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11/83. Retro-odontoid pseudotumor in diffuse idiopathic skeletal hyperostosis.

    STUDY DESIGN: A rare case of retro-odontoid pseudotumor combined with diffuse idiopathic skeletal hyperostosis is presented. OBJECTIVE: To discuss the pathomechanism of retro-odontoid pseudotumor in diffuse idiopathic skeletal hyperostosis. SUMMARY OF BACKGROUND DATA: Reports describing craniovertebral manifestations of diffuse idiopathic skeletal hyperostosis are quite rare. Only two cases of an atlantoaxial subluxation and one case of an odontoid fracture have been reported. Myelopathy resulting from retro-odontoid pseudotumor combined with diffuse idiopathic skeletal hyperostosis has not been reported previously. methods: A 74-year-old man presented with spastic tetraparesis caused by a retro-odontoid pseudotumor combined with diffuse idiopathic skeletal hyperostosis. Transoral removal of the extradural mass combined with a dorsal atlantoaxial fusion was performed using a titanium frame with sublaminar cable wiring. RESULTS: Yellowish amorphous material extruded from between the odontoid process and the arch of C1 when the anterior capsule had been incised. The retro-odontoid mass was very firmly attached to the hypertrophied ligaments. The mass therefore had to be sharply dissected away to expose the dura. The histologic appearance of the mass consisted of poorly cell-degenerated ligament, fibrocartilage, and fibrin. There was a focal proliferation of small vessels, but no significant inflammatory component and no evidence of neoplasia. The ligaments appeared fibrillated, disintegrated, and fragmented. After surgery, the patient's neurologic function improved. CONCLUSIONS: This is the first reported case of a retro-odontoid pseudotumor combined with diffuse idiopathic skeletal hyperostosis. The secondary transfer of mechanical stress to the atlantoaxial segment was presented as a pathomechanism underlying the formation of this retro-odontoid pseudotumor.
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12/83. Coexistence of diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: a case report.

    Diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis are two diseases which are listed in the differential diagnosis of each other. There have been limited numbers of case reports regarding the coexistence of both diseases in the literature. We describe a patient who demonstrated the features of diffuse idiopathic skeletal hyperostosis with coexisting features resembling ankylosing spondylitis in order to discuss the association of the two diseases.
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13/83. acupuncture for back pain in a patient with Forestier's disease (diffuse idiopathic skeletal hyperostosis/DISH).

    acupuncture was used to treat a 54-year-old man with low back pain and Forestier's disease. His symptoms were markedly improved with acupuncture where other treatments in the form of analgesics, non-steroidal anti-inflammatories, physiotherapy and hydrotherapy had proved ineffective. There would appear to be no cases reported in the literature where medical acupuncture has been used to treat back pain in a patient with this condition.
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14/83. Cervical spine control; bending the rules.

    Cervical spine fractures associated with diffuse idiopathic hyperostosis (DISH) are less common than those associated with ankylosing spondylitis and can occur after minor trauma in patients asymptomatic of the disease process. This case report describes a hyperextension injury of the neck in a patient unknown to have DISH, which resulted in an angulated C3/C4 fracture. The position of the fracture was improved by placing the neck in flexion with immediate improvement in the patient's neurological deficit.
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15/83. Diffuse idiopathic skeletal hyperostosis in a patient with idiopathic retroperitoneal fibrosis: a case report.

    Idiopathic retroperitoneal fibrosis (IRF) is a rare rheumatologic disease with obscure pathogenesis. Its manifestations depend upon the structures involved. Diffuse idiopathic skeletal hyperostosis (DISH) is usually seen in male patients over 45 years of age and characterized by new bone formation at the entheses. The dorsal spine is most commonly involved, but radiographic findings in both the spine and extraspinal structures suggest a generalized disorder of ossification rather than a localized spinal disease. The association of IRF and DISH has not been reported before. There is proliferation of connective tissue in both of these diseases, and they may share a common etiopathogenetic basis. We describe a patient having features of both IRF and DISH.
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16/83. Clinical manifestations of diffuse idiopathic skeletal hyperostosis of the cervical spine.

    OBJECTIVES: To describe the clinical manifestations and the complications of cervical spine (C-spine) involvement in diffuse idiopathic skeletal hyperostosis (DISH). methods: Two patients, who presented with dysphagia resulting from large anterior osteophytes of the C-spine, were diagnosed as having DISH. A medline search from 1964 to present, using the terms "diffuse idiopathic skeletal hyperostosis" and "cervical spine," identified several clinical manifestations associated with DISH. RESULTS: Two groups of conditions associated with DISH were found. 1. Spontaneous complications such as: dysphagia, being the commonest, dyspnea, stridor, myelopathy associated with ossification of the posterior longitudinal ligament (OPLL) or with atlanto-axial pseudoarthrosis or subluxation. Other rare events were aspiration pneumonia, sleep apnea and thoracic outlet syndrome. 2. Provoked complications such as endoscopic and intubation difficulties and fractures of the C-spine with frequent transverse shift of the fractured segment and resultant myelopathy. CONCLUSIONS: C-spine involvement in DISH is a recognized cause of various clinical manifestations involving the pharynx, larynx and the esophagus. Prior knowledge of the existence of cervical DISH should alert the clinicians for possible complications, at times severe, during invasive procedures in the neck region and as a consequence of trauma.
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17/83. A structural chiropractic approach to the management of diffuse idiopathic skeletal hyperostosis.

