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.

Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are chronic conditions associated with altered spine architecture that can potentially influence the outcomes of spine trauma. This study aims to compare demographic characteristics, clinical outcomes, and surgical interventions among thoracolumbar spine trauma patients with a concomitant diagnosis of AS or DISH with those with no underlying ankylosing spinal conditions. Our aim is to better understand how these diseases may affect the prognosis and treatment in the context of thoracolumbar spine trauma. A retrospective analysis of patients presenting with thoracolumbar spine trauma at a single-level I trauma center between 2015 and 2024 was conducted (n = 189). The patients were categorized into three groups: those with AS (n = 20), those with DISH (n = 32), and those without either condition (n = 137). Primary outcomes included neurologic status at admission, neurologic outcomes, number of levels fused, postoperative complications, length of hospital stay, in-hospital mortality, and readmission rates. Patients with AS and DISH were generally older (>70 years old) with more comorbidities such as diabetes and osteoporosis (P < 0.001). Mechanisms of injury differed, with motor vehicle collisions more common in the control group and ground-level falls or falls from height being more frequent in patients with AS/DISH. Regarding trauma outcomes, no significant differences in neurologic status or improvement were observed, but patients with AS/DISH required more extensive surgical intervention and more levels fused (P < 0.05). Postoperatively, patients in the AS/DISH groups had higher rates of long-term care admission and in-hospital mortality, although readmission rates and intensive care unit admissions were similar across groups. Although their immediate postoperative outcomes are comparable with those of unaffected individuals, patients with AS and DISH required more extensive surgical interventions and had higher rates of long-term care admissions and in-hospital mortality. These findings underscore the need for tailored management strategies for spine trauma patients with AS and DISH.

This study compared Hounsfield unit (HU) values on computed tomography (CT) scans at fractured sites and each vertebral level of the whole spine among three groups: individuals with diffuse idiopathic skeletal hyperostosis (DISH), young individuals without DISH, and older individuals without DISH. A total of 71 patients with thoracolumbar fracture treated at our hospital from 2011 to 2022 were enrolled. Patients were divided into three groups: those with DISH (22 cases), young without DISH (Y non-DISH; age < 50 years, 24 cases), and older without DISH (O-non-DISH; age ≥ 50 years, 25 cases). The total spine HU values from C2 to S1 were measured from CT axial images, as follows: C2-C6, cervical spine; C7-T4, upper thoracic spine; T5-T9, lower thoracic spine; T10-L2, thoracolumbar spine; and L3-S1, lumbar spine. We compared (1) the HU values between fractured and non-fractured sites in each group (2) the HU values by site within each group, and (3) the HU values at each vertebral level of the whole spine between the three groups. In all groups, the mean HU values were significantly higher in the cervical spine than in the other regions (p < .05) and HU values increase at the fracture site (p < .05). The mean HU values for the lower thoracic, thoracolumbar, and lumbar spine were not significantly different in each group. The mean HU values below T6 were significantly lower in the DISH and O-non-DISH groups than in the Y-non-DISH group (p < .05). The mean HU values, except at T3, did not differ significantly between the DISH and O-non-DISH groups. Among patients with thoracolumbar injuries, spinal HU values were lower in older patients with and without DISH than in younger patients.

Introduction: Remote cerebellar hemorrhage (RCH) is a rare but serious complication following cranial or spinal surgery, typically attributed to excessive cerebrospinal fluid (CSF) loss and subsequent venous tearing. Although uncommon after spinal procedures, RCH warrants prompt recognition, particularly when dural injury occurs during decompression for ossification of the ligamentum flavum (OLF). Case Presentation: A 73-year-old man with hypertension and diffuse idiopathic skeletal hyperostosis (DISH) underwent T1–T2 decompression for upper thoracic OLF. An intraoperative dural tear with CSF leakage was repaired; however, the patient developed postoperative seizures, and imaging revealed bilateral cerebellar hemorrhages. Conservative management, including drainage adjustment and secondary dural repair, resulted in full neurological recovery and complete radiological resolution by postoperative day 34. Conclusion: RCH should be considered in patients presenting with neurological deterioration following spinal surgery complicated by CSF leakage. The coexistence of OLF and DISH increases surgical complexity and may elevate the risk of RCH. Meticulous dural handling and careful CSF management are essential to prevent this rare but potentially serious complication.

