Search Results (34)

Background/Objectives: Ankylosing Spinal Disorders (ASDs) encompass a heterogeneous group of rheumatic diseases characterized by progressive ankylosis of the axial skeleton, including Ankylosing Spondylitis (AS), Diffuse Idiopathic Skeletal Hyperostosis (DISH), and Non-Radiographic Axial Spondyloarthritis (nr-AxSpA). Spinal ankylosis profoundly alters the biomechanical properties of the vertebral column, transforming it into a rigid long-bone equivalent and dramatically increasing fracture risk even after low-energy trauma. Once a fracture occurs, the long lever arm created by the ankylosed segments generates enormous mechanical stress at the fracture site, making surgical stabilization mandatory in the vast majority of cases. Long posterior instrumentation is the treatment of choice; however, no consensus exists regarding the optimal number of instrumented levels. The aim of this study is to clinically and radiologically evaluate long posterior instrumentation in the 3 + 3 (3 proximal and 3 caudal screws), 3 + 2 (3 proximal and 2 caudal screws), or 2 + 2 (2 proximal and 2 caudal screws) configuration for the treatment of traumatic ASD thoracolumbar vertebral fractures, in terms of implant failure, infection rate, and mortality. Methods: Between 2018 and 2023, 65 consecutive patients with ASD-related thoracolumbar vertebral fractures were treated at our institution. After applying pre-defined inclusion and exclusion criteria, 37 patients were enrolled. Patients were retrospectively divided into three groups according to the posterior arthrodesis configuration (notation indicates number of instrumented vertebral levels proximal + distal to the fracture: 3 + 3, 3 + 2, or 2 + 2). Radiological outcomes were assessed for loosening, screw cut-out, and implant breakage. Infection and mortality rates within 3 months from surgery were evaluated as secondary endpoints. Statistical analysis was performed using the Fisher exact test (significance set at p < 0.05). Results: Thirty-seven patients (28 males and 9 females; mean age 77 ± 7.3 years) were included, with a mean follow-up of 30 ± 5.3 months. Instrumentation configurations were as follows: 23 (3 + 3), 5 (3 + 2), and 9 (2 + 2). Three implant failures (8.1%) and four infections (10.8%) were recorded. Eleven patients died within 3 months of surgery. A statistically significant difference was found between instrumentation length and mechanical complications (p = 0.0468), while no significant difference was observed for infection (p = 1) or mortality rate (p = 0.137). Conclusions: In this exploratory retrospective cohort, the 3 + 3 configuration was associated with the lowest observed rate of implant failure in ASD thoracolumbar fractures, suggesting a potential mechanical advantage over shorter constructs that warrants confirmation in larger prospective studies. No significant correlation was found between instrumentation length and infection rate or early mortality. Prospective, multicentre studies with larger cohorts are warranted to establish definitive guidelines for instrumentation length in this challenging patient population. Full article

Background: MRIs of spine Diffuse Idiopathic Skeletal Hyperostosis (DISH) demonstrate inflammation-related lesions such as bone marrow edema (BME) and fatty lesions in vertebral corners. DISH is known to be associated with metabolic syndrome (MeS). Spinal MRI lesions in patients with metabolic syndrome (MeS) alone were not described. Aim: To characterize spine and sacroiliac MRI lesions among patients with MeS. Methods: This study is a small preliminary cross-sectional case–control study. Study groups were defined as patients with and without MeS. All patients were between 40 and 50 years of age and did not have DISH by chest radiography or CT. All patients underwent whole-spine and sacroiliac joint MRI. MRI was scored by a radiologist blinded to the patient’s clinical data for the presence of BME, fat lesion, sclerosis, ankylosis, erosions, enthesitis, and capsulitis. Groups were compared for the prevalence of each lesion, and scores were calculated for inflammatory and structural scores. Clinical data regarding MeS was also collected. Results: Twenty-four patients were included (twelve male; mean age: 45 years at imaging); fifteen with and nine without MeS. Patients in the MeS study group had significantly more MRI lesions, reflected as a higher total sum lesion score (p = 0.013), a higher fat lesion score (p = 0.013), and a higher total structural lesion score (p = 0.014). Also, each of the MeS components was significantly associated with higher MRI scores. Conclusions: Significantly higher spinal and sacroiliac scores of both inflammatory- and structural-related lesions were present on MRI of MeS patients compared to patients without MeS. Full article

