Anterior Cervical Osteophyte Thinning for Forestier's Disease: A Case Series, Scoring System and Treatment Algorithm

Forestier's disease, also known as diffuse idiopathic skeletal hyperostosis, causes abnormal ossification, commonly affecting the anterior cervical spine. Symptomatic patients can experience dysphagia, dyspnea, hoarseness, or aspiration due to the mass effect exerted on midline structures of the neck. When conservative measures have failed, surgical removal or thinning of the osteophytes often alleviates these symptoms. This study offers a case series of patients treated surgically for "diffuse idiopathic skeletal hyperostosis-phagia," a scoring system to identify appropriate surgical candidates, and a management algorithm.

A single-institution, retrospective chart review identified patients who underwent surgical osteophyte removal for Forestier's disease. Preoperative and postoperative evaluations included Glottal Function Index, Penetration-Aspiration Scale, imaging studies including barium swallow tests, and qualitative reports of symptoms. Perioperative imaging, operative time, length of hospital stay, postoperative complications, and the need for enteral (nonoral) nutritional support were assessed.

Six patients who underwent surgical osteophyte removal for management of Forestier's disease were identified. Five of these patients experienced improvement in their preoperative dysphagia as measured by various quantitative and qualitative tests. Two patients had same-day surgery, and no patient was in the hospital for more than 4 days. No patient required a feeding tube perioperatively. All patients tolerated a regular diet at their first follow-up visit. One patient had a postoperative seroma which did not affect his ability to swallow and was treated conservatively. Areas for improvement in patient screening, preoperative evaluation, and postoperative surveillance were noted.

Together, the results demonstrate the utility of surgical osteophyte removal for the management of Forestier's disease. We propose a novel scoring system and management algorithm including standardized clinical and radiographic evaluations, a conservative management trial, multidisciplinary evaluation, and standardized postoperative surveillance.