    OBJECTIVE: To discuss a unique method of treatment for a patient with diffuse idiopathic skeletal hyperostosis (DISH) and the long-term result of this treatment. CLINICAL FEATURES: The patient had a long-standing history of low back pain and stiffness caused by DISH. Coexisting conditions consisted of right-hand paresthesia because of a thalamic stroke, osteoporosis, Barrett's esophagus, thyroid and parathyroid disease, and hypercholesterolemia. INTERVENTION AND OUTCOME: The patient received chiropractic manipulation and drop table adjustments, along with range-of-motion exercise, extension exercise, and standing lumbar extension traction. The magnitude of lumbar lordotic alignment and Ferguson's angle improved with treatment. The patient's subjective perception of pain significantly improved, as documented with the use of numeric rating scales. Flexibility and activities of daily living were also improved. The effect was maintained for 19 months after termination of the active rehabilitative treatment period. CONCLUSION: A paucity of literature exists regarding the chiropractic management of patients with a diagnosis of DISH. Chiropractors should be encouraged to report on their clinical experiences in treating patients with varied conditions and disorders.
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18/83. Spontaneous symptomatic pseudoarthrosis at the T11-T12 intervertebral space with diffuse idiopathic skeletal hyperostosis: a case report.

    STUDY DESIGN: We report on a 69-year-old male who had severe back pain due to spontaneous symptomatic pseudoarthrosis at the T11-T12 intervertebral space with diffuse idiopathic skeletal hyperostosis. OBJECTIVE: To describe a rare clinical entity and successful treatment by spinal fusion with a 4-year follow-up. SUMMARY OF BACKGROUND DATA: There have been a few reports of spontaneous symptomatic pseudoarthrosis of an intervertebral space associated with diffuse idiopathic skeletal hyperostosis, but there have been no reports of surgical treatment for this clinical condition. methods: Plain radiographs of the patient, who was admitted to our hospital with severe back pain but no history of trauma, revealed manifestations of diffuse idiopathic skeletal hyperostosis and a pseudoarthrosis at the T11-T12 intervertebral space. Posterior instrumentation from T9 to L2 and anterior bone grafting at the T11-T12 intervertebral space were performed. RESULTS: The patient has been followed for 4 years and is currently asymptomatic. CONCLUSIONS: A rare case of spontaneous symptomatic pseudoarthrosis at the T11-T12 intervertebral space with diffuse idiopathic skeletal hyperostosis was treated successfully by spinal fusion.
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19/83. Simultaneous occurrence of diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis in the same patient.

    Diffuse idiopathic skeletal hyperostosis (DISH) frequently gives rise to some diagnostic confusion, as it may radiologically mimic ankylosing spondylitis (AS). A patient with features of DISH and AS is described and the literature is reviewed. The diagnostic value of sacroiliac computerized tomography is emphasized. The role of spinal mobility in the appearance of the enthesiophytes is discussed since our patient, who underwent a segmental fusion, presented different radiological features in the mobile segment and the fused region.
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20/83. Management of respiratory compromise caused by cervical osteophytes: a case report and review of the literature.

    BACKGROUND CONTEXT: Diffuse idiopathic skeletal hyperostosis (DISH) is a common condition in the aging spine. DISH is associated with large anterior osteophytes of the cervical spine, which can cause complications by compressing adjoining structures. Dysphagia is reported in up to 28% of patients, but respiratory compromise is rare. There have been no published recommendations for treatment. PURPOSE: To report that resection of cervical osteophytes, without cervical fusion, can be successful in the treatment of severe respiratory distress. STUDY DESIGN: This report describes the management of a patient with DISH and severe respiratory distress resulting from large anterior cervical osteophytes. methods: A team approach was used with collaboration between the orthopedic spine surgeons and the otolaryngologists. RESULTS: This patient was found to have compression of her posterior pharyngeal wall by the osteophytes. tracheostomy was required for the management of the airway. The patient was dependent on the tracheostomy until the osteophytes were resected. The patient was then able to breathe normally. Treatment recommendations were developed based on this case of osteophyte-induced respiratory compromise as well as the previously published accounts of osteophyte-induced dysphagia. CONCLUSIONS: airway obstruction resulting from DISH can be treated according to the same principles as dysphagia resulting from DISH: surgical excision of osteophytes if conservative support fails.
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