Background/Objectives: Ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis produce long-segment spinal ankylosis, altered biomechanics, and high fracture risk in the cervical spine. Paraspinal muscle degeneration (“spine-specific sarcopenia”) has been linked to pain, disability, and worse outcomes after cervical spine surgery, but the relationship between vertebral ankylosis and cervical paraspinal muscle health is unknown. We aimed to evaluate the association between vertebral ankylosis and cervical paraspinal muscle health using MRI-based measures of muscle quantity and quality. Methods: Adult patients with cervical vertebral ankylosis and available cervical MRI were identified at a single academic center and propensity score-matched 1:1 to patients without ankylosing conditions based on age, sex, body mass index, American Society of Anesthesiologists class, and comorbidity index. Axial T2-weighted images at C2-3 through C7-T1 were used to manually trace bilateral deep extensor and deep flexor muscles to obtain bilateral cross-sectional areas (CSAs) at each level. Extensor fatty infiltration was graded using the Goutallier classification. CSAs and Goutallier grades were compared between the matched groups. Results: Compared with matched controls, patients with vertebral ankylosis demonstrated significantly smaller deep extensor CSA at multiple cervical levels and higher Goutallier grades in the lower cervical spine and at the cervicothoracic junction. Deep flexor CSA tended to be smaller in the ankylosis group, but differences did not reach statistical significance. Conclusions: Vertebral ankylosis is associated with poorer cervical paraspinal muscle health, characterized by reduced extensor muscle bulk and increased fatty degeneration. These findings support conceptualizing ankylosing spinal conditions as disorders of both bone and muscle and highlight the cervicothoracic extensors as a potential target for risk stratification and rehabilitation strategies. Full article

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier’s disease, is a non-inflammatory condition characterized by the calcification and ossification of spinal ligaments and entheses, especially the anterior longitudinal ligament. Its prevalence increases with age and it is more common in males. The term DISH usually refers to the imaging aspects of this condition, while “Forestier’s disease” is used for the clinical correlates of the condition, especially the development of dysphagia. Diagnosis is usually made with conventional radiography, based on the Resnick and Niwayama criteria: flowing osteophytes over at least four contiguous vertebral bodies, the preservation of intervertebral disk space, absent facet and costovertebral joint ankylosis, and absent sacroiliac joint abnormalities. A “melted candle wax” appearance along the spine is typical of the advanced disease. Large anterior osteophytes in the cervical spine lead not only to stiffness and chronic neck pain, but also to compressive symptoms such as dysphagia, dysphonia, and even airway compromise. Digital Dynamic Radiography (DDR), thanks to a flat-panel detector system, captures high-temporal resolution sequential low-dose radiographs at high frame rates in dynamic motion studies to provide functional information. We report the case of a 50-year-old female patient diagnosed with Forestier’s disease. Cervical radiography showed coarse anterior osteophytes and calcifications typical of DISH. The patient complained about persistent cervical pain and significant dysphagia. To investigate the underlying mechanism, a DDR with barium oral administration was performed. The examination confirmed the mechanical narrowing of the pharyngeal lumen caused by bulky anterior osteophytes. Given the severity of the symptoms, the patient underwent a surgical resection of the osteophytic and calcified components, with a subsequent improvement of swallowing function. This case highlights how DDR provides functional and morphological information in patients with dysphagia related to cervical DISH. Full article

Background/Objectives: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by calcification and ossification of ligaments and tendons, primarily affecting the spine. While often asymptomatic, DISH in the cervical spine can cause dysphagia and, more rarely, vocal cord paralysis due to compression of the recurrent laryngeal nerve at the cricothyroid joint. Here, we report cases of unilateral vocal fold paresis in two patients with DISH. Case Presentation: Our first case is an 80-year-old male presented with two months of dysphonia. Strobovideolaryngoscopy found left vocal fold paresis with glottic insufficiency. Computed Tomography (CT) imaging showed DISH with large anteriorly projecting osteophytes in the cervical spine causing rightward deviation of the laryngeal structures and compressing the cricothyroid joint. Second, a 30-year-old female with Turner Syndrome and subglottic stenosis who developed progressively worsening dysphonia over 6 months, characterized by diminished voice projection and clarity. Strobovideolaryngoscopy revealed a mild-to-moderate right vocal fold paresis. CT of the neck demonstrated multiple right-sided osteophytes projecting into the right tracheoesophageal groove, along the course of the right recurrent laryngeal nerve, in the absence of significant disc degeneration. Discussion and Conclusions: On our review of the literature, no other similar instances of unilateral vocal fold paresis were found. We present these cases to emphasize the need for early recognition and treatment to prevent symptom progression of DISH. Full article

