Figure 1. CT imaging showing severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable cervical spinal fracture. A and C: Sagittal images showing “flowing” anterior osteophytes (red arrow) characteristic of DISH as well as OPLL (black arrow). A: An unstable C3 fracture with posterior subluxation resulting in >50% osseous narrowing of the spinal canal is present. B: Soft tissue window and D: bone algorithm and bone window showing severe narrowing of the spinal canal. B and D are at the level of the white line seen on A.
Figure 2. Occiput to C6 posterior fusion with C1-C6 laminectomies.
A 54-year old man presented after a fall while intoxicated, during which a small frontal sinus fracture was sustained. Upon initial presentation, he was minimally responsive and eventually developed cardiopulmonary arrest. After intubation and return of circulation, he was immediately transferred from Mexico to an Arizona tertiary medical center, where his head and cervical spine CT showed severe diffuse idiopathic skeletal hyperostosis with ossification of the posterior longitudinal ligament (DISH with OPLL) and an unstable C3 fracture with posterior subluxation and severe canal narrowing (Figure 1).
DISH, also known as Forestier disease, is a skeletal disorder, primarily affecting middle-aged and elderly patients, in which there is a buildup of calcified osseous tissue occurring in the ligaments of the spine. DISH is associated with ossifications occurring specifically in the posterior longitudinal ligaments of the spine, referred to as DISH with OPLL, which is twice as common in men compared to women (1).
DISH with OPLL is often asymptomatic in the early stages of the disease, and thus is often diagnosed either incidentally or after the disease has progressed significantly. Patients with this disease are predisposed to increased risk of spinal fractures, even with relatively minor trauma. Additionally, as DISH with OPLL can result in decreased range of motion, difficult intubation can result, possibly resulting in altered approaches to typical intubation procedures (1).
While the patient likely fractured his spine from the initial fall, it was not determined whether the intubation procedure could have contributed to the spinal fracture subluxation and/or spinal cord injury. Regardless, the patient underwent an occiput to C6 posterior fusion with C1-C6 laminectomies (Figure 2) and will receive long term neurologic rehabilitation.
Stephanie R. Fletcher, BSHS1 and Michael Craig Larson, MD, PhD2
1College of Pharmacy and 2Department of Radiology
University of Arizona
Tucson, AZ USA
- Baxi V, Gaiwal S. Diffuse idiopathic skeletal hyperostosis of cervical spine - An unusual cause of difficult flexible fiber optic intubation. Saudi J Anaesth. 2010 Jan;4(1):17-9. [CrossRef] [PubMed]