Presentation and treatment of anterior cervical hyperostosis

We report a case of severe anterior cervical hyperostosis presenting with dysphagia.     

Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction

Background context

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed condition relating to ossification of spinal ligaments that can cause compression of the esophagus and trachea. According to case reports, dysphagia or airway obstruction resulting from DISH is a rare occurrence.

Purpose

This study was intended to identify all published cases of dysphagia and/or airway obstruction resulting from DISH to increase the epidemiologic/clinical knowledge of these related conditions.

Study design

A systematic review of the literature was performed.

Methods

The articles resulting from the systematic PubMed/EMBASE search of the literature were closely read, and predefined parameters were scored.

Results

The search yielded a total of 118 articles (95 case reports and 23 case series) describing 204 patients with dysphagia and/or airway obstruction resulting from DISH. The number of cases demonstrated a steady increase from 1980 to 2009. This might be a real effect not ascribable to publication bias or expansion of the medical literature alone.

Conclusions

Diffuse idiopathic skeletal hyperostosis as a cause of dysphagia and/or airway obstruction may be an increasing and underappreciated phenomenon. Diffuse idiopathic skeletal hyperostosis should be included in the differential diagnosis of dysphagia and airway obstruction.     

Surgical management of cervical radiculopathy in Forestier's disease. Case report and review

Forestier's disease now called DISH (diffuse idiopathic skeletal hyperostosis) is a non inflammatory enthesopathy ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Radiology performed for minor trauma or to explore a stiff neck provides the diagnosis. The main differential diagnosis is ankylosing spondylitis presenting an inflammatory profile as well as previously existing alterations of the sacroiliac joint. Retinoic acid treatment or ossification of the posterior longitudinal ligament should also be discussed. Dysphagia is the most frequent symptom, but neurological signs are rarely observed. We report a case observed at the cervical level. Anterior decompression and cage-fusion was indicated. Ongoing hyperostosis was also documented. Surgery in DISH is mainly indicated for dysphagia and rarely after cervical trauma. Of note are associated lesions such as OPLL (ossification of the posterior longitudinal ligament) or synovial cysts responsible for the exceptional and severe myelopathy presentation. The neurosurgical community should become better aware of Forestier's disease.     

Zero‐Profile Implant System for Treatment of Dysphagia Caused by Noncontiguous Anterior Cervical Osteophytes—A Case Report with Literature Review

BackgroundEsophageal cervical spondylosis is a rare type of cervical spondylosis which causes dysphagia. Surgical osteophyte resection is taken when conservative treatment does not respond. However, few reports on its operation and postoperative follow‐up. We first present a case showing how the Zero‐Profile implant system is utilized to treat dysphagia caused by noncontiguous anterior cervical osteophytes.Case PresentationA patient with progressive dysphagia was referred to our department. Imaging examinations revealed a large diffuse idiopathic skeletal hyperostosis (DISH) related anterior osteophyte in C3/4, C6/7 and ossification of the anterior and posterior longitudinal ligaments. Anterior cervical osteophytectomy, discectomy, and fusion were performed on C3/4, C6/7. Two Zero‐Profile implants were implanted. Postoperative dysphagia was significantly improved, and the patient was free to swallow large pills or solid foods at nine‐years follow‐up.ConclusionOsteophyte excision can effectively treat esophageal cervical spondylosis, This case shows that fusion using the Zero‐Profile implant system is a viable option for patients with potential cervical instability following osteophyte resection.     

Anterior longitudinal ligament in diffuse idiopathic skeletal hyperostosis: Ossified or displaced?