Background and Objectives: Diffuse idiopathic skeletal hyperostosis (DISH)-related spinal fractures with marked anterior distraction are highly unstable and pose substantial surgical challenges. The transdiscal screw for diffuse idiopathic skeletal hyperostosis (TSD) technique has been proposed to enhance fixation strength by penetrating adjacent vertebral endplates; however, its clinical utility in large-displacement cases remained unclear. Materials and Methods: In this retrospective study, we reviewed 21 patients with thoracolumbar DISH-related fractures and an anterior fracture gap ≥ 15 mm, who underwent posterior fixation between 2010 and 2024. 11 patients underwent TSD fixation (TSD group), and 10 underwent conventional fixation without bilateral TSD (control group). Results: The mean number of fused segments did not differ significantly between the groups (5.0 ± 1.4 vs. 5.0 ± 1.3, p = 0.43). Operative time was comparable (164 ± 57 vs. 168 ± 60 min, p = 0.90). Blood loss tended to be lower in the TSD group (306 ± 334 vs. 528 ± 658 mL, p = 0.33). For fracture-gap reduction, the TSD group improved from 17.4 ± 2.3 mm preoperatively to 13.8 ± 4.4 mm postoperatively and 2.0 ± 3.6 mm at final follow-up, while the control group showed less reduction (16.8 ± 2.2, 15.4 ± 1.4, and 7.0 ± 9.1 mm, respectively). Screw loosening occurred in three TSD patients and six controls (p = 0.13). All patients in the TSD group achieved bone union without reoperation, whereas four controls experienced implant backout, three required reoperation, and two failed to achieve bone union (p = 0.035). Conclusions: Posterior fixation using TSD provided reliable stability, maintained reduction, and reduced the risk of implant failure compared with conventional fixation in highly unstable DISH-related fractures with anterior distraction. Although larger prospective studies are needed, TSD may represent a valuable surgical option for this challenging patient population. Full article

Background: Patients with ankylotic spines suffering from vertebral column fractures are frequently operated on to maintain spinal stability and prevent secondary displacement and nerve damage. The aim of this study was to identify a subset of patients that may be treated non-operatively, thus avoiding operative complications in this group of patients. Methods: Extension-type injuries in patients with DISH (diffuse idiopathic skeletal hyperostosis) not involving the posterior elements of the spine comprised the study group. Results: Twenty two extension fractures occurred in 21 patients with DISH in SZMC (Shaare Zedek Medical Cente) between 2014–2025. All patients were treated non-operatively. Patients were allowed free mobilization, and no orthosis was used. The only limitation was keeping the bed inclined to 20–30 degrees to prevent extension at the fracture site. All fractures healed uneventfully, and no patient required late surgical intervention, and no neurological complications were noted. Conclusions: Patients with DISH who sustain extension-type injuries of the thoracolumbar spine, with no involvement of the posterior elements, may be treated non-operatively, with good results. Full article

Introduction: Biomechanical analysis of spinal structures is crucial in the evaluation of injuries, the risk of fracture, and age-related changes. Osteoporotic vertebrae are very fragile and therefore constitute a serious risk, especially in the elderly. Methods: At present, clinically relevant decision making in fracture risk assessment is predicated upon finite element analysis (FEA), which utilizes high-resolution computed tomography (CT) scans from clinical practice alongside micro-CT scans from laboratory settings. Of particular interest is the utilization of cortical vertebral body thicknesses, as meticulously measured via micro-CT. The data from a body donation over 80 years old with diffuse idiopathic skeletal hyperostosis (DISH) and osteoporosis (OP) were utilized through FEA to evaluate stresses in cortical and trabecular bone and to predict the stiffness and deformability of the examined vertebral bodies. Results: The investigation revealed a higher density of cortical and cancellous bone in vertebrae affected by DISH. Cortical density was highest in the thoracic section (median 188 µm), while cancellous bone density was 222 HU in the cervical vertebrae. The load on cortical bone increased as we progressed towards the lumbar spine; however, it remained quite constant in cancellous bone. Despite a low bone density, we registered no fractures in vertebrae. Conclusions: The data showed that DISH increased the thickness of the cortical bone and the density of the cancellous bone. The combination of increased cortical and cancellous bone density might reduce the risk of fracture in patients with low bone density. These conclusions emphasize the significance of biomechanical properties in the assessment of fracture risk and have important implications for clinical practice, particularly in relation to the prevention of vertebral fractures in osteoporotic patients with DISH. Full article

