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.

Rigid spine injuries - A comprehensive review on diagnostic and therapeutic challenges

Injuries to the rigid spine have a distinguished position in the broad spectrum of spinal injuries due to altered biomechanical properties. The rigid spine is more prone to fractures. Two ossification bone disorders that are of particular interest are Ankylosing Spondylitis (AS) and Diffuse Idiopathic Skeletal Hyperostosis (DISH). DISH is a non-inflammatory condition that leads to an anterolateral ossification of the spine. AS on the other hand is a chronic inflammatory disease that leads to cortical bone erosions and spinal ossifications. Both diseases gradually induce stiffening of the spine. The prevalence of DISH is age-related and is therefore higher in the older population. Although the prevalence of AS is not age-related the occurrence of spinal ossification is higher with increasing age. This association with age and the aging demographics in industrialized nations illustrate the need for medical professionals to be adequately informed and prepared. The aim of this narrating review is to give an overview on the diagnostic and therapeutic measures of the ankylosed spine. Because of highly unstable fracture configurations, injuries to the rigid spine are highly susceptible to neurological deficits. Diagnosing a fracture of the ankylosed spine on plain radiographs can be challenging. Moreover, since 8% of patients with ankylosing spine disorders (ASD) have multiple non-contagious fractures, a CT scan of the entire spine is highly recommended as the primary diagnostic tool. There are no consensus-based guidelines for the treatment of spinal fractures in ASD. The presence of neurological deficit or unstable fractures are absolute indications for surgical intervention. If conservative therapy is chosen, patients should be monitored closely to ensure that secondary neurologic deterioration does not occur. For the fractures that have to be treated surgically, stabilization of at least three segments above and below the fracture zone is recommended. These fractures mostly are treated via the posterior approach. Patients with AS or DISH share a significant risk for complications after a traumatic spine injury. The most frequent complications for patients with thoracolumbar burst fractures are respiratory failure, pseudoarthrosis, pneumonia, and implant failure.

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.

High prevalence of diffuse idiopathic skeletal hyperostosis (DISH) among obese young patients - A retrospective observational study

OBJECTIVE

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of ligaments and entheses, and most commonly affects the spinal column. The prevalence of DISH is increasing with age and is considered uncommon before the age of 50 years, with an estimated prevalence of less than 5 %. DISH is known to be highly associated with metabolic syndrome and obesity. We aim to assess the prevalence of DISH among young (≤50 yr.) patients suffering from severe obesity (BMI of 35 kg/m2 or higher).

METHODS

A retrospective analysis assessing chest and spine radiographs (including Computed Tomography, CT) of patients with BMI≥35 visiting the bariatric ambulatory clinic in an academic medical center from 2013 to 2022. Patients included in the analysis were 31-50 years old. Diagnosis of DISH was made according to the Resnick criteria. The prevalence of DISH was calculated. Demographic, clinical and laboratory data were collected and compared between the DISH and non-DISH groups.

RESULTS

183 young (mean age: 40.4; 118 females, 64.2 %) obese (BMI median: 40.6; range 35-73) patients were included in the radiographic review. DISH was diagnosed in 33 patients (18.0 %; 95 % CI: 13.1-24.2 %) which was significantly higher than the expected 10 % (Z = 3.62, p<.001); another 8 patients (4.4 %; 95 % CI: 2.2-8.4 %) were considered as "near DISH" (not fulfilling yet the Resnick criteria) as it represents a pre-disease state. Patients diagnosed with DISH were significantly older than patients without DISH (t = 4.54, p<.001), as the prevalence of DISH increased by age (linear association=14.95, p<.001). There was a statistically significantly higher prevalence of hypertension (χ2 = 8.30, p<.004), smoking (χ2 = 4.69, p<.03) and OSA (χ2 = 6.16, p<.013) in the DISH group as compared to their non-DISH counterparts.

CONCLUSION

The prevalence of DISH among obese young patients was 18 %, which is much higher than in the general population. Early-onset DISH should be regarded as a musculoskeletal obesity-related complication.

Unveiling the distinctive ossification patterns of diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis using computed tomography three-dimensional reconstruction

OBJECTIVE

To quantitatively analyze the morphological characteristics of osteophytes in DISH and syndesmophytes in AS, and summarize different ossification patterns to help identify the two diseases. Associated factors for new bone formation would be investigated.

METHODS

Fifty patients with DISH and 50 age-, sex-, CT examination site- matched patients with AS were enrolled. Radiographic and clinical data were reviewed. Osteophytes (syndesmophytes) in front of each vertebral body and the corresponding intervertebral disc space were defined as vertebral osteophytes unit (VOU). The volume, angle and location (contralateral, ipsilateral, bilateral) of osteophytes in each VOU were measured and compared between DISH and AS groups.

RESULTS

In each VOU, the volume and angle of osteophytes in DISH were significantly larger. The best osteophytes volume and angle cutoff value in predicting DISH was 0.59 cm3 and 40.15°. Contralateral, bilateral, ipsilateral osteophytes were recorded in 59.32%, 36.38%, 4.3% of assessed VOUs in patients with DISH and 64.78%, 29.31%, 5.91% in AS (p‹0.001), respectively. As to ipsilateral osteophytes, the volume was inversely correlated with the center of the vertebral body to the center of the descending aorta (DISH: r = -0.45, p= 0.01; AS: r = -0.83, p‹0.001). Advanced age, disease duration, smoking and overweight contribute to the progression of osteophytes and syndesmophytes.

CONCLUSION

Morphological features of osteophytes are helpful to distinguish DISH with AS. Aortic pulsations inhibit or hinder new bone formation in both DISH and AS. Maintaining normal BMI could postpone osteophytes formation.

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.

Anterior cervical osteotomy of diffuse idiopathic skeletal hyperostosis lesions with computer-assisted navigation surgery: A case report

Key Clinical Message

Diffuse idiopathic skeletal hyperostosis (DISH) involves spine ligament ossification. Computer-assisted navigation (CAN) effectively aids complex surgeries, such as anterior cervical osteotomy, to alleviate progressive DISH-related dysphagia.

Abstract

We describe a 68-year-old man with sudden onset dysphagia to both solids and liquids. Radiographic Imaging revealed DISH lesions from C2 down to the thoracic spine. The patient was successfully treated with CAN anterior osteotomy and resection of DISH lesions from C3-C6 and had complete symptom relief within 2 weeks post-operatively.

Diffuse idiopathic skeletal hyperostosis as a cause for dysphagia in a patient with ankylosing spondylitis

BACKGROUND

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ankylosing spinal alterations which are often asymptomatic but may typically cause back pain and spinal stiffness. Presence of DISH may complicate spinal trauma and lead to unstable fractures requiring surgical intervention. Treatment options include physical activity, symptomatic treatment, local heat application, and optimization of metabolic comorbidities.

