The X-Files: September 2006

Marshall Deltoff
January 07, 2008
Written by Marshall Deltoff
Thank you to Dr. Jeff Labelle of Toronto for this case.  These sequential lateral views depict a man with diffuse idiopathic skeletal hyperostosis (DISH) in his cervical spine.
50Thank you to Dr. Jeff Labelle of Toronto for this case.  These sequential lateral views depict a man with diffuse idiopathic skeletal hyperostosis (DISH) in his cervical spine.

50bHe first presented to the office for an injury received in a 1996 waterskiing fall.  After the fall, the man experienced vertigo and recurring frontal headaches.  Examination revealed subluxation complex with progression of degeneration and nerve root loss, especially at the brachial plexus.  Cervical range of motion was diminished, as was right brachial strength.

A three-month course of chiropractic care was initiated.  Afterward, the patient discontinued care, only to reappear two years later (1998) with similar complaints.  Three months of corrective care resolved the symptomatology, and, once again, the patient discontinued care.  However, he was seen sporadically more than two years later (2001), followed by another five-year hiatus.  Dr. Labelle feels that this patient would have more greatly benefited from a regular schedule of care rather than the crisis care he kept seeking over the years.

We can follow the radiographic progression of the process over a seven-year period, from October 1998 through March 2001, up to June 2006, age 41-48.  Note the dramatic growth in the hyperostotic bridging spurs, with virtual total retention of discal height.  There is, in addition, some mild to moderate degenerative disc disease at C6-C7.

Some points to remember about DISH:
•     characterized by paravertebral ligamentous calcification and ossification, chiefly involving the anterior longitudinal ligament
•    patient typically male over 50
•    thoracolumbar region is most commonly involved
•    most common symptom is low-grade, aching pain with slowly progressive spinal stiffness
•    linked to diabetes mellitus in 25-30% of cases
•    up to 80% have cervical spine involvement (Forestier’s disease)
•    ossification of the posterior longitudinal ligament in up to 50%, with subsequent spinal stenosis
•    esophageal impingement by prominent anterior osseous protrusion can result in dysphagia

Reference:
Deltoff MN, Kogon PL. The Portable Skeletal X-ray Library. 1997. Mosby Yearbook, St. Louis.

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