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. Full article

Background and Objectives: C-arm-free MIS techniques can offer significantly reduced rates of postoperative complications such as inadequate decompression, blood loss, and instrumentation misplacement. Another advantageous long-term aspect is the notably diminished exposure to radiation, which is known to cause malignant changes. This study emphasizes that, in some cases of spinal conditions that require a procedural intervention, C-arm-free MIS techniques hold stronger indications than open surgeries guided by image intensifiers. Materials and Methods: This study includes a retrospective analysis and review of various cervical and thoracic spinal procedures, performed in our hospital, applying C-arm-free techniques. The course of this study explains the basic steps of the procedures and demonstrates postoperative and intraoperative results. For anterior cervical surgery, we performed OPLL resection, while for posterior cervical surgery, we performed posterior fossa decompression for Chiari malformation, minimally invasive cervical pedicle screw fixation (MICEPS), and modified Goel technique with C1 lateral mass screw for atlantoaxial subluxation. Regarding the thoracic spine, we performed anterior correction for Lenke type 5 scoliosis and transdiscal screw fixation for diffuse idiopathic skeletal hyperostosis fractures. Results: C-arm-free techniques are safe procedures that provide precise and high-quality postoperative results by offering sufficient spine alignment and adequate decompression depending on the case. Navigation can offer significant assistance in the absence of normal anatomical landmarks, yet the surgeon should always appraise the quality of the information received from the software. Conclusions: Navigated C-arm-free techniques are safe and precise procedures implemented in the treatment of surgically demanding conditions. They can significantly increase accuracy while decreasing operative time. They represent the advancement in the field of spine surgery and are hailed as the future of the same. Full article

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. Full article

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory spondyloarthropathy characterized by ectopic calcification of spinal cord tissue. Its etiology is possibly polygenic. However, its pathogenesis and systemic effects remain unclear. Recent studies have reported a high prevalence of DISH in heart failure patients. The authors investigated how the incidence and severity of DISH are associated with vascular calcification and the occurrence of cardiovascular events. In this retrospective chart review study, 500 patients with cardiovascular disease who underwent surgery (cardiovascular events group) and 500 patients with non-cardiovascular disease who underwent computed tomography scans (non-cardiovascular events group) were randomly selected to investigate the degree of ossification of the anterior longitudinal ligament and the incidence of DISH. We found that the incidence of DISH was higher in patients with cardiovascular events and that patients with DISH had more calcification of the coronary arteries and aorta. Next, we examined the relationship between the degree of coronary and aortic calcification, the incidence of DISH, and the degree of ossification of the anterior longitudinal ligament in the non-cardiovascular event group. The prevalence of DISH in the cardiovascular and non-cardiovascular groups was 31.4% and 16.5%, respectively (p = 0.007). Aortic calcification and a predominant degree of vascular calcification with a certain level of ossification of the anterior longitudinal ligament suggest some correlation between DISH and cardiovascular events. This study is important in understanding the pathophysiology and pathogenesis of DISH. Full article

Forestier’s disease is a systemic, degenerative metabolic condition, which is still insufficiently investigated and understood, characterized by the progressive ossification of the ligaments and entheses. This case describes a 63-year-old man admitted to our department after several years of failed attempts to obtain a definitive diagnosis presenting with a painless mass in the pre-auricular region, gradually worsening dysphonia, severe dysphagia relating to solids, stiffness, and mild pain at the back of the neck. After performing further diagnostic tests, in addition to a pleomorphic adenoma, the simultaneous presence of diffuse spondylarthrosis on the cervical spine was highlighted, with beak-like osteophytes at C2–C5 resulting in esophageal compression. Given the absence of upper digestive endoscopy abnormalities, we initiated an intense logopedic and postural rehabilitative treatment, which led to a significant improvement in the patient’s dysphagia symptoms. In addition, we limited the use of medical therapy to solely indomethacin in order to control the osteophytic process. Full article

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. Full article

For older patients with decreased reserve function, traumatic cervical spine injuries frequently lead to early mortality. However, the prognostic factors for early mortality remain unclear. This study included patients aged ≥65 years and hospitalized for treatment of traumatic cervical spine injuries in 78 hospitals between 2010 and 2020. Early mortality was defined as death within 90 days after injury. We evaluated the relationship between early mortality and the following factors: age, sex, body mass index, history of drinking and smoking, injury mechanisms, presence of a cervical spine fracture and dislocation, cervical ossification of the posterior longitudinal ligament, diffuse idiopathic skeletal hyperostosis, American Spinal Injury Association Impairment Scale, concomitant injury, pre-existing comorbidities, steroid administration, and treatment plan. Overall, 1512 patients (mean age, 75.8 ± 6.9 years) were included in the study. The early mortality rate was 4.0%. Multivariate analysis identified older age (OR = 1.1, p < 0.001), male sex (OR = 3.7, p = 0.009), cervical spine fracture (OR = 4.2, p < 0.001), complete motor paralysis (OR = 8.4, p < 0.001), and chronic kidney disease (OR = 5.3, p < 0.001) as risk factors for early mortality. Older age, male sex, cervical spine fracture, complete motor paralysis, and chronic kidney disease are prognostic factors for early mortality in older patients with traumatic cervical spine injuries. Full article