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A m J R oe ntg en ol 131 :1 049 -1053 , D ecem be r 19780 1978 Am erica n R oen tgen R ay Soc ie ty 1049 0361 -803X /78 /i 200 -i 049 $00 .00

A ssoc ia tio n o f D iffu se Id iop a th ic S ke le ta l H ype ro s to s is (D ISH ) andC a lc ific a tio n and O ss ific a tio n o f th e Pos te rio r Long itu d in a l L ig am en t

DONALD RESN IC K ,1 JO SE GUERRA , JR .,1 CHAR LES A . RO B IN SON ,2 AND V INTON C . V IN T3

D if fu se id iopa th ic ske le ta l h ypero s to s is (D IS H ) Is a com m onoss ify ing d ia thes is in m idd le -aged and e lde rly pa tien ts cha r-ac te rized by bone p ro life ra tio n a long th e an te rio r aspec t o fth e sp in e and a t ex tra sp in a l s ite s o f lig am en t and tendona ttachm en t to bone . Fou r p a tien ts w ith D ISH revea led exten -s iv e ca lc ifica tio n and oss ific a t io n o f th e pos te rio r lo ng itu d in a llig am en t In th e ce rv ic a l sp in e . R ev iew o f c erv ic a l sp ine rad io -g raphs in 74 add it Io n a l p a tIe n ts w ith D ISH dem ons tra ted bonyhype ro sto s is o f the pos te rio r a spec t o f th e ve rteb ra e In 41% ,pos te rio r sp ina l o s teophy tos is in 34% , an d p os te rio r lo ng itu dl-n a l lig am en t c a lc if ic a tio n and oss ific a tio n In 50% . TheseIlg am en tous f in d ings , w h ich have p re v ious ly b een desc rib eda lm os t e xc lu s iv e ly In Japanese peop le , appear to be anadd itio n a l sk e le ta l m an ifes ta t io n o f D ISH .

D iffu se id iopa th ic ske le ta l h ype ros tos is (D ISH ) is a com -m on diso rde r cha rac ter iz ed by bone p ro life ra tion in ax ia land ex traax ia l s ite s [1-3 ]. T he m os t cha rac te r is tic abno r-m a lities in th is cond itio n a re lig am en to us ca lc if ica tionand oss ific a tion a long the an te ro la te ra l a spec t o f theve rteb ra l bod ie s w ith lo ca lized os teophy tos is . C hangesin ex trasp ina l lo ca tions a re a lso frequen t, in c lud ingligam en t and tendon ca lc ifica tion and oss ifica tion ,panaa rticu lan os teophy tes , and bony excrescences a ts ite s o f lig am ent and tendon a tta chm en t to bone . A lte r-a tions a long the pos te rio r aspec t o f the ve rteb rae a rera re ly m en tioned in th is cond ition .

O ss ifica tion o f the pos te r io r long itud ina l lig am en t o fthe ce rv ic a l sp ine has been repo rted in a la rge num be ro f Japanese pa tien ts and in a few non -Japanese ind iv id -ua ls [4 -13 ]. T h is oss ific a tion , w h ich has a charac te r is ticappea rance on rad iognaphs , m ay be assoc ia ted w ithce rv ica l m ye lopa thy [4 , 5 , 7 , 8 , 10 , 12 ] on p roduce nosym p tom s and s igns [5 , 1 0 , 1 1 , 13-1S] .

Recen tly w e inves tiga ted fou r pa tien ts w ho dem on -s tna ted ex tens ive pos te rio r long itud ina l lig am en t ca lc ifi-ca tion in the ce rv ica l sp ine on in itia l e va lua tion . S ubse -quen tly , add itiona l nad iognaphs revea led find ings o fD I SH . W e presen t these fou r pa tien ts in de ta il anddesc ribe the in c idence o f rad iog raph ic abno rm a litie sa long the pos te r io r aspec t o f ce rv ica l ve rteb ra l bod ie sand in te rve rteb ra l d iscs in a la rge num be r o f pa tien tsw ith D ISH .

