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Diffuse Idiopathic Skeletal Hyperostosis, Diagnostic imagine, Chiropractic
Objective: To describe the diagnosis and treatment of a patient with low back, left hip and groin pain and numbness of the left anterior thigh.
Clinical Features: A 69-year-old male, complained of very sharp pain radiating from his lower spine to his left hip and vertically from his left hip to the pubic bone. Anterior/lateral thigh numbness was also present. He was symptomatic for 6 months and his pain became severe 1 week prior to his office visit. He stated that he had suffered a traumatic injury to his back when he was 14 years old and that his back had never been the same. He had pain when rising from sitting as well as bending forward and his condition was inhibiting his ability to maintain his organic garden (bending, lifting, carrying, shoveling, etc.) He denied taking any medication for his condition.
Intervention and Outcome: A diagnosis of diffuse idiopathic skeletal hyperostosis (DISH, Forestier’s Disease) was made after examination and diagnostic imaging. Treatment included Coxâ Flexion Distraction spinal manipulation of the lumbar spine to treat his hip, groin and anterior thigh pain. At the onset of treatment, he rated his pain as 10/10 on a 0-10 numeric pain scale rating. After 4 treatments, he had no thigh or hip pain, only low back and groin pain. After 14 treatments, he stated that he was pain-free. Nutritional support with chondroitin sulfate and hyaluronic acid was given. Spine and hip stretching exercises were prescribed. Two return bouts of exacerbation of his left thigh numbness, which he attributed to too much gardening work, resulted in continued manipulation treatment.
Conclusion: Treatment of DISH of the thoraco-lumbar and lumbar spine with distraction spinal manipulation resulted in relief of low back, hip and groin pain and reduction of left anterior thigh pain.
2. Yunoki M, Suzuki K, Uneda A, Okubo S, Hirashita K, Yoshino. The importance of recognizing diffuse idiopathic skeletal hyperostosis for neurosurgeons: a review, Neurol Med Chiropr 2016;56(8):510-515
3. Sarzi-Puttini P, Atzeni F. New developments in our understanding of DISH (diffuse idiopathic skeletal hyperostosis). Curr Opin Rheumatol 2004;16(3):287-292
4. Pavelkova A, Pavelka K. Diffuse idiopathic skeletal hyperostosis and its relation to metabolic parameters. Vnitr Lek 2006;52(5):477-480
5. Mader R, Sarzi-Puttini P, Atzemi F, et al. Extraspinal manifestations of diffuse idiopathic skeletal hyperostosis. Rheumatol 2009;48(12):1478-1481
6. Hamano H, Takahata M, Ota M et al. Teriparatide improves trabecular osteoporosis but simultaneously promotes ankylosis of the spine in the Twy mouse model for diffuse idiopathic skeletal hyperostosis. Calcif Tissue Int 2016;98(2):140-148
7. Westerveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J 2014;1:14(5):729-740
8. Hendrix RW, Melany M, Miller F, Rogers LF. Fracture of the spine in patients with ankylosis due to diffuse skeletal hyperostosis: clinical and imaging findings. Am J Roentgenol 1994;162(4):899-904
9. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J 2009;18(2):145-156
10. Huang YC, Urban JP, Luk KD. Intervertebral disc regeneration: do nutrients lead the way? Nat Rev Rheumatol 2014. doi: 10.1038/nrrheum.2014.91
11. van Blitterswijk W, van de Nes J, Wuisman P. Glucosamine and chondroitin sulfate supplementation to treat symptomatic disc degeneration: biochemical rationale and case report. BMC Compl Altern Med 2003;3:2.
12. Mavrogonatou E, Kletsas D. The effect of glucosamine sulfate on the proliferative potential and glycosaminoglycan synthesis of nucleus pulposus intervertebral disc cells. Spine J 2013;38(4):308–314
13. Sivan SS, Roberts S, Urban JP, Menage J. Injectable hydrogels with high fixed charge density and swelling pressure for nucleus pulposus repair: biomimetic glycosaminoglycan analogues. Acta Biomater 2013. pii: S1742-7061(13)00566-7. doi: 10.1016/j.actbio.2013.11.010
14. Schleich C, Muller-Lutz An, Eichner M, Schmitt B, Matuschke F, Bittersohl B, Zilkens c, Wittsack HJ, Antoch G, Miese F. Glycosaminoglycan chemical exchange saturation transfer of lumbar intervertebral discs in healthy volunteers. Spine J 2016;41(2):146-152
15. Deng M, Yuan J, Chen W, Chan Q, Griffith J, Wang Y. Evaluation of glycosaminoglycan in the lumbar disc using chemical exchange saturation transfer MR at 3.0 tesla: reproducibility and correlation with disc degeneration. Biomed Environ Sci 2016;29(1):47-55. DOI: 10.3967/BES2016.005.
