Resident Florida Atlantic University Rockledge, Florida, United States
Case Diagnosis: Diffuse Idiopathic Skeletal Hyperostosis Lateral Medullary Syndrome
Case Description: 86 yo male with PMH of T2DM, HLD, and HTN presented to the ED with complaints of dizziness, dysphagia, dysarthria, and facial numbness. His speech was slurred and stated that he had trouble walking. The symptoms did not resolve and worsened over the next 15 minutes, before his wife called EMS. When he arrived to the ED, CT w/o contrast revealed an acute ischemic infarct of the right lateral medulla. As the patient's clinical symptoms improved with rehabilitation, his dysphagia continued to worsen. A CT of the cervical spine was taken and showed bulky flowing osteophytes from C2-7, protruding into the soft tissue, consistent with DISH.
Discussions: DISH is a systemic condition defined by ossifications that may manifest in both the spinal column and the peripheral entheses. Studies have shown a notable link between DISH and metabolic disorders, including diabetes mellitus, obesity, dyslipidemia, and hyperuricemia. The pathogenesis and mechanisms behind the characteristic ossification patterns remain subjects of debate, with some authors exploring potential factors like mechanical stress, toxic exposures, and genetic influences (Mader et. al). DISH primarily manifests on the right side of the thoracic spine, due to the presence of the descending aorta on the left. DISH can lead to symptoms such as nerve compression, bone overgrowth, limited spinal mobility, dysphagia, polyarticular pain, and an increased risk of unstable spine fractures. The incidence of DISH increases with age, more prevalent in patient's over 80 years old.
Conclusions: Patients with DISH are often asymptomatic, leading to incidental findings on cervical, thoracic, or lumbar spine imaging such as MRI and CT scan. Differential diagnosis of DISH include ankylosing spondylitis, charcot spine, reactive arthritis, pseudogout, and seronegative spondyloarthropathies. Treatment includes activity modification, physical therapy, NSAIDS and surgical decompression and stabilization if the spinal cord is affected.