CASE

A multimorbid older patient was admitted to the gastroenterological ward for the investigation of progressive dysphagia and weight loss. Gastroscopy revealed a dorsal impression of the esophagus at 25 cm from the incisor. Clinical work-up including computed tomography (CT) and magnetic resonance imaging (MRI) ruled out malignancy but showed ankylosing spondylophytes and non-recent fractures of vertebrae C5-C7, compatible with DISH of the cervicothoracic spine as a cause for the esophageal impression. Notably, imaging diagnostics showed ankylosing spine alterations extending to the lumbar spine and both sacroiliac joints, suggestive of ankylosing spondylitis (AS). Typical imaging characteristics, a history of psoriasis, and positive HLA*B27 status supported the diagnosis of underlying AS in this patient with dysphagia as an unusual primary symptom of DISH. Additionally, pulmonary alterations compatible with a usual interstitial pneumonia (UIP)-like pattern were seen on lung CT.

CONCLUSION

Overlaps among AS, DISH and pulmonary abnormalities including UIP have been described previously; however, they represent unexpected findings in this older patient. This case underlines the importance of interdisciplinary collaboration and consideration of DISH as a differential diagnosis in patients with atypical symptoms.

A radiological study of the natural history of diffuse idiopathic skeletal hyperostosis (DISH): a story of incomplete fusion

Introduction: DISH is an ankylosing disease, when fractured can be challenging to manage. A retrospective radiological study was conducted to evaluate the natural history and radiological characteristics of DISH on Computed tomography (CT).Methods: Paired CT scans with DISH that are separated at least two years apart were used to perform the following radiological measurements: Degree of disc space fusion, Osteophyte and vertebral body linear attenuation coefficients (LAC), and Osteophyte axial area size and location.Results: 164 patients were analysed with a mean duration of 4.49 years between scans. 38.14% (442/1159) of disc spaces had at least partial calcification. Most osteophytes were right sided before becoming more circumferential over time. The average fusion score was 54.17. Most of the changes in fusion occurred in the upper and lower thoracic regions. The thoracic region when compared to the lumbar region had a greater proportion of its disc spaced being fully fused. Disc level osteophyte areas were larger than Body level osteophytes. Disc osteophytes size growth rate drops over time from 10.89mm²/year in Stage 1 to 3.56mm²/year in Stage 3. Stage 3 disc spaces (-11.01HU/year) was also found to have had a reduction in their LAC over time when compared to Stage 1 disc spaces (17.04HU/year). This change in osteophyte LAC was not mirrored in the change in vertebral body LAC. We predict that the age of onset and complete thoracolumbar ankylosis of DISH to be 17.96 years and 100.59 years, respectively.Conclusion: DISH ankylosis of the spine a slow process that starts in the mid to lower thoracic region before extending cranially and caudally. After the bridging osteophyte has fully formed, remodelling of the osteophyte occurs.

Musculoskeletal manifestations in type-2 diabetic patients attending a tertiary care hospital in a North-Eastern city of India-A cross-sectional observational study

Background

Musculoskeletal manifestations of diabetes are common and not life threatening, but these are an important cause of morbidity, pain and disability among diabetic patients. In 2004, the National Health Interview Survey determined that 58% of diabetic patients would have musculoskeletal functional disability. This study was designed to estimate the proportion of musculoskeletal manifestations among Type 2 diabetic patients attending a tertiary care hospital in Tripura and also to determine the association of various musculoskeletal manifestations with glycaemic status, body mass index and duration of diabetes mellitus.

Methods

This hospital-based cross-sectional study was carried out in a tertiary care hospital in a northeastern state of India from December 2020 to November 2021. All the diabetic patients attending diabetes nutrition clinic of a tertiary care hospital for a period of one year were considered for this study. Diagnosis of musculoskeletal disorder was made based on history, physical examination, laboratory test and imaging test. Quantitative data were expressed as mean and standard deviation. Descriptive data was expressed in percentages and frequencies using charts and tables. Chi-square test was applied to explore any association between variables. Ethical approval for the study was obtained from the institutional ethics committee.

Results

Out of four hundred and forty-two diabetic cases and two hundred and thirty-four (52.9%) patients were found with musculoskeletal manifestations, 55% of which belong to 45-59 age group.

Conclusion

Physicians treating diabetic patients should be encouraged for regular examination for musculoskeletal complaints. Early diagnosis will facilitate appropriate treatment and thus prevents further complications.

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.

Not so Mutually Exclusive Diseases: A Case of Co-occurrence of Inflammatory Spondyloarthritis and Diffuse Skeletal Hyperostosis in a Young Patient

Diffuse idiopathic skeletal hyperostosis (DISH) and axial spondyloarthritis (axial SpA) are differential diagnoses of lower back pain. While the latter is considered to be an inflammatory disease, DISH is thought to be a metabolic condition. The authors report a case of a 34-year-old man who presented with a one-year history of axial lower back pain associated to migratory polyarthritis, buttock and heel pain. Imaging revealed contiguous calcification of the anterior longitudinal ligament of the cervical segment, meeting major criteria for DISH. However, he also exhibited signs of bilateral sacroiliitis highly suggestive of axial SpA for which he initiated biological therapy.

LEARNING POINTS

Although the most used criteria for diffuse idiopathic skeletal hyperostosis (DISH) were designed to exclude radiographic signs of spondyloarthritis (SpA), both conditions can be present simultaneously.There are only few case reports in the literature that demonstrate the association of the two diseases.Overlap and misperception of SpA and DISH could result in undertreatment of individual patients and have a negative impact on prognosis.

Outcomes following conservative treatment of extension fractures in the setting of diffuse idiopathic skeletal hyperostosis: is external orthosis alone a reasonable option?

OBJECTIVE

Extension fractures in the setting of diffuse idiopathic skeletal hyperostosis (DISH) represent highly unstable injuries. As a result, these fractures are most frequently treated with immediate surgical fixation to limit any potential risk of associated neurological injury. Although this represents the standard of care, patients with significant comorbidities, advanced age, or medical instability may not be surgical candidates. In this paper, the authors evaluated a series of patients with extension DISH fractures who were treated with orthosis alone and evaluated their outcomes.

METHODS

A retrospective review from 2015 to 2022 was conducted at a large level 1 trauma center. Patients with extension-type DISH fractures without neurological deficits were identified. All patients were treated conservatively with orthosis alone. Baseline patient characteristics and adverse outcomes are reported.

RESULTS

Twenty-seven patients were identified as presenting with extension fractures associated with DISH without neurological deficit. Of these, 22 patients had complete follow-up on final chart review. Of these 22 patients, 21 (95.5%) were treated successfully with external orthosis. One patient (4.5%) who was noncompliant with the brace had an acute spinal cord injury 1 month after presentation, requiring immediate surgical fixation and decompression. No other complications, including skin breakdown or pressure ulcers related to bracing, were reported.

CONCLUSIONS

Treatment of extension-type DISH fractures may be a reasonable option for patients who are not candidates for safe surgical intervention; however, a risk of neurological injury secondary to delayed instability remains, particularly if patients are noncompliant with the bracing regimen. This risk should be balanced against the high complication rate and potential mortality associated with surgical intervention in this patient population.

