Association Between Vertebral Fracture and Diffuse Idiopathic Skeletal Hyperostosis

Abstract

Study Design. Retrospective case-control study. Objective. To investigate the prevalence and characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in vertebral fracture patients admitted to our hospital. Summary of Background Data. Although vertebral fracture is generally treated conservatively with rest and use of a corset, surgery with rigid internal fixation is recommended for vertebral fractures in patients with DISH. Thus, treatment strategies for vertebral fracture differ according to the presence or absence of DISH. However, only a few studies have investigated the prevalence of DISH in vertebral fracture patients. Methods. A total of 159 patients (49 men and 110 women, with a mean age of 82.9 years) who were diagnosed with fresh vertebral fracture and required admission to HITO Hospital. The diagnosis of fresh vertebral fracture was made using x-ray imaging, computed tomography, and magnetic resonance imaging, and the presence or absence of DISH was assessed. In addition, age, sex, bone mineral density ( % young adult mean), blood test results, treatment, and length of hospital stay were compared between patients with and without DISH. Results. The proportion of patients with DISH among the patients with vertebral fracture was 33.9% (54 of 159 patients). The proportions in men and women were 38.8% and 31.8%, respectively, with no significant difference between sexes (P = 0.39). The patients in the DISH group were older than those in the non-DISH group (83.6 vs. 79.4 years, P = 0.009), and the DISH group had higher glycated hemoglobin A1c (P = 0.005), higher bone mineral density (P = 0.042), and longer length of hospital stay (P = 0.0001) compared with those in the non-DISH group. Conclusion. The proportion of patients with DISH among the vertebral fracture patients was 33.9%. Given that patients with DISH may require different treatment approaches, careful observation is needed. Level of Evidence: 3

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.…”

“… 3 , 4 , 7 , 8 Some patients with this condition complain of only mild back pain or may not even notice back pain, which renders them reluctant to seek medical attention immediately after injury. 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. 8 Otherwise, DISH-associated unstable vertebral fractures would not be recognized until neurological deficits appear. A recent nationwide survey in Japan reported that diagnosis was delayed in 40% of cases.…”

Can Diffuse Idiopathic Skeletal Hyperostosis Be Diagnosed by Plain Lumbar Spine X-Ray Findings Alone?

“…DISH, a condition previously not well recognized, has recently attracted attention and has been suggested to affect the surgical procedures for and treatment outcomes of various spinal diseases, including fractures and lumbar spinal canal stenosis. [6][7][8][9][10][11][12][13] Although lumbar spine X-ray is often performed in patients with low back pain or suspected lumbar spinal canal stenosis, thoracic spine X-ray and CT are performed less frequently due to lower incidence of thoracic spine diseases. The ability to infer the presence of DISH on plain X-ray images of the lumbar spine will allow for narrowing down of diseases to be screened and thereby reduce patients' exposure to radiation and medical costs.…”

“…3 Clinical symptoms associated with DISH include back pain, limited range of motion, 4 decreased vital capacity, aspiration, and airway obstruction. 5 Other features characterized by recent reports include increased vulnerability to vertebral fracture, 6 difficulty in achieving bone fusion during conservative treatment after vertebral fracture, 7 high possibility of requiring surgery, 8 a risk factor for thoracic myelopathy, 9 increased risk of pseudarthrosis after lumbar spinal fusion, 10 and a poor prognostic factor due to a high reoperation rate after lumbar decompression surgery. [11][12][13] Hence, DISH affects the diagnosis, treatment, and posttreatment outcome of spinal diseases.…”