Case 19 – Back Swing
A 69 year old male patient develops right sided thoracic back pain 4 weeks ago while golfing. The pain is constant, worse with movement, twisting and taking deep breaths in. No radicular symptoms and no neurological symptoms
On exam, decreased range of spinal motion. In particular, loss of thoracic lateral flexion. Patient had pain on right side at level of Rib 7 tender posterior and with manipulation of ribs. Normal sensation and no rash.
Figure 1: Anteriorposterior view of the thoracic spine (a) and the anterior posterior view of the lumbar spine (b) showing flowing osteophytes.
Figure 2: Lateral view of the cervical spine showing ossification of the anterior longitudinal ligament at C4-5.
Figure 3: Lateral view of the thoracic spine showing anterior osteophytes and ossification of the anterior longitudinal ligament.
Figure 4: Lateral view of the lumbar spine showing flowing anterior osteophytes indicative of diffuse idiopathic skeletal hyperostosis.
Diffuse idiopathic skeletal hyperostosis (DISH) is a relatively common condition affecting about 10% of people over age 50. Its characterized by the ossification of ligaments and entheses especially in the axial skeleton but also the peripheral joints. The thoracic spine is usually affected in this disease though other spinal segments and peripheral joints may also be involved.
DISH patients may experience pain and stiffness in neck, mid and low back and sometimes extremities. Thoracic spinal pain is a much more common complaint than pain in the shoulder, elbow and knee. They also experience reduced spinal motion, especially in the thoracic spine, which is present in most advanced cases. In advanced cases, due to spinal stiffness and lack of range of motion, the vertebral column becomes vulnerable to fracture even with relatively low-energy trauma. In addition, bony proliferation in the anterior part of the cervical spine can lead to dysphagia and mechanical airway obstruction.
On exam, reduced range of spinal motion, particularly thoracic movement, is the most common finding. Palpable nodules may also be felt at the entheses of the elbow, knee and Achilles region.
The main hallmarks of DISH are radiographic abnormalities. Flowing calcification of the anterolateral aspect of the vertebral body in the form of osteophytes is a prominent characteristic of DISH. Bony spurs can be observed in the thoracic, lumbar and cervical spine. Commonly accepted diagnostic criteria by Resnick and Niwayama require flowing osteophytes over four vertebral bodies, preservation of intervertebral disc space without apparent degenerative disc disease, and the absence of apophyseal or sacroiliac joint erosions, sclerosis or ankylosis. Bony proliferation and osteophytes indicative of DISH can also be observed at the iliac crest, ischial tuberosity and trochanter of the hip and pelvis, the ligamentous insertions at the patella, and the doral talus, dorsal and medial tarsal navicular, and lateral and plantar aspects of the cuboid bone of the foot.
DISH shares some features with ankylosing spondylitis, such as their associated with ligamentous ossification and syndesmophytes. However, in ankylosing spondylitis, the bony bridges are slender and involve the outer margin of the annulus fibrosis rather than the anterior longitudinal ligament. Additionally, erosions and bony ankylosis of the sacroiliac and apophyseal joints are not observed in DISH.
Diagnosis: Right Subluxed rib # 7 (costovertebral pain) secondary to loss of range of motion secondary to DISH.
Treatment: Physiotherapy/Chiropractic manipulation for subluxed rib/costoverterbral pain. Various physiotherapeutic modalities for spinal stiffness such as range of motion exercises, heat, ultrasound and gentle exercise. NSAIDS for pain.
Lucas Nguyen (Aug 29, 2018 PR ND)