Diffuse idiopathic skeletal hyperostosis causing dysphagia

Diffuse idiopathic skeletal hyperostosis (DISH) is an osteo-proliferative condition that affects obese men. It leads to calcification of ligaments and entheses of the axial and peripheral skeleton. It is closely associated with the metabolic syndrome. Individuals aged 50 years and above are commonly affected. A 67-year-old male with diabetes mellitus type 2, obesity and DISH presented with dysphagia (more pronounced for solid food) for the past 6 months. He also had pain and stiffness in the back and neck, which worsened with physical activity. Examination revealed markedly restricted neck range of motion in all directions. Upper gastrointestinal endoscopy did not show any abnormality. X-ray cervical spine showed bulky calcification in front of the vertebral bodies, consistent with ossification of the anterior longitudinal ligament (OALL). In addition, linear calcification was seen posterior to the bodies of the cervical vertebrae within the spinal canal, representing ossification of the posterior longitudinal ligament (Fig. 1). Compression of the oesophagus between the trachea anteriorly and OALL posteriorly was the cause of dysphagia in our patient. Surgical decompression by removal of the ossified tissue led to marked improvement. Physiotherapy, and calcium and vitamin D supplementation were given as maintenance treatment.

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FIG 1.

X-ray cervical spine, lateral projection showing bulky calcification in front of the vertebral bodies, the ossification of the anterior longitudinal ligament (white asterisks). Linear calcification is seen behind the vertebral bodies within the spinal canal, the ossification of the posterior longitudinal ligament (white arrows)

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OALL giving rise to ‘flowing’ calcification in front of at least 4 consecutive vertebral bodies, along with normal intervertebral disc heights and sacroiliac joints, constitutes the Resnick and Niwayam criteria for the classification of DISH.¹ Ossified spinal ligaments may be mistaken for bridging syndesmophytes seen in ankylosing spondylitis. Careful differentiation of DISH from spondyloarthritis is necessary for appropriate management.