly men with castration-naïve prostate cancer (CNPC). A total of 134 CNPC patients who were ≥65 years of age without bone metastases were registered in this study. DISH was found in 36.6% (49/134) of the patients in the study population. Patients with DISH were significantly older and had a lower total hip-bone mineral density (BMD) than those without DISH. On the other hand, there were no significant differences in fat distribution, prevalence of hypertension, dyslipidemia, diabetes, fasting plasma glucose (FPG), hemoglobin A1c (HbA1c, prostate-specific antigen (PSA), or lumbar-BMD (L-BMD). A multivariate analysis of age, DISH, body mass index (BMI), visceral fat area (VFA), and total hip-BMD, which were significantly associated with PVF in a univariate analysis, showed that age (OR 1.11; p = .02) and DISH (OR 5.99; p = .0003) were independently associated with PVF. This study suggests that the presence of DISH may not be negligible when assessing the risk of vertebral fracture in prostate cancer patients before treatment.