Osteophytes' position in subjects with DISH and right-sided aorta: verification of the 'aortic pulsation protective effect' theory

OBJECTIVES

To validate in a large cohort with right-sided aorta the theory that thoracic right-sided flowing osteophytes in DISH results from a 'protective' effect of the pulsating descending left-sided thoracic aorta.

METHODS

Chest CTs of patients with DISH and right-sided aorta and controls with DISH and left-sided aorta were evaluated and compared on each intervertebral space (IS) for the location of the aorta (right, left, centre) and the location of the osteophyte relative to the aorta (contralateral, ipsilateral, bilateral).

RESULTS

The study and control cohorts included 31 and 35 subjects, respectively (male 22/9 and female 27/8; median age 64.8/65.3 years; P = 0.86). Osteophytes contralateral to the aorta's location were recorded in the majority of ISs in both the study and control groups (47% and 60%, respectively; P > 0.05), while ipsilateral osteophytes were recorded in 6.9% and 7.7%, respectively (P = 0.002). Bilateral osteophytes located to the right and the left of the aorta were significantly more prevalent in the study group compared with the controls (17.2% and 5.4%, respectively; P = 0.04).

CONCLUSIONS

Aortic pulsation plays an important role in inhibiting the development of osteophytes and results in the majority of contralateral osteophytes on both right-sided and left-sided aortas. However, since both ipsilateral and bilateral osteophytes were not at all rare in both groups, other parameters, which are yet to be established, probably contribute to the location of osteophytes.

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.

The prevalence of diffuse idiopathic skeletal hyperostosis in England and Catalonia from the Roman to the post-medieval periods

OBJECTIVE

Evaluate the prevalence of DISH through time from the Roman to the post-Medieval period in England and Catalonia.

MATERIAL

281 individuals from England and 247 from Catalonia were analyzed.

METHODS

Adult individuals with at least three well-preserved lower thoracic vertebral bodies were analyzed. DISH was assessed considering the early stages of development. Diachronic and geographical dietary shifts were investigated using reported light isotope data, archaeological reports and historical documentation.

RESULTS

Males and older individuals showed consistently higher prevalence of DISH, however, only the English sample showed a significant difference between males and females in the prevalence of DISH. No significant difference was found in the prevalence of DISH though time (from Roman to post medieval periods) nor across regions (England and Catalonia).

CONCLUSION

The development of DISH is probably influenced by a combination of factors including increasing age and sex.

SIGNIFICANCE

This is the first exhaustive analysis of DISH in ancient Catalan populations and the first that considers the early stages of DISH.

LIMITATIONS

Reduced sample size, particularly in post-medieval samples, as a result of the available excavated samples and the inclusion criteria adopted.

FUTURE RESEARCH

Include rural, religious and high-status samples in the analysis of DISH. Re-assess the prevalence of DISH in post-medieval populations.

An isotope signature for diffuse idiopathic skeletal hyperostosis?

OBJECTIVES

Diffuse idiopathic skeletal hyperostosis (DISH) has recurrently been associated with a rich diet (high in protein and higher trophic level foods); however, very few studies have investigated this link using carbon and nitrogen (δ¹³C and δ¹⁵N) stable isotope analysis. This paper explores the relationship between DISH and diet in two Roman urban communities by analyzing individuals with and without DISH.

MATERIALS AND METHODS

δ¹³C and δ¹⁵N analysis carried out on collagen from 33 rib samples (No DISH: 27; early DISH: 4; DISH: 2) selected from individuals buried at the Romano-British site of Baldock (UK), 41 rib samples (No DISH: 38; early DISH: 3) from individuals from the Catalan Roman site of Santa Caterina (Barcelona, Spain). Additionally, six faunal samples from Baldock and seven from Santa Caterina were analyzed.

RESULTS

Standardized human isotope data from Santa Caterina show high δ¹⁵N probably associated to a diet combining terrestrial resources and freshwater fish. In contrast, isotope results from Baldock suggest a terrestrial-based diet. Individuals with DISH do not show isotopic ratios indicative of rich diet and there is no correlation between stage of DISH development and δ¹³C and δ¹⁵N.

CONCLUSION

The results of this study suggest that individuals with DISH followed a similar or isotopically similar diet as those individuals without DISH in Baldock and in Santa Caterina and therefore, while DISH may have been influenced by individual's dietary habits, this is not reflected in their isotopic signature.

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.

Operative Outcomes After Cervical Diffuse Idiopathic Skeletal Hyperostosis Fracture in the Elderly

BACKGROUND

Cervical diffuse idiopathic skeletal hyperostosis (DISH) fractures are frequently unstable and carry significant risk of neurologic injury and death. Most patients with DISH fractures are elderly (>70 years) with significant comorbidities. We assessed factors that contribute to outcomes in elderly patients with cervical DISH fractures.

METHODS

Elderly patients with cervical DISH fractures from 2008 to 2017 were included in this retrospective multi-institutional cohort study. Predictor variables included injury level, surgical approach, preinjury comorbidities, American Society of Anesthesiologists (ASA) score, American Spinal Injury Association (ASIA) impairment scale grade, preoperative anticoagulation status, and the subaxial cervical spine injury classification system (SLIC) score. Univariate and multivariate analyses were utilized to identify factors associated with 30-day mortality and ambulatory status at discharge.

RESULTS

A total of 48 patients, mean age 74.7 years old (range 60-96), underwent cervical fixation for DISH fractures. Average SLIC score was 6.30 ± 1.2 (range 5-8), and most frequent fracture level was at C6 to -C7 (31.3%) followed by C7-T1 (25.0%). Forty (83.3%) patients underwent posterior fixation, 7 (14.6%) with anterior fixation, and 1 (2.1%) had combined approach. Ten (20.4%) patients died within 30 days of surgery. Multivariate analysis demonstrated that poorer preoperative ASIA grade (OR 2.35, P = 0.003, CI = 1.33-4.14) and ASA score >3 (P = 0.027) had increased risk of being nonambulatory at discharge. Higher SLIC score was associated with increased 30-day mortality (P = 0.021, CI = 1.20-9.60).

CONCLUSIONS

Cervical DISH fractures can be highly unstable, for which instrumentation and fixation are indicated. Surgical decision-making should focus on preoperative ASIA grade, SLIC score, and ASA score.

CLINICAL RELEVANCE

The study is relevant due to an aging poulation predisposed to cervical DISH fractures.

LEVEL OF EVIDENCE: 4

Anterior cervical spine surgery for treatment of secondary dysphagia associated with cervical myelopathy in patient with Forestier's disease

Introduction

and importance: Forestier's disease, also known as a vertebral ankylosing hyperostosis or Diffuse Idiopathic Skeletal Hyperostosis (DISH), is a non-inflammatory enthesopathy that affects primarily elderly males and ossifies the anterolateral spine while sparing the intervertebral discs and joint spaces, especially at the cervical spine. Forestier's disease has resulted in the growth of large anterior cervical osteophytes that may compress the pharyngoesophageal region, producing dysphagia. However, symptomatic Forestier's disease presenting with dysphagia and cervical myelopathy is rarely observed.

