Bilateral Massive Pleural Effusion Caused by Spinal Instability in Diffuse Idiopathic Skeletal Hyperostosis: A Rare but Potentially Serious Complication of Spinal Fracture.

Abstract

A 71-year-old man with diffuse idiopathic skeletal hyperostosis (DISH) underwent posterior spinal fixation for a thoracic vertebral fracture at a fused segment, sustained as a result of a fall. One month postoperatively, he was readmitted due to bilateral massive pleural effusions and increased displacement at the fracture site compared to the immediate postoperative state. The effusions were exudative and lymphocyte-predominant. Further evaluation suggested that inflammation and pleural irritation due to spinal instability were the likely causes. Revision fixation led to the resolution of the effusions. Vertebral fractures caused by low-energy trauma, such as a fall, rarely result in spinal instability severe enough to cause pleural effusion, even in cases of nonunion. However, patients with DISH are more prone to highly unstable fractures due to spinal ankylosis and bone fragility. Even after surgical fixation, such fractures may progress to further instability. We report a case in which this instability led to localised inflammation and pleural irritation, ultimately resulting in bilateral pleural effusions. DISH is commonly seen in older adults and has been associated with obesity and diabetes mellitus. Its prevalence is reportedly increasing. Therefore, both internists and orthopaedic surgeons should be aware of the potential for similar cases and consider spinal instability related to DISH in the differential diagnosis and management of unexplained pleural effusions.