Diffuse idiopathic skeletal hyperostosis (DISH) is often theorized to be an ossification of the anterior longitudinal ligament (ALL). Using computed tomography (CT) imaging and cryomacrotome sectioning, we investigated the spatial relationship between the ALL and newly formed bone in DISH to test this hypothesis. In the current study, four human cadaveric spines diagnosed with DISH using CT imaging were frozen and sectioned using a cryomacrotome. Photographs were obtained of the specimen at 125 µm intervals. Manual segmentations of the ALL on cryomacrotome photographs were projected onto the three‐dimensional reconstructed CT scans. The presence and location of newly formed bone were assessed in relationship to the location of the ALL. The ALL could be identified and segmented on the photographs at all levels. The ALL was located at the midline at levels where no new bone had formed. At the locations where new bone had abundantly formed, the ALL was displaced towards to the contralateral side and not replaced by bony tissue. The displacement of the—morphologically normal appearing—ALL away from the newly formed bone implies that newly formed bone in DISH may not originate from the ALL. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society J Orthop Res 36:2491–2496, 2018.     

Horizontal contralateral approach for the distal anterior cerebral artery aneurysm: technical note

Background

The authors present a modified interhemispheric approach for the distal ACA aneurysm to resolve several problems including the narrow surgical corridor, the difficulty of proximal control, and the aneurysmal projection toward the surgeon.

Methods

We refined the positions of the patient's head and the surgeon. The patient's head is fixed with flexion and tilted to the contralateral side. The surgeon sits on the contralateral side of the patient and not on the cranial side.

Results

The present approach allows the surgeon to comfortably use both hands in the horizontal operative filed, to obtain a minimum retraction of the brain, and to easily secure the proximal artery.

Conclusions

This modified interhemispheric approach is useful for a patient with the distal ACA aneurysm.     

Diffuse Idiopathic Skeletal Hyperostosis

DISH is a relatively common disorder affecting between 3% and 30% of men older than the age of 50. It produces nonmarginal osteophyte formation in the spine that often results in ankylosis. Although often asymptomatic, patients may develop stiffness and axial neck or back pain. Most significantly, DISH places patients at great risk of neurologic injury after seemingly insignificant trauma. Treating physicians must maintain a high index of suspicion when evaluating patients who have a history of DISH because even low-energy trauma may have disastrous complications in this patient population.     

Long-term results of surgical treatment of dysphagia secondary to cervical diffuse idiopathic skeletal hyperostosis

Background contextLarge, prominent osteophytes along the anterior aspect of the cervical spine have been reported as a cause of dysphagia. Improvement of swallowing after surgical resection has been reported in a few case reports with short-term follow-up. The current report describes outcomes of a series of five patients with surgical treatment for this rare disorder, with a long-term follow-up.PurposeTo study the clinical and radiographic outcomes of a case series of patients surgically treated for dysphagia secondary to cervical diffuse idiopathic skeletal hyperostosis (DISH).Study designRetrospective review of a case series.Patient sampleFive cases from a University Hospital.Outcome measuresClinical and imagenological follow-up.MethodsThe records of five patients with dysphagia who had undergone anterior surgical resection of prominent osteophytes secondary to DISH were reviewed. Extrinsic esophageal compression secondary to anterior cervical osteophytes was radiographically confirmed via preoperative barium esophagogram swallowing study. All patients underwent anterior cervical osteophytes resection without fusion. Postoperatively, patients were followed-up clinically and radiographically with routine lateral cervical radiographs.ResultsPreoperative esophagogram showed that the esophageal obstruction was present at one level in three cases and two levels in two cases. The C3–C4 level was involved in three cases, C4–C5 in three cases, and C5–C6 in one case. There were no postoperative complications, including recurrent laryngeal nerve palsy, wound infection, or hematomas. All patients had resolution of dyphagia soon after surgery (within 2 weeks). Postoperative radiographs demonstrated complete removal of osteophytes. At final follow-up, ranging from 1 to 9 years (average 59.8 months, median 53 months), no patients reported recurrence of dysphagia. Final radiographic examination demonstrated minimal regrowth of the osteophytes.ConclusionsAlthough rarely indicated, surgical resection of anterior cervical osteophytes from DISH causing dyphagia produces good clinical and radiographical outcomes. After thorough evaluation to rule out other intrinsic or extrinsic causes of swallowing difficulty, surgical treatment of this uncommon condition might be considered.     

