Description

Anterior cervical osteophytes are commonly associated with degenerative spine in elderly people. The complications that arise due to the mechanical compression of cervical osteophytes are dysphagia, dysphonia and dyspnoea. The usual causes are osteoarthritis, ankylosing spondylitis and diffuse idiopathic spinal hyperostosis (DISH). Other causes are trauma, acromegaly, ochronosis, fluorosis and hypoparathyroidism.1 Surgical resection of osteophytes results in excellent relief of symptoms, but patients have a tendency for recurrence of osteophytes.2 We present here a case of dysphagia and dysphonia due to osteophyte recurrence in a postsurgical case of DISH.

A 63-year-old man was admitted with progressive dysphagia, hoarseness of voice and neck pain for 3 months. His history began with neck and right arm pain 2 years back for which he consulted a spine surgeon, where he was diagnosed with C5–C6 herniated cervical disc causing root compression because of underlying DISH. His chief complaints were severe neck pain with radiation to lateral aspect of his right arm. Patient gave no history of hand clumsiness or gait imbalance. On neurological examination, patient was having no motor or sensory deficit with normal deep tendon reflexes. His plantar reflex was flexor. Radiographs, CT and MRI of the cervical spine were subsequently conducted. MRI reported a final impression of cervical spondylosis, disco-osteophytic bulge with paracentral disc protrusion at C5–C6 level causing significant compression of the cord with myelomalacia and focal canal stenosis at this level. An overall picture of DISH was also appreciated. Following this, he underwent C5–C6 anterior cervical discectomy and fusion. Anterior osteophytes at C3–C4 level were also noted in imaging but their size was small and considered insignificant to the patient’s symptoms with which the patient had presented to us. Thus, anterior osteophytes at C3–C4 level were not excised. Postoperatively, he was asymptomatic over the next 2 years. To evaluate for his recently developed symptoms, radiographs of the cervical spine were done (figure 1). Large-sized anterior cervical osteophytes were well appreciated in a characteristic ‘flowing candle-wax’ appearance. Radiographs, however, did not reveal any cage displacement or hardware dislodgement that could explain the possible symptoms. CT chest and neck revealed prominent anterior osteophytes compressing on adjacent wall of oesophagus, narrowing the lumen (figure 2). Patient was subsequently scheduled for surgery and anterior osteophytes were excised uising the anterior cervical approach. After surgery, patient had immediate relief of his symptoms. Patient is now on our regular follow-up with no signs and symptoms of dysphagia or dysphonia. Surgical resection of osteophytes in patients with DISH results in excellent symptom relief but simultaneously there is a high likelihood of the recurrence of osteophytes. Therefore, subtle signs such as dysphagia and dysphonia should be recognised early and maintaining a regular follow-up is crucial in patients of DISH.

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Figure 1

Radiograph of the neck (lateral view) showing large anterior cervical osteophytes at the level of C3, C4, C5, C6. Also, an anterior cervical metallic plate with screw fixation can be appreciated in situ at the level of the C5–C6 vertebral body.

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Figure 2

CT scan of neck and chest (axial view) suggesting large anterior bridging osteophytes at the level of C4–C5 vertebra causing indentation on the posterior pharyngeal wall in the region of upper oesophagus.