A Comparison of Cervical and Thoracolumbar Fractures Associated with Diffuse Idiopathic Skeletal Hyperostosis—A Nationwide Multicenter Study

Abstract

In diffuse idiopathic hyperostosis (DISH), the ankylosed spine becomes susceptible to spinal fractures and spinal cord injuries due to the long lever arms of the fractured segments that make the fracture extremely unstable. The aim of this retrospective multicenter study was to examine the differences in DISH-affected spine fractures according to fracture level. The data of 285 cases with fractures of DISH-ankylosed segments diagnosed through computed tomography (CT) imaging were studied and the characteristics of 84 cases with cervical fractures were compared to 201 cases with thoracolumbar fractures. Examination of the CT images revealed that cervical fracture cases were associated with ossification of the posterior longitudinal ligament and had fractures at the intervertebral disc level, while thoracolumbar fracture cases were associated with ankylosing of the posterior elements and had fractures at the vertebral body. Neurologically, cervical fracture cases had a higher ratio of spinal cord injury leading to higher mortality, while thoracolumbar fracture cases had lower rates of initial spinal cord injury. However, a subset of thoracolumbar fracture cases suffered from a delay in diagnosis that led to higher rates of delayed neurological deterioration. Some of these thoracolumbar fracture cases had no apparent injury episode but experienced severe neurological deterioration. The information provided by this study will hopefully aid in the education of patients with DISH and raise the awareness of clinicians to potential pitfalls in the assessment of DISH trauma patients.

Associations between Clinical Findings and Severity of Diffuse Idiopathic Skeletal Hyperostosis in Patients with Ossification of the Posterior Longitudinal Ligament

“…Therefore, even minor trauma can lead to an unstable spinal fracture. A retrospective study [17,18] reviewed 289 patients…”

“…Therefore, even minor trauma can lead to an unstable spinal fracture. A retrospective study [17,18] reviewed 289 patients with DISH-related spinal fractures and demonstrated that these fractures frequently resulted in spinal cord injury and were sometimes associated with mortality. That study also found that the diagnosis was often delayed, leading to unexpected impairment of neurologic status, especially in patients with a thoracolumbar fracture.…”

Urinary Retention as the Presenting Clinical Manifestation of Unstable Thoracic Spinal Fracture with Diffuse Idiopathic Skeletal Hyperostosis

“…As for treatment, early surgical fixation is recommended in patients with DISH-associated fractures complicated by neurological deficits or if instability is obvious or confirmed by additional stress imaging to avoid secondary neurological deterioration. 3,8,10 Regarding surgical procedure, 2-above and 2-below segmental fixation using the double endplates penetrating screw could be applied in patients with DISH to secure rigid fixation as in this case. 12 Although it has been reported that functional improvement should not be expected once neurological impairment occurs, 8 our patient underwent immediate posterior fixation to prevent further SCI and enhance rehabilitation.…”

“… 8 , 9 From the doctor’s standpoint, insufficient sharing of information about this condition among emergency physicians or primary care physicians may be responsible for a delayed diagnosis. 4 , 10 Non-specific tenderness of the back after a minor trauma would not warrant a thorough radiologic investigation. Hence, CT or magnetic resonance imaging is recommended to avoid a missed or delayed diagnosis.…”

Unstable fracture of fusion mass in old healed tuberculous kyphosis: Case report

“…The patients with ASD are prone to vertebral fracture following minor traumas and vertebral fractures can be missed easily using simple radiographs, increasing the risk of neurologic complications [4] . Conservative treatment for thoracolumbar fracture with ASD is not recommended because of biomechanical behavior [5] , [6] . We present a case in which the diagnosis of lumbar fractures in post-tuberculosis kyphosis had been delayed and conservative management had failed and surgery was performed.…”