前路减压治疗脊髓型颈椎病的疗效分析

目的探讨颈椎前路减压治疗脊髓型颈椎病的疗效。方法回顾性研究了我院因脊髓型颈椎病行颈前路减压、手术治疗的32例患者,对其手术前后的JOA评分(均数)进行分析。结果手术后患者的JOA评分(均数)均较手术前有明显提高,经随机区组设计资料的方差分析(α水准为0.05),P<0.05,有显著性差异。术后随访患者的JOA评分(均数)呈逐渐上升之势,但各组间评分P>0.05,无显著性差异。结论颈椎前路减压是治疗脊髓型颈椎病的一种有效的手术方法。但术前需仔细的研究影像学资料,结合患者的临床体检特点来进行手术部位的选择。     

Awake tracheal intubation with the intubating laryngeal mask in a patient with diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis, otherwise known as Forestier's disease or ankylosing hyperostosis, is a relatively common condition that is distinguished from ankylosing spondylitis by the relative preservation of spinal function and the characteristic 'candle flame' lipping of the vertebrae. We report a patient with this condition and a well-recorded history of impossible intubation who presented for emergency laparotomy. The patient was intubated awake using the intubating laryngeal mask and sedation and anaesthesia were provided by a target-controlled infusion of propofol.     

三种方法恢复颈椎生理曲度及椎间高度的比较

目的　分析颈前路减压术中不同撑开技术对恢复颈椎生理曲度及椎间高度的影响。方法　 1995 .7— 2 0 0 1.3月间施术的颈椎病患者 5 4例 ,按照术中椎间隙牵开方法的不同分为徒手牵开组、Cage牵开组及牵开器牵开组等三种。分别测量各组术前、术后颈椎生理曲度及椎节高度值 ,测量结果进行统计学比较。结果　牵开器牵开法及Cage牵开法较徒手牵开法颈椎生理曲度及椎节高度增加值大 ,且具显著性差异 (P <0 .0 1)。结论　术中牵开技术可影响颈椎生理曲度及椎节高度的恢复 ,牵开器牵开法对改善颈椎生理曲度及椎节高度较为理想。     

Microsurgical anterior approach to cervical discs review of 60 consecutive cases of discectomy without fusion

Summary During the past six years 60 patients have undergone anterior cervical microsurgical discectomy without exogenous intercorporal grafting using the operating microscope. This alternative method of treatment is a further refinement of previous techniques for the removal of cervical disc protrusions, which fulfils all the criteria of effective surgery. Discectomy provides ample exposure of the neural elements through the disc space. The visualisation of the underlying pathology is adequate through direct light and magnification of the operating microscope. A radical surgery is possible without danger of injury to the nervous structures or to the vertebral artery. The functional stability of the adjacent vertebral segment is present immediately after discectomy. A spontaneous fusion occurs in 70% of cases in six months to one year. Risks and complications of the procedure are few. Long term results are excellent, with overall benefit from surgery in 95% of cases. Comparing the results of anterior microdiscectomy without bone grafting with those of other procedures, there are no significant differences.Presented at the 7th European Congress of Neurosurgery in Brussels, September 1983.     

颈椎前路减压带锁钛板内固定治疗颈椎损伤

目的评价颈椎前路减压带锁钛板内固定治疗颈椎骨折并脊髓损伤的临床疗效。方法对46例颈椎骨折并脊髓拟伤的患皙施行颈椎前路臧压、自体髂骨植骨和颈椎带锁钛板内固定。术后定期复查X线片,判定脊髓功能恢复情况,结果随访41例,平均随访时间2．5年。术后3个月植骨块获得骨性融合,颈椎椎间高度和生理曲度维持满意,无内置物并发症,脊髓功能平均提高1级。结论颈椎骨折并脊髓损伤前路减压、应用带锁钛板内崮定有利植骨融合和事建颈椎稳定。     

Myelography in the late postoperative period in patients subjected to anterior cervical decompression and fusion

