Elsevier

Journal of Clinical Neuroscience

Volume 67, September 2019, Pages 151-155
Journal of Clinical Neuroscience

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

https://doi.org/10.1016/j.jocn.2019.05.057Get rights and content

Highlights

  • Resection of symptomatic osteophytes in DISH can be performed safely and with good clinical results.

  • Patients should be informed that a recurrence is possible.

  • Preoperative functional X-ray images are recommended.

  • The indication for an accompanying ACDF/anterior plating must be decided individually.

  • A multicenter registry is useful to investigate the rare clinical syndrome more closely.

Abstract

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.

Introduction

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is a non-inflammatory, systemic skeletal disease [1]. Risk factors are male sex, older age (>50 years), diabetes, arterial hypertension and obesity [2], [3]. DISH leads to increased calcification and ossification of the ligaments and tendon attachment sites [4], [5]. The anterior region of the spine is particularly affected [6], [7]. The associated formation of anterior cervical osteophytes can impair swallowing [8], [9]. The resulting dysphagia can be so severe that oral nutrition is seriously affected. In these cases the osteophytes have to be surgically removed [10]. The number of publications on DISH has risen continuously over the past decades, but most articles are only case reports [4], [11], [12], [13], [14], [15], [16], [17]. In 2011, Verlaan et al. [10] published a systematic review of the literature with a total of 204 patients. 95 case reports (n = 1 or 2) and 23 case series (n ≥ 3) were included. However, only a part of these cases was treated surgically (n = 134). Furthermore, the type of treatment was heterogenous and the follow-up period was usually short. There was therefore little evidence in the literature concerning the long-term course of surgically treated DISH patients. Since then, some slightly larger case series have been published with five to six operated patients, whereby the longest mean follow-up was only 42.3 months [18], [19], [20]. The aim of the present study is the retrospective assessment of the peri- and postoperative course after surgical therapy of patients with dysphagia due to DISH as well as the collection of data on long-term progression.

Section snippets

Patients

In this retrospective, single-center cohort study all patients with DISH causing dysphagia and following anterior resection of osteophytes in our department between 2005 and 2015 were included. DISH was diagnosed based on preoperative imaging and criteria established by Resnick and Niwayama, which implied anterolateral bridging osteophytes of at least four contiguous vertebrae and preservation of the intervertebral disk spaces [21].

Dysphagia was evaluated by an otorhinolaryngologist before

Results

Five male patients with a mean age of 61.6 years (range, 43–77) were operated in our department in the mentioned time period (Table 1). The numbering of the patients from Table 1 and Fig. 1 is used in the following text (not included in Fig. 1 is patient 5 who died five years after surgery). Identified risk factors for DISH were type 2 diabetes (patient 2), overweight with a body mass index higher than 25.0 kg/m2 (patient 1, 2 and 3) and arterial hypertension (patient 2 and 5). All patients had

Discussion

DISH is a systemic disease that mainly affects older men [22]. In a systematic review by Verlaan et al. [10], men were affected about six times more frequently than women. In our study, all treated patients were male. Younger patients may also be affected, but from the literature the mean age for men is about 70 years and for women about 65 years [10], [23]. Our male patient cohort had a slightly lower average age of 61.6 years. Diabetes mellitus, arterial hypertension and obesity are described

Conclusion

Resection of symptomatic anterior osteophytes in DISH can be performed safely and with good clinical results. Patients should be informed that a recurrence is possible. A regular follow-up examination is therefore recommended, at least when symptoms reoccur. Preoperative functional X-ray images with the question of cervical instability are recommended from our point of view. In accordance to the literature, we believe that the indication for an accompanying ACDF with or without anterior plating

Declaration of Competing Interest

The authors report no conflict of interests. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Parts of this work were presented as ePosters at the annual conference of the Spine Section of the DGNC (09/2018, Hamburg) and at the German Spine Congress of the DWG (12/2018, Wiesbaden). The abstract submitted for the DWG was published in the European Spine Journal.

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