Yonsei Med J.  2020 Apr;61(4):341-348. 10.3349/ymj.2020.61.4.341.

Surgical Outcomes of Dysphagia Provoked by Diffuse Idiopathic Skeletal Hyperostosis in the Cervical Spine

• Chung YS
• Zhang HY
• Ha Y
• Park JY

• KMID: 2471920
• DOI: http://doi.org/10.3349/ymj.2020.61.4.341

Abstract

PURPOSE
This study aimed to predict the surgical outcomes of diffuse idiopathic skeletal hyperostosis (DISH)-related dysphagia (DISH-phagia) and to evaluate the importance of prevertebral soft tissue thickness (PVST).
MATERIALS AND METHODS
In total, 21 surgeries (anterior osteophytectomy or anterior cervical decompression and fixation) were included in this study for DISH-phagia from 2003 to 2019. Clinical outcomes were assessed using the Dysphagia Outcome and Severity Scale (DOSS) preoperatively, at 1 month postoperatively, and last follow up (mean 29.5 months). PVST was measured using lateral plain radiographs. Paired t-test and Spearman's correlation test was used to identify relationships between various PVST indices and DOSS.
RESULTS
Comparisons were made from 17 patients out of 21, in which the record had all of three measurements. The narrowest PVST preoperatively was 2.55±0.90 mm, with a DOSS score of 4.47±1.61, and that at 1 month after surgery was 5.02±2.33 mm, with a DOSS score of 6.12±1.32. At last follow up, PVST and DOSS values were 3.78±0.92 mm and 5.82±1.34, and three patients experienced symptom relapse. Significant relationships were found between PVST and DOSS at all time points: before surgery (R=0.702, p<0.001), 1 month after surgery (R=0.539, p=0.012), and last follow up (R=0.566, p=0.020).
CONCLUSION
Surgical removal of anterior osteophytes is an effective treatment option for DISH-phagia, and PVST is a useful parameter in DISH-phagia. The goal of DISH surgery should be to remove DISH as much as possible to ensure sufficient PVST postoperatively.

Keyword

Diffuse idiopathic skeletal hyperostosis; dysphagia; osteophyte

MeSH Terms

Decompression
Deglutition Disorders*
Dioctyl Sulfosuccinic Acid
Follow-Up Studies
Humans
Hyperostosis, Diffuse Idiopathic Skeletal*
Osteophyte
Recurrence
Spine*
Dioctyl Sulfosuccinic Acid

Figure

• 

  Fig. 1 Laryngoscopic view of severe diffuse idiopathic skeletal hyperostosis. The asterisk indicates the vertebral osteophyte. The hypopharynx and epiglottis are also seen. BOT, base of the tongue.

• 

  Fig. 2 Radiologic parameters related with diffuse idiopathic skeletal hyperostosis. As PVL alignment is well preserved, distances from the PVL were measured. (A) PVL-O (ossified) is defined as the distance between the PVL and the most anterior portion of the ossified lesion, and each imaginary line is perpendicular to the PVL. (B) PVL-T (trachea) is defined as the distance from the PVL to the posterior border of the trachea, and each imaginary line is perpendicular to the PVL. Both the PVL-O and PVL-T are measured from the C2 lower endplate to C7 upper endplate. (C) By simple geometric logic, prevertebral soft tissue thickness was calculated as (PVL-T minus PVL-O). PVL, posterior vertebral line.

• 

  Fig. 3 Change in PVST before and after the surgery. (A) Before surgery, the narrowest PVST (2.9 mm) was located in the C4 upper endplate, and the preoperative DOSS score was 5. (B) Anterior osteophytectomy was performed, and PVST changed to 5.7 mm at postoperative 1 month. Symptoms had also improved (DOSS=6). (C) Five years after surgery, bony spur regrowth with a narrowing of PVST (2.6 mm) was noted, and dysphagia occurred again (DOSS=5). PVST, prevertebral soft tissue thickness; DOSS, Dysphagia Outcome and Severity Scale.

• 

  Fig. 4 Comparison of PVST with previous studies. Two previous studies suggested mean PVST values at each level for a healthy population (Omercikoglu et al.,15 Rojas et al.16). PVST in our data was relatively lower than that of normal values due to the presence of anterior osteophytes. PVST, prevertebral soft tissue thickness.

• 

  Fig. 5 Measurement of mean PVST and DOSS before and after the surgery (n=17). (A) Mean PVST was 2.55±0.90 mm preoperatively. However, it changed to 5.02 ± 2.33 mm after 1 month and narrowed to 3.78±0.92 mm due to recurrence in some cases. These changes were all statistically significant (p<0.001, p=0.016). (B) Likewise, DOSS scores were 4.47±1.61, 6.12±1.32, and 5.82±1.34, respectively (p=0.001, p=0.096). The graphs represent means and standard errors. *Statistical significance in paired t-test. DOSS, Dysphagia Outcome and Severity Scale; PVST, prevertebral soft tissue thickness.

• 

  Fig. 6 Scatter plot of DOSS and PVST parameters. At each time point, a scatter plot is depicted, and Spearman's correlation test was performed. (A) Preoperatively (n=21), the correlation coefficient (R) value was 0.702 (p<0.001). Postoperatively, R values were 0.539 (p=0.012) after 1 month (n=21) (B) and 0.566 (p=0.020) at last follow up (n=17) (C). DOSS, Dysphagia Outcome and Severity Scale; PVST, prevertebral soft tissue thickness.

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