Diffuse idiopathic skeletal hyperostosis in patients with prediabetes.

Odontogenic infections are a leading cause of deep neck space infections, with potential to progress rapidly and cause life-threatening complications if untreated. Herein this report presents the case of a 63-year-old male with a history of diabetes mellitus, autism spectrum disorder, and tobacco chewing who developed a submandibular and sublingual abscess secondary to dental caries. The patient presented with progressive dysphagia, swelling, and fever. Laboratory investigations revealed anemia and a markedly elevated C reactive protein level, while imaging demonstrated diffuse soft tissue edema and an abscess in the left masseter muscle, along with incidental findings of diffuse idiopathic skeletal hyperostosis (DISH). Surgical incision and drainage were performed, followed by extraction of the diseased tooth and intravenous antimicrobial therapy, leading to clinical resolution. This case emphasizes the importance of early recognition and multidisciplinary management of odontogenic infections, particularly in patients with comorbidities such as diabetes and autism, and draws attention to the perioperative implications of incidental DISH in airway management.

Cervical Diffuse Idiopathic Skeletal Hyperostosis (DISH) as an Underrecognized Cause of Dysphagia: A Case Series and Review of the Literature

Ossification of the Posterior Longitudinal Ligament (OPLL) and Diffuse Idiopathic Skeletal Hyperostosis (DISH) are debilitating conditions characterized by pain, stiffness, myelopathy, and impaired mobility due to progressive enthesopathies and spinal fractures. These disorders worsen with age and may lead to hemiplegia. The underlying mechanisms of these diseases remain poorly understood, and effective treatments are currently lacking. To elucidate the pathogenesis of OPLL, we conducted a prospective study involving plasma analyte measurement in 50 consecutive OPLL and 25 consecutive cervical osteoarthritic (OA) patients who presented for surgical correction within the same time frame, followed by exome sequencing of 19 genes associated with phosphate wasting and spinal ligament enthesopathy/ossification. Our study identified a significant association between OPLL and ENPP1 deficiency. Specifically, we observed that OPLL patients exhibited decreased plasma levels of inorganic pyrophosphate (PPi) while maintaining unaltered alkaline phosphatase levels. Additionally, 17% of OPLL patients harbored monoallelic pathogenic variants in ENPP1, the mammalian enzyme responsible for extracellular PPi. Using Enpp1-deficient mice (Enpp1asj) to model the condition, we discovered pathologic mineralization of the spine, long bones, and tendons, alongside increased long bone and spinal fracture risk by 17 wk of age. We further assessed the therapeutic potential of two forms of ENPP1 enzyme replacement therapies. Bone-targeted ENPP1 significantly ameliorated the spinal hyperostosis, improved or normalized spinal and long bone fragility, ameliorated tendon enthesopathies, and improved trabecular microarchitecture. Meanwhile, soluble ENPP1 prevented tendon enthesopathies, normalized cortical bone microarchitecture, and improved long bone fragility. Our findings establish a clear link between decreased plasma PPi, ENPP1 deficiency, and OPLL, unveiling additional therapeutic targets to more effectively manage this poorly treated condition.