Case presentation

A 48-year-old male presented with progressive dysphagia and cervical myelopathy. Based on the presence of radiographic study, Forestier's disease was suspected. Large anterior cervical osteophytes at C4–C6 levels compressed the pharyngoesophageal structure posteriorly. Multilevel degenerative discs compressing the C4 to C6 spinal cord were also seen on sagittal MRI T2-weighted images. Anterior cervical osteophytectomy with anterior cervical discectomy and fusion (ACDF) were performed. The patient made a complete neurological recovery and had no recurrent symptoms at the 5-year follow-up. The patient was extremely satisfied with this treatment and can improved his quality of life (QOL).

Clinical discussion

Treatment of symptomatic Forestier's disease with secondary dysphagia and cervical myelopathy is rare evidenced by the dearth of reports on surgical treatment. Surgical intervention appears to be safe, effective, and able to halt disease progression.

Conclusion

Anterior cervical osteophytectomy combined with ACDF with plate fixation is a preferred technique in both neural decompression and swallowing improvement. Surgical intervention, we consider, provides superior results than prolonged non-surgical treatments.

•

Forestier's disease or Diffuse Idiopathic Skeletal Hyperostosis (DISH) presenting with secondary dysphagia associated with cervical myelopathy is a rare condition treated by surgery.

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Anterior cervical osteophytectomy with simultaneous anterior cervical discectomy and fusion (ACDF) is a challenging surgical procedure for the patients in this condition.

•

Surgical management provides superior result than non-surgical treatments.

Surgical management of Diffuse Idiopathic Skeletal Hyperostosis (DISH) causing secondary dysphagia (Narrative review)

Objectives: To summarize the current evidence on surgical treatment for large bridging osteophytes of the anterior cervical spine from Diffuse Idiopathic Skeletal Hyperostosis (DISH). Overview of Literature: In the current review, the surgical treatment of secondary dysphagia from DISH was the most useful treatment. We propose a treatment algorithm for management of this condition because currently there are only case reports and retrospective studies available. Methods: Literature search was performed using the MeSH terms "Anterior Cervical Osteophyte," "Diffuse Idiopathic Skeletal Hyperostosis (DISH)," and "Dysphagia" and "Treatment" for articles published between January 2000 and February 2020. PubMed search identified 117 articles that met the initial screening criteria. Detailed analysis identified the 40 best matching articles, following which the full inclusion and exclusion criteria left 11 articles for this review. Results: Incidence of secondary dysphagia was associated with DISH in elderly patients (average 65 years). The major clinical findings were dysphagia or respiratory compromise, with the most common level of bridging osteophytes of the cervical spine at C3-C5. There were 10 articles on surgical treatment involving anterior cervical osteophytectomy without fusion, 1 for multilevel cervical oblique corpectomy, 1 for anterior cervical discectomy with fusion plus plate, and 1 for anterior cervical osteophytectomy with stand-alone PEEK cage or plus plate. All the cases resulted in significant improvement without recurrence, with only 1 case having post-operative complications. Follow-up duration was 3-70.3 months. Conclusions: Surgical intervention for anterior cervical osteophytectomy appears to result in improved outcomes. However, there could be disadvantages concerning cervical spine motion if cervical osteophytectomy with cervical discectomy and fusion (ACDF) plus plate system is done.

Rice transcription factor GAMYB modulates bHLH142 and is homeostatically regulated by TDR during anther tapetal and pollen development

GIBBERELLIN MYB GENE (GAMYB), UNDEVELOPED TAPETUM1 (UDT1), TDR INTERACTING PROTEIN2 (TIP2/bHLH142), TAPETUM DEGENERATION RETARDATION (TDR), and ETERNAL TAPETUM 1/DELAYED TAPETUM DEGENERATION (EAT1/DTD) are important transcription factors that play a crucial role during pollen development in rice. This study demonstrates that bHLH142 acts downstream of UDT1 and GAMYB and works as a 'hub' in these two pollen pathways. We show that GAMYB modulates bHLH142 expression through specific binding to the MYB motif of the bHLH142 promoter during the early stage of pollen development, while TDR acts as a transcriptional repressor of the GAMYB modulation of bHLH142 by binding to the E-box close to the MYB motif on the promoter. Altered expression of these transcription factors highlights that a tight, precise, and coordinated regulation among them is essential for normal pollen development. Most notably, we show that the regulatory pathways of GAMYB and UDT1 rely on bHLH142 in a direct and indirect manner, respectively, and function in different tissues with distinct biological roles during pollen development. This study advances our understanding of the molecular mechanisms of rice pollen development.

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.

Percutaneous, PMMA-augmented, pedicle screw instrumentation of thoracolumbar ankylotic spine fractures

Introduction

Fractures in the ankylotic spine may have an insidious presentation but are prone to displace with devastating consequences. The long lever arm of ankylosed spine fragments may lead to pulmonary and great vessel injury and is difficult to adequately immobilize. Conservative treatment will produce in many cases poor outcomes with high morbidity and mortality. Open surgical treatment is also fraught with technical difficulties and can lead to major blood loss and prolonged operative times.

In recent years, percutaneous instrumentation of non-ankylotic spine fractures has gained popularity, producing similar outcomes to open surgery with shorter operative times and reduced blood loss and hospital length of stay. We describe our experience implementing these techniques in ankylotic spine patients.

Methods

We retrospectively retrieved from our hospital’s electronic health records all patients treated for thoracolumbar spine fractures between 2008 and 2015 with a diagnosis of ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH). Operative and postoperative data, results, and complications were tabulated, and radiographic parameters were evaluated.

Results

Twenty-four patients with ankylotic spine disease underwent percutaneous augmented instrumentation between 2008 and 2015. The mean age was 76. All patients had at least one comorbidity. The mean number of ankylosed levels was 14. Mean operative time was 131 min. The average postoperative hemoglobin decrease was 1.21 gr/%, with only 4 patients requiring blood transfusion.

45.8% of the patients had postoperative medical complications. One patient (4.2%) had a superficial postoperative infection, and one patient died in hospital. The average hospital length of stay was 14.55 days.

All patients retained their preoperative ASIA grades, and 3 improved one grade. All patients united their fractures without losing reduction.

Conclusions

PMMA-augmented percutaneous instrumentation is an attractive surgical option for this difficult patient subset, especially when compared to other available current alternatives.

Relationship between diffuse idiopathic skeletal hyperostosis and fragility vertebral fracture: a prospective study in older men

OBJECTIVE

To analyse the risk of incident vertebral and non-vertebral fracture in men with DISH.

METHODS

In 782 men ages 50-85 years, DISH was diagnosed using Resnick's criteria. In men followed prospectively for 7.5 years, a radiographic incident vertebral fracture was defined by a decrease of ≥20% or ≥4mm in any vertebral height vs baseline. Self-reported incident non-vertebral fractures were confirmed by medical records.

