Abstract
Introduction
Symptomatic ossification of the anterior longitudinal ligament is rarely pathology. Diffuse idiopathic skeletal hyperostosis (DISH) is a common condition in the aging spine. DISH, also called with the eponym Forestier's disease, is a clinical syndrome characterized by the abnormal formation of osteopytes involving the spine. These are largely asymptomatic, however are recognized as an unusual cause of dysphagia, which may occur secondary to the mechanical compression with partial obstruction or perioesophageal inflammation caused by pharyngo- esophageal motion over the osteophytes. Dysphagia is reported in up to 28% of patients. Surgical treatment is advocated only after failure of conservative therapies. Conversely, in absence of relevant clinical signs due to the presence of DISH, surgery is not considered mandatory. However, surgical resection of the osteophyte has been reported to be an effective treatment for severe cases. Therefore, from 1995, we started to observe long-term postoperative courses of DISH patients with recalcitrant dysphagia who underwent surgical resection of osteophytes. The purpose of this study was to examine these surgical outcomes and literature review.
Material and Methods
Case 1. A 70-year-old man referred to our clinic because of progressive dysphagia for solids and liquids and cervical pain. A lateral cervical spinal X-ray and cervical MRI revealed giant cervical osteophytes at the ventral portion of the C 2/3/4 vertebral bodies and contiguous calcification of the anterolateral cervical vertebral bodies. Case 2. A 57-year-old man presented with a 1.5-year history of increased difficulty swallowing. A plain lateral radiograph revealed OALL ventral to the C3–5 vertebral bodies. Three- dimensional computerized tomography studies further demonstrated extensive C3–5 OALL. Case 3. A 75-year-old white man was seen at Hospital with the main complain of increased difficulty in swallowing solid food over the past two years. Routine cervical spine films revealed prodigious osteophytes of the cervical spine involving the bodies of C-2, C-3, C-4, C-5 and C-6 consistent with DISH. A magnetic resonance imaging (MRI) scan of the cervical spine revealed an elongated ossification of the frontal planes of the vertebral bodies, with spurs projecting into the soft tissues of the neck.
Results
The three patients underwent uneventful operative excision of the anterior cervical osteophytes. Surgery was performed with an anterolateral approach. They had marked improvement in swallowing function and were able to resume a normal diet after one to two months.
Conclusion
Diffuse idiopathic skeletal hyperostosis or Forestier's disease is an uncommon etiology of progressive dysphagia. This unrecognized condition may provide a new challenge for spine surgeons who are not as familiar with DISH as rheumatologists. Surgical decompression through osteophytectomy is effective for patients who fail conservative treatment