INTRODUCTION. Dysphagia is a feeling of obstruction to the normal passage of ingested food. The average duration of the swallowing disorder without determining its cause is (2.8±0.7) years, which is associated with difficulties in interpreting clinical symptoms of patients in primary care institutions. Therefore, it is necessary to remember about the existence of rare causes of dysphagia. One of them is Forestier’s disease – diffuse idiopathic skeletal hyperostosis. AIM . To present an analysis of the clinical and diagnostic features of dysphagia in DF based on a clinical case. CLINICAL CASES. This work presents an analysis of the clinic and diagnosis of dysphagia in an older patient. The peculiarity of this clinical case is the monosymptomatics of Forestier’s disease, the patient noted only the presence of dysphagia and associated suffocation, without complaining of back pain, upper extremities, etc. The non-specificity of clinical manifestations made diagnosis difficult, despite the severity of the dysphagia phenomenon. This confirms the need to describe clinical cases of DIGS in order to raise awareness among doctors. CONCLUSIONS . The description of such clinical cases is necessary for the formation of alertness about the rare causes of dysphagia in doctors. The described clinical case demonstrates that the search for the cause of dysphagia requires a thorough analysis of the anamnesis, clinical picture, instrumental and laboratory studies.

This study investigates the efficacy of open osteophytectomy in patients with dysphagia associated with cervical osteophytes, stratified by C-spine level and presence of diffuse idiopathic skeletal hyperostosis (DISH). PubMed and ScienceDirect. We conducted a systematic review of published literature pertaining to osteophyte-related dysphagia. Patients with objective measurements of dysphagia severity who underwent an open surgical approach for osteophytectomy were included. Demographics, symptomatology, and patient outcomes were analyzed. A total of 44 articles with 214 cases (mean age = 67, 85% male) were included. Outcomes after osteophytectomy were analyzed in DISH vs non-DISH groups, as well as stratified by demographics and cervical levels affected. Patients with osteophytes at or above C4 were more likely to demonstrate pre-operative aspiration (P = .018). Short- and long-term outcomes among patients with DISH and non-DISH osteophytes were similar (P = .269 and .476). Outcomes among patients with osteophytes at or above C4, at or below C4, and diffuse presentations were also similar. Among all cases, 84% of patients experienced significant short-term initial improvement in their dysphagia. At long-term follow-up, 82% of patients had continued significant improvement in their dysphagia outcome. Open surgical approaches for osteophytectomy demonstrate good short- and long-term efficacy. Patients with osteophytes at or above C4 were more likely to aspirate pre-operatively, but osteophyte level, age, sex, and presence of DISH did not impact likelihood of operative success.

Objective: To retrospectively analyze the efficacy and feasibility of surgical management in patients with cervical dysphagia secondary to Diffuse idiopathic skeletal hyperostosis(DISH)of the cervical spine. Methods: A retrospective analysis was conducted on 6 patients who presented with dysphagia as the primary symptom, were diagnosed with cervical DISH, and underwent surgical treatment in the Department of Otorhinolaryngology Head and Neck Surgery of The Second Xiangya Hospital of Central South University from January 2018 to February 2024. There were 5 males and 1 female, aged from 65 to 78 years (70.2±4.7 years). The duration of dysphagia prior to admission was 13 to 18 months (14.7±2.2 months). All patients had the symptom of dysphagia, and at least one other clinical manifestation of cervical DISH (dyspnea, restricted neck mobility, sleep apnea, odynophagia). One patient had undergone tracheotomy due to laryngeal obstruction before surgery. Surgical intervention was performed after failure of conservative management in all patients. All patients underwent anterior cervical osteophyte resection via the Smith-Robinson approach without concomitant spinal fusion. In the patient with prior tracheotomy for airway obstruction, epiglottoplasty and right arytenoidectomy were performed simultaneously. The swallowing function was evaluated by water swallow test, FEES, M. D. Anderson Dysphagia Inventory. Clinical and imaging evaluations were conducted for follow-uppostoperatively. Preoperative and 30-day post operative data were statistically analyzed using paired samples t-test. Results: Cervical computed tomography revealed osteophyte involvement from C2 to T1 with a median of 4 vertebral segments affected. The most frequently involved vertebral segments were C4-C6 (all 6 patients were involved). The anteroposterior diameter of the most prominent osteophyte was 12.0 to 20.0 mm (16±3.1 mm). The time to resumption of a regular diet was 6 to 20 days(12.7±5.3 days), and the time to remove the nasogastric tube was 8 to 25 days(15.2±6.2 days). In the patient with prior tracheotomy, the tracheostomy tube was successfully decannulated 30 days after initial tube capping following conversion to a metal tube. All cervical DISH-related symptoms except for limited neck mobility improved postoperatively. Both water swallow test and the Rosenbek Penetration-Aspiration Scale showed significant improvement postoperatively. At 30 days postoperatively, MDADI scores significantly improved in all domains: l global (73.33±10.33), emotional (85.56±8.35), functional (83.33±5.89), and physical (82.08±6.60). No major perioperative complications occurred. and the length of hospital stay was 7 to 10 days (7.8±1.2 days). The follow-up time was 12 to 84 months (43.7±27.2 months). All patients maintained sustained symptom relief, with no evidence of osteophyte recurrence during follow-up. Conclusion: Cervical DISH is an under-recognized causes of dysphagia in elderly patients and warrants attention from otolaryngologists. For patients erefractory to conservative treatment, anterior resection of cervical osteophytes via the Smith-Robinson approach is a safe, minimally invasive procedure with favorable short-and long-term outcomes in improving swallowing function.

