# Delayed Paraplegia by Thoracolumbar Fracture in Diffuse Idiopathic Skeletal Hyperostosis Developed After Femur Fracture Surgery: A Case Report

## TL;DR

An elderly woman with a femur fracture developed delayed paraplegia due to an undetected spine fracture linked to a bone condition called DISH.

## Contribution

Highlights the diagnostic challenges of DISH spine fractures and advocates for proactive evaluation in patients with DISH.

## Key findings

- DISH spine fractures can be asymptomatic initially but lead to neurological deficits if undiagnosed.
- Early mobilization after femur surgery may reveal hidden spine injuries.
- Imaging and physical exams are crucial for detecting hidden DISH spine fractures.

## Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) increases with aging, as does osteoporotic fracture. DISH spine fractures are sometimes difficult to detect at the initial evaluation and result in neurological compromise. We report a case of unstable DISH spine fracture with neurological deficits developing from an asymptomatic DISH spine fracture. A 98-year-old independent female suffered from a right femoral shaft fracture due to a ground-level fall. After she started early mobilization following fracture surgery, she developed mild back pain and became paraplegic. Imaging studies showed DISH spine fracture at Th10 level with cord compression. She underwent posterior spinal fusion for the DISH spine fracture, but the muscle weakness in her lower limbs persisted. Unlike the painful and non-ambulatory femoral shaft fracture, DISH spine fractures present diagnostic challenges. Asymptomatic cases could result in delayed diagnosis with neurological deficits and other morbidities. Although CT with multiplanar reformatted imaging and MRI are useful for detecting subtle fractures, the requirements for spinal CT and MRI examination in low-energy trauma settings in patients without back pain remain controversial. The proactive diagnostic approach, consisting of physical evaluations for pain and neurological deficits and the complementary imaging studies, should be encouraged for the early detection of hidden spine injury in patients having DISH spine.