Diffuse idiopathic skeletal hyperostosis (DISH) with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine without neurological deficit - A Case report

Abstract

Introduction: Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier disease, is a condition characterized by calcification and ossification of ligaments and enthuses (ligament and tendon insertion sites), which mainly affect the vertebral column. The clinical manifestation of DISH is variable. Some patients can be completely asymptomatic, whereas others can complain of painful stiffness, decreased range of movement, and myelopathy symptoms. OPLL usually produce myelopathy symptoms. Combined of OPLL and DISH are rare case.

Illustration: A 59 years old woman patient complained of neck and shoulder pain in the last 20 years ago, with decreased neck range of motion and dysphagia. There was no gross abnormality on patient's neck and back. Cervical x ray was showing a continuous ossification extending from the anterior surface of C2 to C7 in lateral radiograph. A similar ossification was also noticed on the posterior surface of the vertebral bodies from C2 to C6 abutting the spinal canal.

Discussion: Despite striking abnormal appearance of cervical DISH and OPLL seen on radiologic examinations, absence of myelopathy is an indication to non-operative treatment. Presence of dysphagia was not an indication of surgery in this patient, as dysphagia was not severe and myelopathy was absent. Patient was observed during her clinical course to document the progression of myelopathy. Prophylactic surgery was not indicated for this patient, and progression of myelopathy during observation is an indication for surgical intervention.

Conclusion: Diffuse and large abnormalities in cervical area with normal neurological function is not indication for surgery. Selective treatment based on individual case.

Keywords: Case report; DISH cervical; Myelopathy; OPLL; Observation.

Fig. 1

Clinical Manifestation. No sign of deformity.

Fig. 2

Plain Cervical X ray. Lateral view radiograph shows 'flowing' anterior osteophytes and ossification of the posterior longitudinal ligament and calcification of the posterior longitudinal ligament.

Fig. 3

CT Cervical. Axial and sagittal view showed diffuse ossification of the corpus of vertebra cervical 2 to 7 and anterior thickening of the OPLL.

Fig. 4

MRI Cervical. The axial and sagittal MRI showed diffuse ossification of the corpus of vertebra cervical 2 to 7 and anterior thickening of the OPLL but there is no sign of protrusion, compression nor destruction of spinal canal.