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.

The first report of diffuse idiopathic skeletal hyperostosis (DISH) in the Parthian cemetery of Liyarsangbon, Guilan, Iran

Considerations on the historical origin of diffuse idiopathic skeletal hyperostosis

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.

Andersson-like lesions (ALL) in diffuse idiopathic skeletal hyperostosis (DISH) are rare and often underrecognized entities that can mimic infective spondylodiscitis or inflammatory lesions such as Andersson lesion (AL) in ankylosing spondylitis (AS). Timely differentiation is crucial to avoid misdiagnosis and inappropriate treatment. We report a 57-year-old diabetic male presenting with progressive cervical myelopathy and radiological findings suggestive of a discovertebral lesion at C6-C7 in the setting of DISH. Despite initial suspicion of infection, negative inflammatory markers and sterile intraoperative cultures, along with imaging and intraoperative findings, supported a diagnosis of ALL. The patient underwent staged surgical management with posterior decompression and fusion followed by anterior cervical discectomy and fusion, resulting in significant neurological and functional improvement. This case highlights the importance of recognizing ALL in DISH as a mechanical, non-infective lesion that can lead to spinal instability and neurological compromise. Differentiation from infectious or inflammatory pathologies is essential to guide timely surgical intervention and avoid adverse outcomes.

Diffuse idiopathic skeletal hyperostosis (DISH) may reduce spinal mobility and affect muscle quantity and quality, increasing sarcopenia risk. However, longitudinal data are limited. We investigated muscle quantity, quality, and their changes in DISH using computed tomography (CT) and bioelectrical impedance analysis (BIA). We analysed health screening data including participants who underwent CT and BIA twice over five years. We identified 143 DISH patients (58.0 ± 8.4years, 19 females) and 143 age- and sex-matched controls (58.4 ± 8.8years, 19 females). At L3, psoas and posterior paraspinal muscle (PSM) areas were measured on CT and normalized to height squared as muscle index (MI, cm2/m2). Muscle density was assessed in Hounsfield units (HU). Skeletal muscle mass index (SMI, kg/m2) was obtained from BIA. At baseline, DISH had higher MI (psoas: 347.5 ± 86.0 versus 294.8 ± 81.7, p < 0.001; PSM: 809.3 ± 146.2 versus 758.8 ± 130.7, p = 0.002) but lower HU (psoas: 36.0 ± 9.1 versus 40.9 ± 5.2, p < 0.001; PSM: 39.0 ± 8.8 versus 42.0 ± 7.4, p = 0.002). SMI was similar (7.9 ± 0.9 versus 7.7 ± 0.9, p = 0.212). Over five years, DISH MI declined (psoas: 334.3 ± 94.9, p = 0.006; PSM: 782.6 ± 166.4, p = 0.007), while controls showed no change (psoas: 294.7 ± 94.1, p = 0.695; PSM: 757.2 ± 170.3, p = 0.776). DISH patients have greater muscle mass but lower quality and trend toward decline, suggesting sarcopenia risk.

