Spinal Hematoma Following Trauma in Patients with Diffuse Idiopathic Skeletal Hyperostosis

Overview

This study investigates the incidence of spinal hematoma in patients with DISH who sustain spinal fractures, highlighting the risk of spinal cord impingement and injury even after low-energy trauma. MRI and CT imaging were used to identify hematomas and assess neurological outcomes in a cohort of 70 patients with DISH-related spinal fractures.

Background

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by new bone formation leading to ankylosis predominantly in the thoracic and cervical spine. This ankylosis predisposes patients to unstable spinal fractures and spinal epidural hematomas (SEH), often after low-energy trauma such as ground-level falls. SEH is rare in the general population but can cause spinal cord injury if not diagnosed and treated promptly. MRI is the preferred imaging modality for detecting spinal hematomas, although diagnosis requires experienced radiologists.

Data Highlights

A retrospective review of 2256 MRI referrals identified 125 patients with spinal fractures and ankylosis, of which 70 met criteria for DISH. Imaging included 64-slice CT scans and 1.5-T MRI scans. Neurological function was assessed using Frankel grades at multiple time points. The study focused on the presence of spinal hematoma, spinal cord impingement, and spinal cord injury in this population.

Key Findings

• Spinal hematomas, including epidural and subdural types, were identified in patients with DISH following trauma, even from low-energy mechanisms.
• MRI was essential for detecting spinal hematomas and assessing spinal cord impingement and injury.
• Patients with DISH-related ankylosis are at increased risk for unstable spinal fractures and subsequent spinal cord injury.
• Neurological deficits were documented and monitored using Frankel grading, showing changes from acute to final evaluation.
• CT imaging revealed characteristic aorta-evading syndesmophytes over at least four adjacent vertebrae, aiding in the diagnosis of DISH.

Clinical Implications

Clinicians should maintain a high index of suspicion for spinal hematoma and spinal cord injury in patients with DISH who sustain spinal trauma, even from low-energy events. Prompt MRI evaluation is critical for diagnosis and guiding timely treatment to prevent permanent neurological impairment. Awareness of DISH-specific radiologic features can aid in accurate diagnosis and risk stratification.

Conclusion

Spinal hematoma is a significant complication in patients with DISH following spinal trauma, necessitating careful imaging and neurological assessment. Early recognition and intervention are vital to mitigate the risk of permanent spinal cord injury in this vulnerable population.

References

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2. Mader et al. 2013 -- Clinical associations of DISH
3. Westerveld et al. 2013 -- Spinal fractures in ankylosing spinal disorders
4. Figueroa et al. 2017 -- Spinal epidural hematoma in ankylosed spines
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9. Liao et al. 2010 -- Spinal subdural hematoma characteristics
10. Resnick and Niwayama 1976 -- Radiologic criteria for DISH
11. Kuperus et al. 2019 -- Early-stage DISH imaging features
12. Mader et al. 2017 -- CT imaging in DISH diagnosis
13. Mader et al. 2018 -- Syndesmophyte orientation in DISH
14. Westerveld et al. 2015 -- Spinal fractures and hematomas in ankylosed spines
15. AO Spine Knowledge Forum Trauma 2013 -- Fracture classification
16. Denis 1983 -- Three-column concept of spinal stability
17. Pape et al. 2007 -- Polytrauma definition
18. Frankel et al. 1969 -- Neurological assessment grading