16. Arogenate E, Kletsas D. The effect of glucosamine sulfate on the proliferative potential and glycosaminoglycan synthesis of nucleus pulposus intervertebral disc Cells. Spine J 2013;38(4):308–314
17. Alekseeva L, Benevolenskaia L, Nasonov E, Chichasova N, Kariakin A. [Structum (chondroitin sulfate)--a new agent for the treatment of osteoarthrosis]. Ter Arkh 1999;71(5):51-53
18. Nemoto W, Yamada K, Ogata Y, Nakagawasai O, Onodera K, Sakurai H, Tan-No K. Chondroitin sulfate attenuates formalin-induced persistent tactile allodynia. J Pharmacol Sci 2016. PII: S1347-8613(16)30091-3. DOI: 10.1016/J.JPHS.2016.07.009
19. Stephan S, Johnson We, Roberts S. The influence of nutrient supply and cell density on the growth and survival of intervertebral disc cells in 3d culture. Europ Cells Materials 2011;22:97-108
20. Gu W, Zhu Q, Gao X, Brown M. Simulation of the progression of intervertebral disc degeneration due to decreased nutrition supply. Spine J 2014;39(24):E1411–E1417
21. Purmessur D, Cornejo M, Cho S, Roughley P, Linhardt R, Hecht A, Iatridis J. Intact glycosaminoglycans from intervertebral disc-derived notochordal cell conditioned media inhibits neurite growth while maintaining neuronal cell viability. Spine J 2015:S1529-9430(15)00101-1. DOI: 10.1016/J.SPINEE.2015.02.003
22. Mercy Center Consensus Conference: Guidelines for Chiropractic Quality Assurance and Practice Parameters. Aspen; Bethesda, MD 1993:108, 208
23. Cox J, Feller J, Cox-Cid J. Distraction chiropractic adjusting: clinical application and outcomes of 1000 cases. Topics Clin Chiropr 1996;3(3):45-59, 79-81
24. Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: Characterizing the literature. J Manipulative Physiol Ther 2001;24(6):407-411
25. Gudavalli MR, Cox JM. Real-time force feedback during flexion-distraction procedure for low back pain: A pilot study. J Can Chiropr Assoc 2014;58(2):193-197
26. Gudavalli MR, Vinning RD, Salisbury SJ, et al. Clinician proficiency in delivering manual treatment for neck pain within specified force ranges. Spine J 2015;15(4):570– 576
27. Cox JM, Hazen LJ, Mungovan M. Distraction manipulation reduction of an L5-S1 disc herniation. J Manipulative Physiol Ther 1993;16(5):342-346
28. Cox JM. Lumbosacral disc protrusion: a case report. J Manipulative Physiol Ther 1985;8(4):261-266
29. Cox JM, Feller J. Chiropractic treatment of low back pain: a multi-center descriptive analysis of presentation and outcome in 424 consecutive cases. J Neuromusculoskeletal Syst 1994:2(4):178-190
30. Cox JM, Hazen LJ, Mungovan M. Distraction manipulation reduction of an L5-S1 disc herniation. J Manipulative Physiol Ther 1993;16(5):342-346
31. Neault CC. Conservative management of an L4-L5 left nuclear disc prolapse with a sequestrated segment. J Manipulative Physiol Ther 1992;15(5):318-321
32. Snow G. Chiropractic management of a patient with lumbar spinal stenosis. J Manipulative Physiol Ther 2001; 4(4):300-304
33. Beira B, Peers A. A study of the effects of chiropractic therapy on the diameter of the spinal canal in patients with low back pain and radiculopathy. J Neuromusculoskeletal Sys 1998;6(3):114-126
34. Choi J, Lee S, Jeon C. Effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis. J Phys Ther Sci 2015;27(6):1937-9. doi: 10.1589/jpts.27.1937
35. DuPriest CM: Nonoperative management of lumbar spinal stenosis. J Manipulative Physiol Ther 1993;16(6):411-414
36. Stuber K, Sajko S, Kristmanson K. Chiropractic treatment of lumbar spinal stenosis: a review of the literature. J Chiropr Med 2009;8(2):77-85. doi: 10.1016/j.jcm.2009.02.001.
37. Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar spinal stenosis: A prospective observational cohort study. BMC Musculoskeletal Disorders 2006; 7:NIL_1-NIL_8
38. Cox JM, Shreiner S. Chiropractic manipulation in low back pain and sciatica: statistical data on the diagnosis, treatment, and response of 576 consecutive cases. J Manipulative Physiol Ther 1984;7(1):1-11
39. Cox JM, Trier K. Chiropractic adjustment results correlated with spondylolisthesis instability. J Man Med 1991;6:67-72.
