What is DISH and what does it have to with auto crashes?
We were recently asked to consult on an interesting auto accident question. Briefly, the case was a 45 y/o woman, who was involved in an auto crash. The client was the front seat passenger in a vehicle that was struck laterally on the front driver’s side. The crash impact was enough to cause a good deal of damage to both cars and the client required Emergency Department admittance due to complaints of severe back and hip pain.
The client had no previous history of back or hip problems. After the accident the client reported persistent numbness in both arms as well as loss of sensation in all four extremities. As an example, the client is a nurse and can no longer determine a patient’s heart rate by palpation (felt with the hands) because she cannot feel a patient’s pulse when placing her fingertips over the radial artery in the wrist. She had no difficulty palpating before the accident.
Over time the client’s pain and loss of sensation continued to worsen. The client developed severe depression as a direct result of dealing with injuries caused by the crash. Despite treatment with medication, physical therapy and water exercise therapy, there was no improvement in her physical condition.
On a follow-up appointment with her family doctor the client had an x-ray of her back. The purpose of the x-ray was to follow up on the client’s back pain, however the radiologist also discovered the client had Diffuse Idiopathic Skeletal Hyperostosis (DISH). DISH or Forestier's disease is a form of degenerative arthritis. It is characterized by calcification along the sides of the vertebrae of the spine. DISH has a relatively low incidence in individuals before age 50, however, at least 10% of the population over 70 has DISH. In your older clients DISH is not uncommon.
One question in the case became “What is the correlation between DISH and trauma?” Additionally, “Can trauma accelerate, aggravate or complicate DISH or in the reverse, can DISH aggravate or complicate the consequences of the trauma?”
The medical literature does not support the idea that DISH can be brought on by physical trauma. It is quite clear, however, that trauma can have catastrophic back and neurologic consequences in individuals with DISH. In an article in the Journal of American Orthopedic Surgery the authors state “There may be a delay in diagnosis of spinal fractures in a patient with DISH because the patient often has a baseline level of spine pain and because the injury may be relatively trivial.” In the Annuals of Emergency Medicine the authors state “Diffuse idiopathic skeletal hyperostosis is a little known but potentially devastating disorder of the spine. It has been associated with fractures following minor trauma which tend to be unrecognized, unstable and associated with treatment delays and permanent neurological deficits”.
The trauma from an automobile crash is significant enough to cause major problems in individuals with DISH. The range of problems can be anything from severing the spinal column to developing severe chronic back and neck pain. Without the trauma a person with DISH would not develop these kinds of problems.
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