Conservative treatment for stable low-energy thoracolumbar vertebral fractures in nonfused segments among elderly patients with diffuse idiopathic skeletal hyperostosis

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is the spontaneous osseous fusion of the spine with anterior bridging osteophytes. It is well-known that conservative treatment for vertebral fractures of fused segment among DISH spines is associated with worse clinical outcomes. However, the prognosis of conservatively treated stable vertebral fractures in neighboring nonfused segments among DISH spines is still unknown. The purpose of this study was to analyze the results of conservative treatment of stable low-energy thoracolumbar (TL) vertebral fracture in nonfused segments among patients with DISH lesions. A total of 390 consecutive patients who visited an emergency department by ambulance with spinal trauma between 2013 and 2017 were retrospectively reviewed. The diagnosis of DISH was determined based on fused spinal segments with bridging osteophytes in at least 3 adjacent vertebrae. For each case of stable TL vertebral fractures in nonfused segments of the DISH spine, we identified 2 age-, sex-, and fracture lesion-matched non-DISH controls who underwent conservative treatment for low-energy TL vertebral fractures during the same period. Of the 33 identified cases of TL fractures with DISH, 14 met our inclusion criteria. The bony union rates of the DISH group and control group were 57% and 75% at the 3-month follow-up examination ( P = .38) and 69% and 100% at the 6-month follow-up examination ( P = .02), respectively. Among the 13 patients with fractures below the TL junction, fused segments were not diagnosable based on the initial standard radiographs of the lumbar spine for 61.5% of patients. Although this study design was exploratory and the sample size was small, our results suggest that with conservative treatment, stable fractures in nonfused segments in the DISH spine might have a worse prognosis than ordinary osteoporotic vertebral fractures. The diagnosis of coexisting DISH lesions can be missed when only radiographs of the lumbar spine are used to determine the diagnosis.

A Scoring System for Anterior Longitudinal Ligament Ossification of the Lumbar Spine in Diffuse Idiopathic Skeletal Hyperostosis: Relationship Between the Extent of Ligament Ossification and the Range of Motion

“…The problem with progressive bridging of vertebral bodies in DISH is the reduced flexibility of the entire spine, which predisposes the patient to a vertebral fracture after minor trauma and contributes to low rates of bone fusion after fractures. 24 Reduced spinal flexibility leads to chronic mechanical stress, which may cause thoracic spondylotic myelopathy, 27 and could become a risk factor for poor postoperative outcomes and reoperation in lumbar canal stenosis. 25 Low rates of bone union after spinal fusion surgery may also be due to reduced spinal flexibility.…”

“… 21 - 23 When a fracture occurs in the vertebra just below the bridged vertebral bodies, the extended lever arm causes a high stress concentration, making it more difficult for the fracture site to fuse. 24 Similarly, progressive degeneration after lumbar decompression may necessitate reoperation, and spinal fusion is more likely to result in a nonunion. 25 , 26 In thoracic vertebrae, there is a higher likelihood that thoracic spondylotic myelopathy develops between the vertebral bodies that are bridged together or in the adjacent vertebra.…”

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.…”

Effect of postural nursing intervention on preventing pressure injury after thoracolumbar incision and internal fixation in southern China

“…Thoracolumbar fractures are mainly due to indirect or direct violence in the spine (Vanek et al, 2020;Wallace et al, 2019;Mazel & Ajavon 2018). If the treatment is not timely or the method is not appropriate, it is easy to cause complications such as nerve damage and vertebral body instability, affecting the patient's normal life and work (Okano et al, 2019;Lee et al, 2019). Surgery is currently the main clinical treatment of thoracolumbar vertebral fractures (Ye et al, 2017).…”