RESULTS

Men with DISH had higher BMD at the lumbar spine (P < 0.05), but not at other skeletal sites. After adjustment for confounders including disc space narrowing (DSN) and endplate irregularity, the risk of vertebral fracture was higher in men with DISH vs men without DISH [10/164 (6.1%) vs 16/597 (2.7%), P < 0.05; odds ratio (OR) 2.89 (95% CI 1.15, 7.28), P < 0.05]. DISH and low spine BMD were each associated with a higher vertebral fracture risk. The vertebral fracture risk was higher in men who had both DISH and severe DSN. DISH and endplate irregularities (EIs) were each associated with higher vertebral fracture risk. DISH, DSN and EIs define the intervertebral space dysfunction, which was associated with higher vertebral fracture risk [OR 3.99 (95% CI 1.45, 10.98), P < 0.01]. Intervertebral space dysfunction improved the vertebral fracture prediction (ΔAUC = +0.111, P < 0.05), mainly in men with higher spine BMD (>0.9 g/cm2; ΔAUC = +0.189, P < 0.001). DISH was not associated with the risk of non-vertebral fracture.

CONCLUSION

DISH is associated with higher vertebral fracture risk, independently of other risk factors. Assessment of the intervertebral space dysfunction components may improve the vertebral fracture prediction in older men.

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.

Diffuse Idiopathic Skeletal Hyperostosis of Cervical Spine with Dysphagia-Molecular and Clinical Aspects

Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by the calcification and ossification of the ligaments of the cervical spine; in some cases, it may result in dysphagia. The condition is more common in men over 50 years of age with metabolic disorders, and it is often asymptomatic and not a major issue for patients. The etiology of DISH is poorly understood, and known genetic factors indicate multiple signal pathways and multigene inheritance. In this review, we discuss the epidemiological, clinical, and etiological aspects of DISH with a special focus on dysphagia.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) and a Possible Inflammatory Component

PURPOSE OF REVIEW

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is considered a metabolic condition, characterized by new bone formation affecting mainly at entheseal sites. Enthesitis and enthesopathies occur not only in the axial skeleton but also at some peripheral sites, and they resemble to some extent the enthesitis that is a cardinal feature in spondyloarthritis (SpA), which is an inflammatory disease.

RECENT FINDINGS

We review the possible non-metabolic mechanism such as inflammation that may also be involved at some stage and help promote new bone formation in DISH. We discuss supporting pathogenic mechanisms for a local inflammation at sites typically affected by this disease, and that is also supported by imaging studies that report some similarities between DISH and SpA. Local inflammation, either primary or secondary to metabolic derangements, may contribute to new bone formation in DISH. This new hypothesis is expected to stimulate further research in both the metabolic and inflammatory pathways in order to better understand the mechanisms that lead to new bone formation. This may lead to development of measures that will help in earlier detection and effective management before damage occurs.

Behavioral role of PACAP signaling reflects its selective distribution in glutamatergic and GABAergic neuronal subpopulations

The neuropeptide PACAP, acting as a co-transmitter, increases neuronal excitability, which may enhance anxiety and arousal associated with threat conveyed by multiple sensory modalities. The distribution of neurons expressing PACAP and its receptor, PAC1, throughout the mouse nervous system was determined, in register with expression of glutamatergic and GABAergic neuronal markers, to develop a coherent chemoanatomical picture of PACAP role in brain motor responses to sensory input. A circuit role for PACAP was tested by observing Fos activation of brain neurons after olfactory threat cue in wild-type and PACAP knockout mice. Neuronal activation and behavioral response, were blunted in PACAP knock-out mice, accompanied by sharply downregulated vesicular transporter expression in both GABAergic and glutamatergic neurons expressing PACAP and its receptor. This report signals a new perspective on the role of neuropeptide signaling in supporting excitatory and inhibitory neurotransmission in the nervous system within functionally coherent polysynaptic circuits.

[CME Rheumatology 24/Answers: DISH of the Hand and Undifferentiated Polyarthritis]

CME Rheumatology 24/Answers: DISH of the Hand and Undifferentiated Polyarthritis Abstract. We present a case with undifferentiated, unclassified polyarthritis and with peripheral diffuse idiopathic skeletal hyperostosis (DISH). We discuss the differential diagnoses of "seronegative" polyarthritis and explain the radiographic findings of the little-known peripheral aspects of DISH.

[CME Rheumatology 24: DISH of the Hand and Undifferentiated Polyarthritis]

CME Rheumatology 24: DISH of the Hand and Undifferentiated Polyarthritis Abstract. We present a case with undifferentiated, unclassified polyarthritis and with peripheral diffuse idiopathic skeletal hyperostosis (DISH). We discuss the differential diagnoses of "seronegative" polyarthritis and explain the radiographic findings of the little-known peripheral aspects of DISH.

Surgical treatment of diffuse idiopathic skeletal hyperostosis of cervical spine with dysphagia - Case report

Introduction

Diffuse idiopathic skeletal hyperostosis of cervical spine can lead to dysphagia.

Presentation of case

A 73-year-old male weighing 110 kg and diagnosed with diffuse idiopathic skeletal hyperostosis in cervical spine with dysphagia. Patient manifested local pain of neck, a gradual limitation of spinal mobility. The surgery decision was based on swallowing problems, not pain in the spine. Before surgery radiographs, magnetic resonance images, computed tomography of the cervical spine and gastroscopy were obtained. Osteophytes were removed from the anterior approach with present otolaryngologist by surgery.

Discussion

In this case used gastroscopy, CT and MRI for diagnostics. During the procedure we had support otolaryngologist. The patient has not been found a stenosis spinal canal and neurological symptoms. We were removed the ostheophytes. Interbody implants have not been applied.

Conclusion

Disc degeneration disease itself can be asymptomatic or not a dominant problem for the DISH patients. Clinical signs may pharyngoesophageal and tracheal compression, causing dysphagia, shortness of breath and stridor. In this case, the cervical spine was stability and not demonstrated a stenosis in the spinal canal. Isolate removing of the osteophytes without implants in DISH of cervical spine can be enough solution.

Surgical treatment of anterior cervical osteophytes causing dysphagia

PURPOSE

Dysphagia due to anterior cervical osteophytes is a rare condition. However, it can become serious enough to permanently impair the quality of life up to making normal food intake impossible. If conservative treatment fails, there is the option of surgical resection of the osteophytes. The objective of this study was to assess the outcomes of resections of anterior cervical osteophytes causing spondylogenic dysphagia, taking literature into consideration.

METHOD

Resection of anterior cervical osteophytes using a standard anterior approach was performed in 14 consecutive patients with spondylogenic dysphagia between 2009 and 2015. Indomethacin or radiation was used to prevent recurrence. Imaging and clinical data were collected in follow-up examinations over an average of 50 months.

RESULTS

The osteophytes were sufficiently resected in all cases. Anterior plates were placed in three patients due to pronounced segmental mobility. Five patients were given recurrence prevention in the form of indomethacin, nine with radiation. One patient required revision surgery for a hematoma. No other serious complications were observed. All patients had significant improvement of their symptoms. No recurrences or signs of increasing instability were found during the follow-up period.

