It is a holiday weekend and the first one without our beloved Grandpa. Our family is locked in the "what if" mode of grief. What if grandpa hadn't had that last surgery that surely resulted in his death? Would he have died anyway? Can you help me sort through this myself? He was 77-years-"young" (as he liked to say). He had a condition called DISH but it wasn't until he fell and fractured C567 that he needed surgery. Then it was all downhill: pneumonia, a blood clot, and he was gone in two weeks.
Even from your brief description, it sounds like your Grandpa's situation was very complex. Medical and surgical treatment can be challenging for anyone with DISH complicated by multiple-level cervical spine fractures but even more so for an older adult. Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a condition in the spine caused by ligaments that turn into bone. Spinal ligaments along the front and back of the spine that help stabilize the spine are affected. As a result of this condition the spine becomes stiff, rigid, and more fragile in the older adult. A fall (even from ground level) can cause spinal fractures affected by this condition. We can provide some perspective from a recent study. Surgeons from three separate medical centers reviewed their charts for patients who had a diagnosis of DISH, then fell, fractured their cervical spine (neck), and were treated surgically to fuse the spine. Patient characteristics and results of treatment were key areas of interest. The goal was to understand this problem better and eventually develop guidelines for treatment. As it turned out, there were many surgical and medical complications associated with cervical fractures in patients with DISH. As these surgeons suspected from their experience, this group of patients were at high risk for further problems during surgical management. All the patients in the study had a spinal fusion because the fractured spine was unstable. Ages ranged from 53 up to 98 years old. Concern for serious neurologic damage (including paralysis from spinal cord injury) was the main reason for fusion as the recommended choice of treatment. Several studies reporting on conservative (nonoperative) care for serious injuries in patients like these have shown poor results. About half of the 33 patients in this study were fused from the front of the spine, called an anterior fusion. Another one-third had a posterior fusion (from the back). And the rest had both anterior and posterior fusions done. In all cases, more than one level was fused (some patients had as many as eight spinal levels fused). The type of problems encountered during treatment included pneumonia, pulmonary edema (fluid in the lungs), respiratory failure, urinary tract infections, seizures, blood clots, and even death. The nine patients who died had a spinal cord injury from the cervical fracture before surgery was done. The medical complications and the deaths of all 33 patients were linked with the post-injury/pre-operative neurologic damage. This study points out very clearly how fragile patients are who have DISH and then sustain cervical spine fractures. Despite surgery, serious disability and often death are the outcomes. Should surgery even be done for these individuals? That is a tough question to answer. Other experts who have studied this problem say these patients are at high risk for poor results but the outcomes are still better than without surgery. Patients and their family members are always made aware of the high risk for serious complications and told that a second surgery may be needed. Death is always a possibility with any surgery but especially in this situation. None of this information changes your situation. But knowing that everything was done to treat your Grandpa should be a comfort. Without surgery he was likely at grave risk for spinal cord injury that could result in complete paralysis. More study is definitely needed to improve the prognosis for patients with DISH who fall or somehow end up with an unstable spinal fracture. Future studies may also help surgeons develop a treatment protocol for managing these kinds of complex cases.