Cervical Fractures in Older Adults with DISHDiffuse Idiopathic Skeletal Hyperostosis (DISH) is a condition in the spine caused by ligaments that turn into bone. Spinal ligaments along the front and back of the spine that help stabilize the spine are affected.
The ligament along the front of the spine is called the anterior longitudinal ligament. The ligament that attaches to the back of the spine is called the posterior longitudinal ligament. These are the spinal ligaments that can turn into bone in Diffuse Idiopathic Skeletal Hyperostosis (DISH).
As a result of this condition the spine becomes stiff, rigid, and more fragile in the older adult. A fall (even from ground level) can cause spinal fractures affected by this condition. In this study, surgeons from three separate medical centers reviewed their charts for patients who had a diagnosis of DISH, then fell, fractured their cervical spine (neck), and were treated surgically to fuse the spine.
Patient characteristics and results of treatment were key areas of interest. The goal was to understand this problem better and eventually develop guidelines for treatment. As it turned out, there were many surgical and medical complications associated with cervical fractures in patients with DISH. As these surgeons suspected from their experience, this group of patients were at high risk for further problems during surgical management.
All the patients in the study had a spinal fusion because the fractured spine was unstable. Ages ranged from 53 up to 98 years old. Concern for serious neurologic damage (including paralysis from spinal cord injury) was the main reason for fusion as the recommended choice of treatment. Several studies reporting on conservative (nonoperative) care for serious injuries in patients like these have shown poor results.
About half of the 33 patients in this study were fused from the front of the spine, called an anterior fusion. Another one-third had a posterior fusion (from the back). And the rest had both anterior and posterior fusions done. In all cases, more than one level was fused (some patients had as many as eight spinal levels fused).
The type of problems encountered during treatment included pneumonia, pulmonary edema (fluid in the lungs), respiratory failure, urinary tract infections, seizures, blood clots, and even death. The nine patients who died had a spinal cord injury from the cervical fracture before surgery was done. The medical complications and the deaths of all 33 patients were linked with the post-injury/pre-operative neurologic damage.
This study points out very clearly how fragile patients are who have DISH and then sustain cervical spine fractures. Despite surgery, serious disability and often death are the outcomes. Should surgery even be done for these individuals? That is a tough question to answer. Other experts who have studied this problem say these patients are at high risk for poor results but the outcomes are still better than without surgery.
The authors conclude that surgeons counseling patients and their family members must be aware of the high risk for serious complications. A second surgery may be needed. Death is always a possibility with any surgery but especially in this situation. More study is needed to improve the prognosis for this group. Future studies may also help surgeons develop a treatment protocol for managing these kinds of complex cases.
Richard J. Bransford, MD, et al. Cervical Spine Trauma in Diffuse Idiopathic Skeletal Hyperostosis. In Spine. November 1, 2012. Vol. 37. No. 23. Pp. 1923-1932.
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