Case presentation

A 73-year-old man with a medical history of paroxysmal atrial fibrillation receiving anticoagulant therapy and hyperuricemia, treated with rivaroxaban, bisoprolol, and allopurinol, was referred to the Rheumatology Department for evaluation of solid-food dysphagia associated with choking episodes.

Initial cervical radiographs demonstrated prominent anterior osteophyte formation involving the C4-C6 vertebral levels (Figure 1). The patient denied neck pain or dyspnea. Further evaluation included esophagogastroduodenoscopy (EGD) with videofluoroscopic swallowing study, followed by CT and MRI.

Figure 1: Lateral Cervical Spine RadiographLateral radiograph of the cervical spine demonstrating prominent, flowing anterior ossification along the anterolateral aspect of multiple contiguous vertebral bodies, consistent with ossification of the anterior longitudinal ligament. Intervertebral disc spaces are relatively preserved, and there is no radiographic evidence of significant apophyseal joint ankylosis.

Upper gastrointestinal endoscopy demonstrated marked posterior pharyngoesophageal compression (Figure 2). CT revealed prominent anterior marginal osteophytes, particularly at C5-C6, causing significant indentation of the esophageal lumen. These imaging findings were consistent with DISH (Figure 3). MRI demonstrated ossification of the anterior longitudinal ligament with bridging ossification across C3-C4 and C4-C5. Prominent right anterolateral anterior osteophytes were also identified at C5-C6 and C7-T1, further supporting the diagnosis of DISH (Figure 4).

Figure 2: Esophagogastroduodenoscopy (EGD)EGD demonstrating marked posterior pharyngoesophageal compression, suggestive of extrinsic compression.

Figure 3: Computed Tomography (CT)Sagittal and axial cervical CT images showing prominent anterior marginal osteophytes, particularly at C5-C6, causing significant impression on the esophageal lumen (arrow). Findings are compatible with advanced diffuse idiopathic skeletal hyperostosis.

Figure 4: Magnetic Resonance Imaging (MRI)Sagittal cervical MRI demonstrating ossification of the anterior longitudinal ligament with bridging ossification at C3-C4 and C4-C5. Prominent right anterolateral marginal osteophytes are identified at C5-C6 and C7-T1, consistent with diffuse idiopathic skeletal hyperostosis (DISH).

The radiological findings, together with the clinical presentation, were consistent with DISH causing secondary esophageal compression. The imaging findings fulfilled the Resnick and Niwayama diagnostic criteria for DISH [6]. The patient was referred to the Department of Neurosurgery for further evaluation. Following multidisciplinary assessment, he was considered a suitable candidate for anterior cervical osteophytectomy with intraoperative tissue sampling.