Dysphagia associated with lower thoracic spondylosis
F. Z. J. Cai1,
M. Rischmueller1,
K. Pile1,2 and
S. J. Brady3
1The Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, SA 5011, 2University of Adelaide, North Terrace, Adelaide, SA 5000 and 3The Department of Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
Correspondence to:
M. Rischmueller. E-mail: maureen.rischmueller{at}nwahs.sa.gov.au
SIR, A 73-yr-old man presented with several weeks of severe mid-thoracic back pain and dysphagia, which occurred only on assuming a supine position. The pain was likened to being thumped by a truckload of watermelons, and was associated with a sensation of struggling to swallow. Both symptoms were prominent in the recumbent position and settled promptly with change of posture.
His past medical history included seropositive rheumatoid arthritis diagnosed at age 50 and currently well controlled, left elbow prosthesis, inactive peptic ulcer disease, mild gastro-oesophageal reflux symptoms relieved with antacids, hypertension, hypercholesterolaemia, ischaemic heart disease and cerebral vascular disease. He was taking hydroxychloroquine and sulphasalazine, was a non-smoker and did not drink alcohol nor use non-steroidal anti-inflammatories. Examination revealed a symmetrical deforming polyarthropathy with no active synovitis, and reduced movements of the cervical spine. Examination was otherwise unremarkable.
Imaging studies revealed thoracic spondylosis and diffuse idiopathic skeletal hyperostosis (DISH), with large osteophytes projecting anteriorly from the ninth and tenth thoracic vertebrae (Fig. 1A). In the supine position these osteophytes caused extrinsic oesophageal compression (Fig. 1B, C). We suggest that in this patient with spondylosis and DISH, the weight of the diaphragm and other thoracic organs during recumbence caused compression of the oesophagus against the large anterior osteophytes, causing pain and dysphagia. Symptoms settled following the initiation of a proton pump inhibitor and avoidance of lying flat, thus surgical treatment was avoided.

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FIG. 1. (A) Lateral chest radiograph shows large osteophytes at the ninth and tenth thoracic vertebrae, and calcification of the anterior longitudinal ligament bridging the lower thoracic vertebrae. (B) Supine barium swallow shows compression of the oesophagus at the level of the tenth thoracic vertebra. (C) Computed tomography confirms the presence of the anterior osteophyte at the level of the tenth thoracic vertebra, with no other abnormality detected.
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Anterior vertebral osteophytes of the mid- to lower cervical spine have previously been reported as a cause of extrinsic oesophageal compression and dysphagia in patients with spondylosis and/or DISH [13], with one case reported of oesophageal compression by a thoracic osteophyte at the level of the fourth thoracic vertebra (T4) [4]. It has been postulated that fixation of the oesophagus is a prerequisite for its extrinsic mechanical obstruction; in the cervical spine the cricoid cartilage prohibits forward movement of the oesophagus [5], whereas at the level of T4 the aortic arch lies anterior to the oesophagus [4]. The oesophagus is also potentially fixed where it penetrates the diaphragm at approximately T10, although this level can alter with posture and respiration. We hypothesize that in our patient, in whom radiological imaging demonstrated extrinsic oesophageal compression at this level, localized mucosal inflammation was likely to have exacerbated his symptoms, which were readily amenable to anti-reflux treatment.
The authors have declared no conflicts of interest.
References
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- Willing S, El Gammal T. Thoracic osteophyte producing dysphagia in a case of diffuse idiopathic skeletal hypertrophy. Am J Gastroenterol 1983;78:3813.[ISI][Medline]
- Smythe H, Littlejohn G. Diffuse idiopathic skeletal hyperostosis. In: Klippel JH, Dieppe P, eds. Rheumatology. London: Mosby, 1994:Chapter 7; 9.19.6
Accepted 17 April 2003