CONCLUSION

When conservative treatment fails, surgical resection of cervical osteophytes is a sufficient method for treating spondylogenic dysphagia. High patient satisfaction and improvement of the quality of life are achieved with a low complication rate. Routine additional stabilization has been discussed as recurrence prevention. Prophylaxis using indomethacin or radiation, known primarily from hip replacement, also appears to be an option.

Correlation between HER2 Expression and Clinicopathological Features of Breast Cancer: A Cross- Sectional Study in Vietnam

BACKGROUND

HER2 is the target of the therapeutic agents which are used to treat HER2-positive breast cancer. Reports have shown that the HER2 oncogene expression and its association with clinicopathological factors remain unclear in breast cancer (BC) patients.  This study aimed to determine the correlation between HER2 expression and clinicalpathological characteristics of breast cancer in Vietnamese women.

METHODS

Between June 2016 and August 2018, paraffin-embedded specimens from 237 patients with primary invasive breast carcinoma in Hue University Hospital and Hue Center Hospital, Hue city, Vietnam were examined for pathological features. The gene expression of HER2, ER, PR and Ki-67 were determined by immunohistochemistry (IHC). The gene amplification of Her2 was assessed by using Dual color in situ hybridization (DISH).

RESULTS

The most frequent histological type was invasive carcinoma of no special type (NST) with 77.35%, the highest percentage of patients with Grade II was detected (59.36%), tumor size > 2 cm accounted for 71.31% of cases, Lymph node metastases were available in 57.86% cases. Most patients were diagnosed at stage II (59.18%). The majority of patients were classified as moderate Nottingham prognostic index (54.9%). Estrogen receptor and Progesterone receptor were positive in 53.16% and 50.63%, respectively. 76.37% of cases were in high expression group of Ki-67 (≥14%). HER2 IHC 2+, 3+ were accounted for 28.69% and HER2 gene amplification was detected in 31% cases. HER2 gene amplification and/or overexpression was significantly associated with cell proliferation index Ki67. Furthermore, HER2 gene expression tended to be more frequently found in tumors with large tumor size, high grade, high stage and high Nottingham prognostic index and confirmed their prognostic independent role.

CONCLUSIONS

Our data indicated that HER2 gene expression was significantly correlated with cell proliferation index Ki67, but not significantly associated with another clinicopathological factors in breast cancer of Vietnamese women.
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Thoracic hyperextension injury with opening wedge distraction fracture in DISH -consideration of surgical strategy based on intraoperative pathological findings

Diffuse idiopathic skeletal hyperostosis (DISH) is a well-recognized disease characterized by calcifications and ossifications of the entheses mainly in the spine. Patients with DISH are prone to sustaining spinal injuries even after minor trauma because of the long-lever arm mechanism induced by any type of force acting on the rigid yet brittle spine. The number of cases of trauma in DISH-affected spines is predicted to increase during the coming decades because of an increase in DISH-related comorbidities. Generally, posterior fixation with spinal instrumentation spanning three levels above and below the injured site is regarded as a standard treatment for hyperextension fractures of the thoracolumbar spine in patients with DISH. However, no consensus has been reached regarding whether additional anterior fixation is needed for hyperextension injuries with remarkable vertebral body wedge. We experienced one case of hyperextension injury at the thoracic level in patient with DISH. A remarkable remodeling phenomenon in the fractured vertebral body was intraoperatively noticed, which was pathologically confirmed. This is the first report to have confirmed pathologically new bone formation in the anterior column wedge despite the fact that only 1 month had passed since the first injury. Although whether additional anterior fixation is needed for hyperextension injuries with remarkable vertebral body wedge is controversial, this report supports that posterior fixation alone might be an adequate treatment.

Radiographic/MR Imaging Correlation of Paravertebral Ossifications in Ligaments and Bony Vertebral Outgrowths: Anatomy, Early Detection, and Clinical Impact

This article focuses on the variety of imaging features of paravertebral ossifications that are of practical interest in the diagnosis of diseases. The spinal anatomy is reviewed and correlated to paravertebral ligamentous ossifications and their potential clinical impact. A vertebral bony outgrowth is secondary to inflammation or degeneration and can be characterized based on its origin and growth direction, in addition to appreciation of intervertebral disc space preservation or loss. Imaging in rheumatology patients is highlighted because early detection of disease is of increasing importance. A correlation between radiographs and MR imaging is made.

Back to the beginning: Identifying lesions of diffuse idiopathic skeletal hyperostosis prior to vertebral ankylosis

OBJECTIVE

To better understand the pathogenesis of DISH, identifying early or pre-DISH lesions in the spine and investigating the relationship between spinal and extra-spinal manifestations of DISH.

MATERIAL

44 skeletonized individuals with DISH from the WM Bass Donated Skeletal Collection.

METHODS

For each vertebra, location, extension, point of origin and appearance of vertebral outgrowths were recorded. The size of the enthesophytes at the olecranon process, patella and calcaneal tuberosity was measured with digital callipers.

RESULTS

At either end of the DISH-ankylosed segment, isolated vertical outgrowths arising from the central third of the anterior aspect of the vertebral body can usually be observed. These bone outgrowths show a well-organized external cortical layer, an internal structure of trabecular bone and usually are unaccompanied by or show minimal associated endplate degeneration. Analysis of the relationship between spinal and extra-spinal manifestations (ESM) suggests great inter-individual variability. No correlation between any ESM and the stage of spinal DISH was found.

CONCLUSIONS

Small isolated outgrowths represent the earliest stages of the spinal manifestations of DISH. The use of ESM as an indicator of DISH should be undertaken with great caution until the relationship between these two features is understood.

SIGNIFICANCE

Improved accuracy of paleopathological diagnostic criteria of DISH.

LIMITATIONS

Small sample comprised of only individuals with DISH. FUTURE RESEARCH: micro-CT analysis to investigate the internal structure of the spinal lesions. Analysis of extra-spinal enthesophytes in individuals with and without DISH to understand their pathogenesis and association with the spinal lesions in individuals with DISH.

Enthesopathy of the anterior chest wall joints in patients with diffuse idiopathic skeletal hyperostosis (DISH): a retrospective analysis of computed tomography scans

PURPOSE

To evaluate and characterize anterior chest wall (ACW) joint's enthesopathy on CT scans in patients with DISH compared with age- and gender-matched control group.

MATERIAL AND METHODS

Retrospective evaluation for enthesopathy features of ACW joints-sterno-clavicular (SCJ), manubrio-sternal (MSJ), costo-sternal 1-7 (CSJ)-on chest CT scans of subjects with DISH (Resnick criteria) and of age- and gender-matched control subjects was performed. 183 subjects (DISH: 92, control: 91); male:female: 126:57, average age: 71.7 years (range 50-94) were evaluated. Total enthesopathy scores per subjects and per each joint were compared.