Summary During a 13 year period, 286 patients with cervical disc herniation and/or spondylotic spurs, were subjected to anterior decompression and vertebral interbody fusion with autologous bone.Twenty patients were re-admitted in the late postoperative period due to recurrent radicular symptoms and/or signs of myelopathy. In these patients myelography was performed again. In 14 patients spinal cord compression and/or nerve root involvement at a new level was visualized. At the operated level, however, the myelograms demonstrated a smooth anterior wall in the spinal canal.The series confirms the safety, effectiveness and reliability of the Cloward procedure in achieving long term spinal cord and nerve root decompression, and a solid vertebral interbody fusion.     

Irreducible anterior and posterior dislocation of the shoulder due to incarceration of the biceps tendon

Mechanical obstacles may infrequently impede closed reduction of anterior shoulder dislocation. Imaging techniques such as arthrography, computed tomography (CT) and magnetic resonance imaging (MRI) complement conventional radiography by allowing identification of obstacles to reduction. We present a case of irreducible anterior glenohumeral dislocation resulting from an initial anterior dislocation, converted to a posterior dislocation with an attempt at reduction, then converted back to anterior dislocation with a second reduction attempt. Soft tissue obstacles to shoulder reduction should be suspected when plain films do not identify a bony fragment as the culprit. CT and MRI are useful for identifying the cause of irreducibility and for operative planning.     

Influence of bone adaptation on tendon‐to‐bone healing in bone tunnel after anterior cruciate ligament reconstruction in a rabbit model

Anterior cruciate ligament (ACL) reconstruction with placement of grafted tendon in bone tunnel is a common surgical procedure. Bone tunnel creation may result in stress shielding of postero‐lateral regions of tibial tunnel. The present study was designed to characterize the changes of peri‐graft bone and compare with tendon‐to‐bone (T‐B) healing in spatial and temporal manners after ACL reconstruction in rabbit. Surgical reconstruction using digital extensor tendon in bone tunnel was performed on 48 rabbits. Twelve rabbits were sacrificed at 0, 2, 6, and 12 weeks postoperatively for radiological and histological examinations. Bone mass and microarchitecture at the anterior, posterior, medial, and lateral regions of tunnel wall at distal femur and proximal tibia were evaluated. Using peripheral quantitative computed tomography, a 26, 22, and 42% decrease in bone mineral density (BMD) relative to baseline was present in the medial region of the femoral tunnel and the posterior and lateral regions of the tibial tunnel, respectively, at week 12 postoperatively (p < 0.05). It was accompanied by a decrease in trabecular number and increase in trabecular spacing, the shift of platelike to rodlike trabeculae, and loss of anisotropy under micro‐computed tomography evaluation. This finding was echoed by histology showing increased osteoclastic activities and poor T‐B healing in these regions. In conclusion, the postoperative bone loss and associated poor T‐B healing was region‐dependent, which may result from adaptive changes after tunnel creation. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:1447–1456, 2009     

Ⅰ期前后路手术治疗下颈椎骨折脱位

目的 评价Ⅰ期前后路手术治疗下颈椎骨折脱位伴关节突绞锁的可行性和近期临床效果.方法 对27例下颈椎骨折脱位伴关节突绞锁的患者,Ⅰ期行后路复位和前路减压植骨内固定术,定期X线摄片观察损伤节段的稳定性和融合率,观察有无并发症发生,以ASIA分级判定脊髓功能的恢复情况.结果 随访6～32个月(平均21.5个月),27例患者均获得了完全复位,损伤节段稳定,颈椎高度和生理曲度维持良好,融合率为100%,内固定位置良好,无植骨块脱出或钢板、螺钉松动、断裂等并发症,脊髓功能平均提高1.4级,无一例患者出现神经症状加重.结论 Ⅰ期前后路手术治疗下颈椎骨折脱位伴关节突绞锁可获得满意的复位、彻底的减压和即刻稳定性的重建,有利于脊髓功能的恢复,近期临床疗效满意.