40. Cox JM, Trier K. Chiropractic adjustment results correlated with spondylolisthesis instability. J Manipulative Physiol Ther 1991;6:67-72
41. Dunn AS, Baylis S, Ryan D. Chiropractic management of mechanical low back pain secondary to multiple-level lumbar spondylolysis with spondylolisthesis in a United States Marine Corps veteran: a case report. J Chiropr Med 2009;8(3):125-30.
42. Cox JM, Cox II, JM. Chiropractic treatment of lumbar spine synovial cysts: a report of two cases. J Manipulative Physiol Ther 2005; 28(2):143-147
43. Taylor DN. Spinal synovial cysts and intersegmental instability: a chiropractic case. J Manipulative Physiol Ther 2007;30(2):152-157
44. Hazen LJ, Cox, JM. Lumbar intraspinal extradural synovial cyst: a case study. J Neuromusculoskeletal System 1993;1(4):167-169
45. Cox JM. Chiropractic management of a patient with lumbar spine pain due to a synovial cyst: a case report. Chiropr Med 2012; 11(1):7-15
46. Bergmann TF, Jongeward BV. Manipulative therapy in lower back pain with leg pain and neurological deficit. J Manipulative Physiol Ther 1998; 21(4):288-294
47. Lillie GR. Resolution of low back and radicular pain in a 40-year-old male United States Navy Petty Officer after collaborative medical and chiropractic care. J Chiropr Med 2010 9(1):17-21. doi: 10.1016/j.jcm.2009.12.006.
48. Bergmann TF, Jongeward BV. Manipulative therapy in lower back pain with leg pain and neurological deficit. J Manipulative Physiol Ther 1998;21(4):288-294
49. Kruse R, Gudavalli S, Cambron J: Chiropractic treatment of a pregnant patient with lumbar radiculopathy. J Chiropr Med 2007; 6(4):153-158
50. Rowell RM, Rylander SJ. Low-Back Pain, Leg Pain, and Chronic Idiopathic Testicular Pain Treated with Chiropractic Care. J Altern Complement Med 2012. [Epub ahead of print] 18(4):420-422.
51. Coulis CM, Lisi AJ. Chiropractic management of postoperative spine pain: a report of 3 cases. J Chiropr Med. 2013;12(3):168-75. doi: 10.1016/j.jcm.2013.10.006.
52. Greenwood D: Improvement in chronic low back pain in an aviation crash survivor with adjacent segment disease following flexion distraction therapy: a case study. J Chiropr Med 2012;11(4):300-305
53. Gudavalli MR, Olding K, Joachim G, Cox JM chiropractic distraction spinal manipulation on postsurgical continued low back and radicular pain patients: a retrospective case series. J Chiropr Med 2016;15(2):121-128
54. Kruse R, Cambron J. chiropractic management of postsurgical lumbar spine pain: a retrospective study of 32 cases. J Manipulative Physiol Ther 2011;34(6):408-412
55. Gudavalli R, Cambron JA, McGregor M et al. A randomized clinical trial and subgroup analysis to compare flexion–distraction with active exercise for chronic low back pain. Europ Spine J 2006;15:1070-1082
56. Cambron GA, Gudavalli MR, McGregor M et al. Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain. Chiropr Osteop 2006;14:19
57. Cambron GA, Gudavalli MR, Hedecker D et al. One-Year Follow-Up of a Randomized Clinical Trial Comparing Flexion Distraction with an Exercise Program for Chronic Low-Back Pain. J Altern Compl Med 2006;12(7):659-668
58. BenEliyahu DJ. Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. J Manipulative Physiol Ther 1996;19(9):597-606
59. Bulbulian R, Burke J, Dishman JD. Spinal reflex excitability changes after lumbar spine passive flexion mobilization. J Manipulative Physiol Ther 2002;25:526-532
60. Hope, M. The effect of flexion distraction therapy on the lumbar spine on the electromyographic effect of the erector spinae muscles in lumbar facet dysfunction patients. University of Johannesburg Chiropractic Clinic. Published 6-30-11 (https://ujdigispace.uj.ac.za/bitstream/handle/10210/3765/Hope.pdf?sequence=1)
61. Maciocia, Giovanni. The practice of Chinese medicine: the treatment of diseases with acupuncture and Chinese herbs. Churchill Livingstone, New York,NY;1994: 564
62. Kruse R. Chiropractic management of cervicalgia in a patient with diffuse idiopathic skeletal hyperostosis utilizing Cox manual cervical distraction: a case report. J Acad Chiropr Orthop 2017; 14. http://dcorthoacademy.org/journal-issues/chiropractic-management-of-cervicalgia-in-a-patient-with-diffuse-idiopathic-skeletal-hyperostosis-utilizing-cox-manual-cervical-distraction-a-case-report/