A 65 years old caucasian male complaining about neck stiffness and bilateral upper limb pain.
This gentleman underwent cervical spine x-rays because of longstanding stiffness and limited range of motion of the neck associated to bilateral upper limb pain. The lateral radiograph showed a continuous ossification extending from the anterior surface of C2 to C7 (Figure 1a, thin arrows). A similar ossification was also noticed on the posterior surface of the vertebral bodies from C2 to C6 abutting the spinal canal (Figure 1b, thick arrows). Intervertebral discs heights were normal. Radiologic findings were consistent with diffuse idiopathic skeletal hyperostosis (DISH) and concomitant ossification of the posterior longitudinal ligament (OPLL) causing cervical radiculopathy.
DISH is a degenerative disease of unknown origin which causes ossification of tendons, ligaments and fasciae of the axial and appendicular skeleton. Spine involvement is characterized by ossification of the anterior longitudinal ligament resulting in extensive osseous vertebral bridging. 1 DISH mainly causes pain and stiffness of the affected spine segments; cervical tract involvement may also lead to dysphagia and dyspnea because of mechanical impingement with pharyngoesophageal and tracheal structures. 2,3
OPLL is considered a distinct spinal disease entity; as an isolated form has a higher incidence in Asians, while is more commonly seen in association with DISH in Caucasians. OPLL involves the posterior aspect of vertebral bodies and discs causing variable degrees of spinal canal stenosis. Though the majority of patients are asymptomatic, some may develop neurological symptoms because of spinal cord and nerve roots compression. 4
Both DISH and OPLL are readily demonstrated on lateral radiographs. Videofluoroscopy, CT and MRI could be used for a more accurate evaluation of swallowing function, spinal canal width and nervous structures compression. 1,3,4 These diseases may be managed conservatively in patients with milder symptoms while surgery is reserved for patients with relevant dysphagia or neurologic compression syndromes.
DISH and OPLL of the cervical spine.
Based on the patient's lateral cervical X-ray images (as shown in example Figures a and b), the following features can be observed:
1. A continuous bony bridge is visible along the anterior aspect of the cervical spine (anterior longitudinal ligament), accompanied by marked osteophytes at the anterior edges of the vertebral bodies, suggesting ossification or calcification of the anterior longitudinal ligament.
2. In certain vertebral bodies posteriorly (in the region of the posterior longitudinal ligament), localized dense shadows are visible, indicating possible varying degrees of posterior longitudinal ligament ossification.
3. The intervertebral disc spaces appear generally preserved, with no significant collapse noted.
4. The vertebral body heights are largely maintained, with no evident signs of fracture or vertebral collapse.
5. The physiological curvature of the cervical spine may exhibit some alteration (commonly due to degenerative changes).
Overall, these imaging findings are consistent with degenerative osteophyte formation, ligament ossification, and related pathologies. The bony structures may exert an impact on surrounding soft tissues, possibly causing limited neck mobility or nerve compression.
Based on the radiological findings, the patient’s demographics (65-year-old male), and chief complaints (neck stiffness and bilateral upper limb pain), the following diagnoses or differential diagnoses should be considered:
1. Diffuse Idiopathic Skeletal Hyperostosis (DISH)
- Key features: Ossification of the anterior longitudinal ligament and extensive osteophyte formation at the anterior edges of the vertebral bodies, commonly observed in middle-aged and elderly individuals.
- Radiological presentation: X-ray may reveal a continuous bony bridge on the anterior aspect of the spine, often without significant narrowing of the intervertebral disc spaces.
- Clinical presentation: Patients may experience restriction of neck movement and stiffness; in severe cases, swallowing or breathing may be affected.
2. Ossification of the Posterior Longitudinal Ligament (OPLL)
- Key features: Ossification within the region of the posterior longitudinal ligament, which may sometimes coexist with DISH.
- Radiological presentation: Often presents as band-like or patchy areas of high density along the posterior edge of the vertebral bodies, potentially causing spinal canal narrowing.
- Clinical manifestations: Many patients remain asymptomatic in early stages, but significant ossification can lead to spinal cord or nerve root compression, resulting in symptoms such as limb numbness or weakness.
3. Other Cervical Degenerative Diseases
- Cervical osteoarthritis or facet joint degeneration can also lead to uncovertebral joint hypertrophy or vertebral margin osteophytes, but they rarely present with such pronounced, continuous ligament ossification.
- Most commonly manifest as localized joint overgrowth or disc degeneration. Comparing with the imaging in this case, DISH/OPLL should still be ruled out.
Considering the patient’s age (65 years), clinical symptoms (neck stiffness and bilateral upper limb pain), and imaging findings (extensive ossification of the anterior longitudinal ligament along with focal areas of posterior longitudinal ligament ossification), the most likely diagnosis is:
Diffuse Idiopathic Skeletal Hyperostosis (DISH) with partial Ossification of the Posterior Longitudinal Ligament (OPLL).
This conclusion is based on the typical degenerative changes, as well as the location and extent of ligament ossification. If the patient exhibits significant neurological compression symptoms or has difficulty swallowing, further CT or MRI would be necessary to determine the degree of spinal canal involvement and the affected neural structures.
1. Conservative Treatment:
- Pharmacotherapy: Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to alleviate pain and inflammation. For marked muscle spasms, short-term muscle relaxants may be considered.
- Physical Therapy: This includes modalities such as heat therapy, ultrasound, and local massage to reduce muscle tension and promote local circulation.
- Exercise/Posture Training: Adopting proper cervical posture and mindful daily activities is recommended, avoiding prolonged forward head posture or a single position for extended periods.
2. Surgical Intervention:
- If severe dysphagia, respiratory compromise, or intensified neurological symptoms occur (e.g., declining muscle strength, upper limb sensory changes), surgical decompression and removal of ossified segments may be considered.
- Postoperative rehabilitation is essential to maintain and improve cervical range of motion and to prevent recurrent adhesions or ossification.
3. Rehabilitation Exercise Prescription:
In accordance with the FITT-VP principle (Frequency, Intensity, Time, Type, Progression, Volume):
- Frequency: Perform exercises daily or on alternate days; aim for at least 3-4 sessions per week focusing on the cervical spine.
- Intensity: Low to moderate intensity, ensuring no severe pain or dizziness is induced.
- Time: Each session can last 10-15 minutes, possibly divided into shorter intervals (e.g., morning, noon, and evening). Excessively long sessions may lead to fatigue.
- Type: Stretching and isometric exercises for the neck, primarily targeting reduced muscle tension and maintaining cervical mobility. Shoulder and neck exercises may also be included, such as scapular retraction, gentle neck rotations, and postural correction exercises (e.g., standing against a wall with chin up and chest out).
- Progression: Gradually increase range of motion and repetitions as pain and stiffness improve. Proceed step by step and avoid sudden increases.
- Precautions: Patients with osteoporosis or compromised cardiopulmonary function should exercise under professional supervision. Avoid excessive flexion/extension or high-speed rotations. If dizziness, nausea, or severe pain occurs during training, stop immediately and seek medical attention.
This report offers a reference analysis based on the patient's history and imaging data, and it does not replace in-person consultation or professional medical advice. A specialist should determine the specific treatment plan by integrating clinical presentation, laboratory results, and other auxiliary examinations.
DISH and OPLL of the cervical spine.