RESULTS

Total enthesopathy score of ACW joints was significantly higher among DISH compared to controls (64.03 ± 15.1, 50.47 ± 12.4, p < 0.001). At joint level, SCJ and CSJ enthesopathy, but not MSJ was significantly more prevalent in DISH compared to controls.

CONCLUSION

ACW joints' enthesopathy as seen on CT scans, an entity not included in the Resnick classification criteria, is common among DISH subjects. The difference between SCJ and CSJ prevalence compared to MSJ may result from different joint type. ACW joints' enthesopathy may be considered to be included in future modified radiographic criteria for DISH.

Surgical management of ossification of the posterior longitudinal ligament in the cervical spine

OPLL is a progressive process that can result in spinal cord compression and myelopathy. Various surgical approaches for the management of OPLL in the cervical spine exist. Our goal is to present our institution's experience in the management of OPLL over the last 20 years. Sixty-eight patients underwent surgery for cervical OPLL. Mean age at surgery was 56.9 years. No differences between demographic characteristics and surgical approach were identified. There were no significant differences between the approaches regarding the mean estimated blood loss, occurrence of durotomy, reoperation rate, positive K-line and preoperative cervical spine sagittal balance. Number of levels operated on was significantly different (anterior approach 2 ± 0.8 levels, posterior approach 4.3 ± 1.3 levels, combined approach 3.3 ± 0.9 levels, p-value <0.01), but postoperative sagittal balance was not (anterior approach Cobb angle 11.9 ± 5.8 degrees, posterior approach Cobb angle 7 ± 3.5 degrees, combined approach Cobb angle 16.7 ± 7.3 degrees, p-value = 0.09). Functional outcomes were good for 70% of patients and did not significantly differ across approaches (anterior approach 28%, posterior approach 33%, combined approach 9%, p-value = 0.46). Good functional outcomes were more commonly observed in patients with a positive K-line (OR 0.2, 95% CI 0.04-0.9, p-value 0.05) while poor outcomes were most commonly observed in patients with an occupational ratio >0.6 (OR 6.9, 95% CI 1.35-42.7, p-value 0.02). OPLL is a rare disease for which prompt referral for surgical decompression may lead to good clinical outcomes.

A case study of vertebral fusion in a 19th-century horse from Serbia

OBJECTIVE

To evaluate the etiology of skeletal changes noted in equid vertebrae from a 19^th- century context near Belgrade, Serbia.

MATERIALS

A vertebral column consisting of 15 fused thoracic vertebrae (T2-T16), with right ribs fused to T4 and T5 and small remnants of ribs articulating with T4, T5 and T6 on the left side were accidentally recovered during industrial exploitation of sand.

METHODS

The specimen was subjected to morphological analysis and collagen fingerprinting by mass spectrometry for species identification. In order to determine the absolute temporal context, radiocarbon dating was employed. Pathological changes were analyzed macroscopically and then underwent X-ray and (CT) imaging.

RESULTS

Species identification indicates that the vertebral column belonged to a domestic horse (Equus caballus) living in the early 19^th century. Pathological changes included exuberant bone proliferation, fusion of small articulations, enthesopathy formation, complete fusion between the vertebral bodies, and ossification of the anterior longitudinal ligament.

CONCLUSIONS

Pathological changes represent signs of an advanced stage of vertebral fusion consistent with diffuse idiopathic skeletal hyperostosis (DISH).

SIGNIFICANCE

This case study provides a clear distinction between diffuse idiopathic skeletal hyperostosis (DISH) and other vertebral column diseases in equids. It also presents a new and significant contribution to the nascent discipline of animal paleopathology in present-day Serbia.

LIMITATIONS

Given that only 15 thoracic vertebrae were discovered, the impact of this disease on other parts of the horse skeleton remains unknown, as does the archaeological context of the remains.

SUGGESTIONS FOR FURTHER RESEARCH

Research into the frequency of DISH in equids, as well as the historical context of equine husbandry in Serbia will allow greater insight into the causes and effects of this pathological condition.

Diffuse idiopathic skeletal hyperostosis in a 33-year-old woman with PCOS and metabolic syndrome: a rare scenario

Diffuse idiopathic skeletal hyperostosis (DISH) is a common degenerative enthesopathy seen in the elderly with male preponderance. It is uncommon in patients before 50 years of age and is extremely rare in patients younger than 40 years. We report a case of 33-year-old unmarried woman who presented with inflammatory spinal pain and stiffness, limited chest expansion, decreased range of spinal motion and postural abnormalities, all of which suggested the diagnosis of ankylosing spondylitis, considering the patient's age. But, further evaluation led us to the final diagnosis of DISH with associated metabolic syndrome and polycystic ovarian syndrome (PCOS). To the best of our knowledge, our patient is the first reported case of DISH in a woman less than 40 years of age, and also the first case of DISH associated with PCOS and metabolic syndrome.

Long-term results after surgical treatment of diffuse idiopathic skeletal hyperostosis (DISH) causing dysphagia

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory, systemic skeletal disease. The associated formation of anterior cervical osteophytes can cause severe dysphagia, so the osteophytes have to be surgically removed. Because the clinical syndrome is rare, long-term outcome after surgical therapy is likewise scarce. In this retrospective, single-center study, five consecutive patients with DISH causing dysphagia and following resection of osteophytes between 2005 and 2015 were included. Patient and surgical reports were evaluated regarding surgery-related and postoperative complications. For the short term, the outpatient visits three months and one year after the surgery were evaluated. For the long-term results, patients were followed via questionnaires concerning actual complaints, complications or further treatment associated to DISH. Five male patients (61.6 years old; range, 43-77) were operated. One patient had a transitory worsening of a preexisting hoarseness and one patient had permanent problems with singing postoperatively. All patients reported improvement of dysphagia after three months. One patient deceased five years after surgery independently of DISH without complaining about recurring dysphagia. After a mean follow-up of 70.3 months (range, 24-126 months), dysphagia was consistently improved in all remaining four patients. The patient with the slightest improvement and clinical deterioration in the course had an initially incomplete resection of osteophytes. Imaging showed a re-increase of ossifications 2.5 years after the surgery. Resection of symptomatic anterior osteophytes in DISH is a safe and promising procedure to improve dysphagia in the long-term, but the recurrence of osteophytes is possible years after initial treatment.

Subjects with diffuse idiopathic skeletal hyperostosis have an increased burden of coronary artery disease: An evaluation in the COPDGene cohort

BACKGROUND AND AIMS

Diffuse idiopathic skeletal hyperostosis (DISH) is a common incidental finding on medical imaging and often thought to be benign. Our objective was to investigate whether DISH is associated with coronary artery disease as measured with the coronary artery calcification (CAC) score in a large cohort of current and former smokers.

METHODS

In a subset of subjects from the COPDGene study, DISH was scored by a minimum of two independent readers if there were four adjacent levels of flowing osteophytes and a third reader adjudicated discrepancies. CAC was calculated using a modified Agatston method. Associations of DISH with the presence and extent of CAC were analyzed with and without adjustment for COPD and known atherosclerotic risk factors, including age, sex, race, diabetes, hypertension, high cholesterol, body mass index and smoking.