An 86-year-old man underwent closed reduction and internal fixation of a comminuted intertrochanteric hip fracture with a cephalomedullary nail on a Hana table. Postoperatively, a displaced fracture subluxation of L1 was detected, resulting in complete loss of motor and sensory function below L1. Urgent posterior decompression and fusion from T10-L4 was performed. Diffuse idiopathic skeletal hyperostosis (DISH) was only diagnosed after the incident. A diagnosis of DISH, with increased risk of occult fracture and/or iatrogenic spine injury during hip fixation, may be unknown before surgery. Multiple fractures may prompt consideration of a trauma workup even in assumed low-energy injuries.

BackgroundThis study aims to examine the surgical outcomes and complications associated with minimally invasive stabilization using percutaneous pedicle screws (MIS-PPS) versus open surgical management (OSM) among patients with spine fractures in the setting of hyperostotic spine diagnosis.MethodologyThis retrospective, case-control study was conducted at a single Level I Trauma Center, including 30 consecutive patients (nine ankylosing spondylitis patients and 21 diffuse idiopathic skeletal hyperostosis patients) who underwent surgery for thoracolumbar extension-distraction fractures. Collected data included patient demographics, comorbidities, injury mechanism, spine region, fracture level, and intraoperative and postoperative complications. Continuous variables included age, body mass index, estimated blood loss, operative time, number of levels instrumented, and length of stay.ResultsBetween 2002 and 2020, 15 patients underwent MIS-PPS (3 females, 12 males, average age of 75.3 years) and 15 underwent OSM (3 females, 12 males, average age of 73.6 years). The MIS-PPS group had significantly lower blood loss (95 ± 31.6 mL vs. 643.3 ± 534.4 mL; p < 0.001) and shorter operative time (130.7 ± 36.4 minutes vs. 208.7 ± 41.8 minutes; p < 0.001). They also required fewer levels of instrumentation (5.2 vs. 6.8; p < 0.001). There were no significant differences in postoperative infection rates, epidural hematomas, or implant revisions between the groups.ConclusionsMIS-PPS provides the benefits of reduced blood loss, shorter operative time, and fewer levels of instrumentation compared to OSM, with no significant differences in postoperative complications.

This is a finite element study. To identify optimal trajectory, screw size, and screw shape using the finite element method. Patients with diffuse idiopathic skeletal hyperostosis often develop spinal instability after fractures due to ankylosis and bone fragility. We developed single or double endplate penetrating screw trajectory (SEPST/DEPST) to improve fixation strength by penetrating the vertebral endplate. However, the optimal screw length, diameter, and shape remain unclear. Finite element models of T12 and L1 were constructed from computed tomography images of osteoporotic patients. Three analyses were conducted: (1) the impact of various screw diameters with DEPST, (2) a comparison of fixation strength between short DEPST (S-DEPST), which penetrates the posterolateral endplate, and conventional DEPST (C-DEPST), and (3) a comparison between conventional cancellous thread screws (CTS) and endplate screws (ETS). Pullout strength (POS) was measured in all analyses. Vertebral motion angle (VMA) of the lower instrumented vertebra (LIV) was measured in analyses (2) and (3), and the four-directional load test (4DLT) was performed in analysis (2). Larger screw diameters with DEPST correlated with elevated POS. S-DEPST demonstrated significantly better fixation strength with a POS 1.46 times higher than C-DEPST and 2.5 times higher than traditional trajectories. S-DEPST also demonstrated higher fixation in all directions in 4DLT. However, no significant difference was observed in the VMA of LIV. ETS demonstrated slightly higher fixation than CTS, but the difference was not statistically significant. Fixation strength improved with larger screw diameters in DEPST. S-DEPST provided additional fixation due to rim penetration. ETS may offer a higher fixation strength and warrants further validation.