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NEUROIMAGES
Year : 2016  |  Volume : 64  |  Issue : 3  |  Page : 571-572

Exuberant heterotopic ossification following anterior cervical fusion


Department of Neurosurgery, Rush University Medical Center, Chicago, IL 60612, USA

Date of Web Publication3-May-2016

Correspondence Address:
Dr. Manish K Kasliwal
Department of Neurosurgery, Rush University Medical Center, Suite 855, Chicago, IL 60612
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.181546

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How to cite this article:
Kasliwal MK, Tan LA, Wewel JT, Traynelis VC. Exuberant heterotopic ossification following anterior cervical fusion. Neurol India 2016;64:571-2

How to cite this URL:
Kasliwal MK, Tan LA, Wewel JT, Traynelis VC. Exuberant heterotopic ossification following anterior cervical fusion. Neurol India [serial online] 2016 [cited 2022 Aug 19];64:571-2. Available from: https://www.neurologyindia.com/text.asp?2016/64/3/571/181546


A 72-year-old male patient with significant past medical history of anterior cervical corpectomy and fusion about 15 years ago presented with difficulty in swallowing with complaints of food impaction and palpation of a hard mass in front of the neck on the left side. There was absence of any new onset motor or sensory deficits. The computed tomography scan of the cervical spine performed as a part of work-up showed evidence of prior corpectomy with the anterior fusion instrumentation extending from the C3 to the T2 levels. However, there was presence of exuberant heterotopic ossification (HO) bridging the cornu of the hyoid bone and the thyroid lamina to the cervical spine on the left side leading to an impression on the lateral wall of the hypopharynx [Figure 1]. Furthermore, prominent posterior osteophytes and calcification of the ligamentum flavum at multiple levels with severe spinal stenosis were present. Endoscopy performed as a work-up for dysphagia showed exposure of the instrumentation from protrusion of one of the screws with a small esophageal perforation. The patient was referred for repair of his esophageal perforation and was recommended to follow-up with us for his cervical canal stenosis and HO for elective surgery.
Figure 1: Sagittal (left) and axial (right) computed tomography of the cervical spine showing evidence of prior corpectomy with anterior fusion instrumentation extending from the C3 to the T2 levels along with extensive heterotopic ossification (white arrow) bridging the cornu of the hyoid bone and the thyroid lamina to the cervical spine on the left side with an impression on the lateral wall of the hypopharynx

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HO is defined as the formation of bone outside the skeletal system.[1] In the cervical spine, following fusion or artificial disc placement, it may consist of ectopic bone formation anywhere around the implant.[2] If it involves the adjacent disc after anterior cervical fusion or the index level after total disc replacement (TDR), it can lead to loss/reduced motion at the respective intervertebral disc.[1],[2] It is very commonly assessed after placement of TDR as the pathology has the potential to affect the motion of the artificial disc due to HO across the disc space. The incidence of HO after cervical TDR varies greatly in the literature, from as high as two-thirds of patients to none. Tu et al., reported about 50% incidence of HO with more than 96% of these levels remaining mobile with no adverse effect on the clinical outcome.[1] Multiple-level surgery, male sex, old age, trauma to the longus colli muscle, hypertrophic osteoarthritis, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), and extensive bone removal have been implicated in the development of HO.[1] Use of abundant intraoperative irrigation and limited muscle retraction has been advocated to potentially decrease or prevent the development of postoperative HO.[1] While patients with DISH can have dysphagia due to giant osteophytes on the ventral aspect of the spine,[3] an occurrence of HO of such a magnitude resulting in dysphagia has never been described in the literature. Ample irrigation and placement of anterior cervical plate at least 5 mm away from the adjacent disc space may help to avoid HO, especially in patients with DISH who may be more prone to such a complication as compared to patients without DISH.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Traynelis is a consultant for and a patent holder with Medtronic and receives institutional fellowship support from Globus and AO Spine. However, there are no direct conflicts of interest with regard to this manuscript.

 
  References Top

1.
Tu TH, Wu JC, Huang WC, Guo WY, Wu CL, Shih YH, et al. Heterotopic ossification after cervical total disc replacement: Determination by CT and effects on clinical outcomes. J Neurosurg Spine 2011;14:457-65.  Back to cited text no. 1
    
2.
McAfee PC, Cunningham BW, Devine J, Williams E, Yu-Yahiro J. Classification of heterotopic ossification (HO) in artificial disk replacement. J Spinal Disord Tech 2003;16:384-9.  Back to cited text no. 2
    
3.
Von der Hoeh NH, Voelker A, Jarvers JS, Gulow J, Heyde CE. Results after the surgical treatment of anterior cervical hyperostosis causing dysphagia. Eur Spine J 2015;24 Suppl 4:S489-93.  Back to cited text no. 3
    


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