RESULTS

DISH was present in 361 subjects (13.2%) from a total group of 2728. Median (interquartile range) Agatston was 81 (0-329) in DISH subjects compared to 0 (0-94 in subjects without DISH (p < 0.001). DISH prevalence was 8.8% in CAC = 0, 12.8% in CAC1-100, 20.0% in CAC100-400 and 24.7% in CAC.400. Subjects with DISH had a significantly higher risk of having coronary artery calcifications; OR [CI95%] 1.37[1.05-1.78] (p=0.019) after correction for age, gender, race, COPD and atherosclerotic risk factors.

CONCLUSIONS

Subjects with DISH, a common musculoskeletal disorder involving bone formation anterior to the spine, have an increased burden of coronary artery disease, and therefore DISH may be a more relevant incidental finding than commonly thought.

Degenerative changes of the thoracic spine do exist in patients with diffuse idiopathic skeletal hyperostosis: a detailed thoracic spine CT analysis

Background Degenerative intervertebral disease (DID) is an exclusion criterion in the Resnick and Niwayama radiographic classification for diffuse idiopathic skeletal hyperostosis (DISH). However, although DID was previously described in DISH, no systematic computed tomography (CT) analysis has been reported so far. Purpose To assess for the presence and prevalence of such changes on CT examinations of the thoracic spine of individuals with DISH. Material and Methods Intervertebral space (D1-L1) on chest CT examinations of DISH patients was retrospectively evaluated for the presence of DID. Parameters evaluated were disc space height, disc protrusion, subchondral cysts/sclerosis, Schmorl nodes, vacuum phenomenon, and posterior elements including costovertebral and facet joints. Parameters were compared with two age- and gender-matched control groups of individuals whose entire spine CT lacked evidence of DISH (Control 1 individuals < 2 flowing osteophytes, Control 2 individuals < 4 and ≥ 2 flowing osteophytes). Results A total of 158 participants (DISH/Control 1/Control 2 = 54/54/50; 106 men, 52 women; average age = 70.6 years) were evaluated. Average intervertebral disc height was significantly lower in the DISH group compared with both control groups (DISH/Control 1/Control 2 = 4.55/5.13/5.01 mm, P < 0.001). Costovertebral degenerative changes were more prevalent in DISH patients ( P < 0.05) and, except for vacuum phenomenon (more prevalent in controls), other DID changes were as prevalent in DISH as in controls. Conclusion The presence of degenerative intervertebral changes on thoracic CT should not deter from diagnosing DISH. Thus, the radiographic Resnick and Niwayama DISH criteria cannot be directly adapted to CT.

Prevalence of HER2 Positivity and Its Clinicopathological Correlation in Locally Advanced/Metastatic Gastric Cancer Patients in Malaysia

Purpose

Human epidermal growth factor receptor 2 (Erbb2/HER2) overexpression, which was previously detected in invasive breast cancer, has now been implicated in advanced gastric cancer (GC) and gastroesophageal junction cancer (GEC). A study was conducted to determine the rate of HER2 positivity in patients with locally advanced or metastatic GC and GEC in Malaysia and to assess the impact of various demographic and clinical parameters on HER2 positivity.

Methods

A total of 228 adult patients with GC or GEC were enrolled from Subang Jaya Medical Centre, Malaysia, for retrospective (210) and prospective study. All patients were subjected to the HER2 immunohistochemistry test using an FDA-approved, standardized test kit. Carcinomas scoring 2+ on immunohistochemistry were further tested with HER2 in situ hybridization (ISH) using an FDA-approved test kit.

Results

The overall rate of HER2 positivity in the population studied was 24.6% (n = 56). The rate was significantly higher in men than in women (29.6 vs. 16.3%; p = 0.024). HER2 overexpression was significantly more common in diffuse type than in intestinal type of tumors (39.8 vs. 14.9%; p < 0.001). In our study, out of 56 samples, 44 (78.6%) were considered for gene amplification testing, out of which 40 (90.1%) samples showed gene amplification. There was no statistically significant correlation between HER2 positivity and patient age, race, tumor location, tumor differentiation, and TNM staging.

Conclusions

HER2 overexpression was evident in nearly 25% of the Malaysian patients with locally advanced or metastatic gastric cancer. The overexpression correlated significantly with male gender and diffuse-type tumors. The majority of the IHC-positive tumors demonstrated c-erb2 gene amplification and this finding reached statistical significance.

Extracapsular fracture of the femur in an elderly male from the Church of Nossa Senhora da Anunciada (Setúbal, Portugal)

In modern populations, hip fractures in older people are associated with high morbidity and mortality. Their incidence is rising; notwithstanding, fractures of the proximal femur are still relatively uncommon in archeological contexts. This case study represents a well-healed hip fracture in an aged male skeleton from Church of Nossa Senhora da Anunciada (16th-19th centuries AD) in Setúbal (Portugal). The individual was also diagnosed with diffuse idiopathic skeletal hyperostosis. Fractures of the proximal femur are usually associated with bone loss but in this case other causes are proposed, including the anatomy of the proximal femur, and the potential combined effect of diffuse idiopathic skeletal hyperostosis, cardiovascular disease, diabetes mellitus and falls.

Spine Fractures in Ankylosing Diseases: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Review of literature and case series.

OBJECTIVES

Update and review of current treatment concepts for spine fractures in patients with ankylosing spinal disorders.

METHODS

Case presentation and description of a diagnostic and therapeutic algorithm for unstable spinal injuries with an underlying ankylosing spinal disorder (ASD) of the cervical and thoracolumbar spine.

RESULTS

Nondisplaced fractures can be missed easily using conventional X-rays. Thus, computed tomography (CT) scans are recommended for all trauma patients with ASD. In doubt or presence of any neurologic involvement additional magnetic resonance imaging (MRI) scans should be obtained. Spine precautions should be maintained all times and until definitive treatment (<24 h). Nonoperative fracture treatment is not recommended given the mechanical instability of the most commonly seen fracture patterns (AOSpine B- and C-type, M2) in patients with ASD and inherent high risk of secondary neurologic deterioration. For patients with ankylosing spondylitis (AS) or diffuse idiopathic hyperostosis (DISH) sustaining cervical spine fractures, a combined anterior-posterior instrumentation for fracture fixation is recommended. Closed reduction and patient positioning can be challenging in presence of preexisting kyphotic deformities. In the thoracolumbar (TL) spine, a posterior instrumentation extending 2 to 3 levels above and below the fracture level is recommended to maintain adequate reduction and stability until fracture healing. Minimally invasive percutaneous pedicle screws and cement augmentation can help to minimize the surgical trauma and strengthen the construct stability in patients with diminished minor bone quality (osteopenia, osteoporosis).

CONCLUSIONS

Current concepts, treatment options, and recommendations of the German Orthopedic Trauma Society-Spine Section for spinal fractures in the ankylosed spine have been outlined.