Diffuse idiopathic skeletal hyperostosis (DISH) : the impact of spinal ankylosis on trauma patients

In this thesis the clinical relevance of diffuse idiopathic skeletal hyperostosis (DISH) and its associated morbidity was investigated. We focused on the current and expected prevalence of DISH in the Netherlands, the clinical outcome of patients with an ankylosing spinal disorder (ASD) after spinal fractures and the characteristics of the ‘flowing wax’ morphology of DISH with respect to fracture mechanisms specific for this condition. We demonstrated that the prevalence of DISH in the Netherlands was higher than expected and relatively high compared to other sources in literature. By means of logistic regression analysis we demonstrated that the diagnosis DISH was statistically significant related to male gender and increasing age. In cadaveric spines with DISH the ossification mass was measured with CT scanning, demonstrating that the ossification mass was maximal at the level of the intervertebral disc (IVD) and minimal at the level of the vertebral body. This finding may explain the predilection for fractures through the vertebral body in DISH; since the ossifications provide a solid bridge spanning over the IVD space between two adjacent endplates, the vertebral body becomes the weakest link in the DISH affected spine. We also demonstrated that the vertebral segmental arteries were consistently localized at the mid-vertebral level, where the ossification was minimal, in both DISH specimens and controls. These findings suggest that new bone formation does not take place in the proximity of vascular structures. It was demonstrated that bone mineral density (BMD) was not elevated in the vertebral body in DISH. We measured BMDs in cadaveric human spines with DISH from different experimental orientations, either including or excluding the soft tissue ossifications in the DXA scanning field, and compared the results with control specimens. The ossifications projected in the field of view influenced BMD measurements, depending on the orientation in which BMD was measured. BMDs in the (unaffected) left half of the anteroposterior scan did not significantly differ from control BMDs. The findings of this study imply that BMD measurements in DISH patients may be unreliable when the ossifications are present in the field of view. Finally we investigated whether the presence of an ASD influenced clinical outcome after a spinal fracture. We performed a literature review and a retrospective review of patients at our own institution. The outcome of patients with ASD was considerably poorer than the general trauma population. Patients with ASD were admitted more frequently with a neurological deficit associated with their injury, leading to higher complication and mortality rates. Establishing a timely diagnosis was more difficult in patients with ankylosing spondylitis (AS) and DISH, because fractures often resulted from trivial trauma and were masked or obscured on radiographs because of pathological osseous changes. Because of unstable (hyperextension) fracture configurations, operative treatment may be beneficial over nonoperative treatment in this patient category. Because of global demographic ageing and the increase in metabolic conditions such as obesity and type 2 diabetes mellitus, which are highly related to DISH and have become endemic in the past few decades, the prevalence of DISH will increase in the future. Therefore, clinicians should be prepared to care for more trauma patients with DISH

Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients.

Background context The clinical outcome of patients with ankylosing spinal disorders (ASDs) sustaining a spinal fracture has been described to be worse compared with the general trauma population. Purpose To investigate clinical outcome (neurologic deficits, complications, and mortality) after spinal injury in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) compared with control patients. Study design Retrospective cohort study. Patient sample All patients older than 50 years and admitted with a traumatic spinal fracture to the Emergency Department of the University Medical Center Utrecht, the Netherlands, a regional level-1 trauma center and tertiary referral spine center. Outcome measures Data on comorbidity (Charlson comorbidity score), mechanism of trauma, fracture characteristics, neurologic deficit, complications, and in-hospital mortality were collected from medical records. Methods With logistic regression analysis, the association between the presence of an ASD and mortality was investigated in relation to other known risk factors for mortality. Results A total of 165 patients met the inclusion criteria; 14 patients were diagnosed with AS (8.5%), 40 patients had DISH (24.2%), and 111 patients were control patients (67.3%). Ankylosing spinal disorder patients were approximately five years older than control patients and predominantly of male gender. The Charlson comorbidity score did not significantly differ among the groups, but Type 2 diabetes mellitus and obesity were more prevalent among DISH patients. In many AS and DISH cases, fractures resulted from low-energy trauma and showed a hyperextension configuration. Patients with AS and DISH were frequently admitted with a neurologic deficit (57.1% and 30.0%, respectively) compared with controls (12.6%; p=.002), which did not improve in the majority of cases. In AS and DISH patients, complication and mortality rates were significantly higher than in controls. Logistic regression analysis showed the parameters age and presence of DISH to be independently, statistically significantly related to mortality. Conclusions Many patients with AS and DISH showed unstable (hyperextension) fracture configurations and neurologic deficits. Complication and mortality rates were higher in patients with ASD compared with control patients. Increasing age and presence of DISH are predictors of mortality after a spinal fracture

The influence of diffuse idiopathic skeletal hyperostosis on bone mineral density measurements of the spine

Rheumatology Advance Access originally published online on July 14, 2009 Rheumatology 2009 48(9):1133-1136; doi:10.1093/rheumatology/kep177 © The Author 2009. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected] The influence of diffuse idiopathic skeletal hyperostosis on bone mineral density measurements of the spine L. Anneloes Westerveld1, Jorrit-Jan Verlaan1, Marnix G. E. H. Lam2, Wendy P. Scholten2, Ronald L. A. W. Bleys3, Wouter J. A. Dhert1,4 and F. Cumhur Oner1 1Department of Orthopaedics, 2Department of Radiology and Nuclear Medicine, 3Department of Anatomy, University Medical Center Utrecht and 4Faculty of Veterinary Medicine, University of Utrecht, Utrecht, The Netherlands. Correspondence to: Jorrit-Jan Verlaan, Department of Orthopaedics, University Medical Center Utrecht, G 05.228, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail: [email protected]

Automated optimization for cervix brachytherapy requires more than the EMBRACE-II planning aims

Biological, physical and clinical aspects of cancer treatment with ionising radiatio

Automated optimization for cervix brachytherapy requires more than the EMBRACE-II planning aims

Biological, physical and clinical aspects of cancer treatment with ionising radiatio

Memory for faces and paired associates after temporal lobectomy in childhood

Findings are reported from the first examination of the Beardsworth Memory for Children's Faces Test (BMCFT) (Beardsworth & Zaidel, 1994) tested on a selected sample of 10 left (LATL) and 7 right (RATL) anterior temporal lobectomy patients an average of 7 years post surgery. No differences between LATL and RATL groups were found on immediate or delayed memory trials of the BMCFT. Verbal memory was assessed with a verbal analogue of this test, the Extended Verbal Paired Associates Test (EVPAT) specifically constructed for this study. Differences were obtained on the immediate (F = 5.17; p < .01) and delayed (F = 6.55; p < .01) memory trials of the EVPAT with LATL patients learning and retrieving fewer verbal associations than their right ATL counterparts. No differences were found on the memory decline to delayed recall scores on the EVPAT. The findings suggest that people who have left or right ATL in childhood cannot be distinguished on the basis of their immediate or delayed memory for paired faces an average of 7 years post-surgery. These results are consistent with the immediate memory performance of children 6 months post-surgery as reported by Beardsworth and Zaidel (1994), but are not consonant with the delayed memory performance of their children on this task. This indicates that left-right dissociations found in children on measures of delayed memory for faces 6 months post-surgery may represent a component of memory that is still in a state of recovery. The findings for the immediate memory trials of the EVPAT conformed to expectations and underscore the dependability of simple rote verbal memory tasks in dissociating left from right ATL 7 years post-surgery. The study addresses the issue of the recovery of immediate versus delayed memory and time of assessment post-surgery