Program Director University of Kentucky Lexington, Kentucky, United States
Case Diagnosis: Diffuse idiopathic skeletal hyperostosis (DISH) in the setting of dysphagia
Case Description: A 70-year-old male with history of hypertension presented to acute inpatient rehabilitation following a left frontal lobe ischemic stroke. His stroke sequelae and complications included profound dysphagia. The patient also presented with expressive aphasia and could not provide additional personal medical history. Per family, the patient had neck pain for years, and over the week proceeding his stroke, was showing signs of dysphagia. He was admitted to the rehabilitation hospital on NPO status and received all nutrition via a nasogastric tube. A modified barium swallow was conducted which revealed bony protrusions about the cervical spine. Plain radiographs were obtained which revealed a large bridging osteophyte anterior to C4, C5 and C6 suggesting DISH.
Discussions: To date, there is no known definitive cause for DISH. However, there are several identified possible contributors including exposure to high levels of vitamin A, ingestion of retinoid medications and overproduction of insulin-like growth factor 1. DISH, when combined with a common rehabilitation diagnosis of dysphagia, theoretically amplifies the possibility of adverse events for our patients. As such, rehabilitation physicians should be knowledgeable of the condition, its etiology, treatments available, and indications for surgical referral. Additionally, discussion of prognosis with regard to dysphagia after stroke would be altered if there are concomitant medical issues which might delay progress.
Conclusions: DISH is a condition of bony overgrowth that most often affects the spinal tendons and entheses of the thoracic spine. However, it may be present in the cervical spine, which can lead to dysphagia. Presence of this condition in stroke patients with dysphagia could alter prognosis and traditional treatment recovery timeline.