C ase 1C ase Repo rts

A 71 -yea r-o ld wh ite m an w as eva lua ted a t the H osp ita l o fS cr ipps C lin ic because o f le ft low e r ex trem ity pa in and w eak-

ne ss fo r 1 5 yea rs . T he pa in began a s a ting ling sen sa tio n on thedo rsum o f the le ft fo o t a nd p rog re sse d to in vo lve th e ank le ,knee , h ip , and le ft bu tto c k . A n ex tens ive neuno log ic and on -thoped ic eva lua tion 4 yea rs p r io r to the cu rren t eva lua tionin c luded m yebog raphy and e lec trom yog raphy w ith in conc lu s iveres u lts . T h e presen t ph ys ica l exam ina tio n ou tlin e d he rp es zos -ten on the le ft bu ttoc k , p ronounced res tric tion o f m o tion o f thece rv ica l sp ine , an d m usc le a tro ph y and decreased pa in andsensa tion in th e le ft low er e x trem ity . L a bo ra to ry eva lua tio n w asun rema rkab le , a lth ough non spe c ific e le c trom yogra ph ic a lten a -tio ns w ere appa re n t in the le ft leg .

R ad io g raph ic e xam in a tion re vea led th e fin d ing s o f D ISH ,in c lu d in g ca lc ific a tion a nd oss ifica t ion a lon g the a n te rio r asp ec to f th e en tire ve r te b ra l co lum n (fig . iA ), bo ny e xc resc en ce sabou t the pe lv is , an d panaa ce tab u la r o s teo ph y te s . P rom in en tca lc if ica tio n and oss ific a tio n o f th e pos te rio r lo ng itu d ina l l ig a -m en t w as no ted in the cerv ica l sp ine (fig . iB ). Lum ba r m yebog -naphy dem ons tra ted no s ig n ifica n t a bnorm a lit ies ; th e ce rv ica lcana l w as no t exam ined . The fina l im p ress ion a fte r ex tens iveneu ro bog ic e va lu a tion w as tha t the sym p tom s w e re p robab lyre la ted to n e rve ro o t in vo lvem en t in the lum bosac ra l sp in e , a n dtha t they we re accen tua ted by the p resence of he rpes zos te r.Case 2

A 57 -year-o ld w h ite m an had a com p lica ted m ed ica l h is to rywh ic h inc lud ed pu lm onary re se c tio n fo r a g ra nubom a re la te d tococ c id io idom ycos is , ad u lt -on se t d ia be tes m e llitu s , typ e IV hy -pe rlipo p ro te in em ia , h ype rte ns io n , a nd a h yd roce le o f the le fttes tic le . H is cu rren t ev a lua tio n a t th e H osp ita l o f S c ripp s C lin icfo r in c re as in g pa in and s tiffne ss in th e nec k and low e r b ack fo rseve ra l y ea rs re vea led m arked re s tric tio n o f m o tio n o f thece rv ic a l sp ine w ith p a rasp ino us m usc le sp asm . S om e re s tric t iono f m o tio n in th e lum ba r sp in e w ith fla tte n ing o f th e lum barlo rdos is w as a lso ev iden t. Labo ra to ry exam ina tion w as un re -markab le .

R ad iog raph ic eva lua tion ou tlined find ings o f D IS H , in c lud ingnew bone fo rm a tio n a lon g the an te no la ten a l a sp ec t o f the en tireve rteb ra l co lum n , p a raa ce tab u la r b on y exc res cen ce s , sac ro iliacjo in t o s te op hy tos is , an d pa te l la r hyp e ros tos is . R a d io g ra ph yinc lud ing tom ograph y o f the ce rv ica l s p in e ou tlin ed e xub eran tca lc if ica tio n and o ss ifica tio n o f the pos te rio r lo ng itu d ina l liga -ment (fig s . 2A and 2B ) w h ich w as fu r the r d ocum en ted oncom pu ted tom ography (fig . 2C ). T he pa tien t w as re fe rred fo rapp ro p ria te p h ys ic a l the ra py .

C ase 3A 64 -yea r-o ld w h ite m an w as seen a t the Hosp ita l o f S c ripps

C lin ic becau se o f low bac k and low e r e x trem ity p a in fo r a bou t1 3 years w h ich had re qu ired low e r lum ba r lam ine c tom y fo r, th re e s lipp ed d iscs . A dd itio n a l m uscu lo ske le ta l c om p la in tsw ere num bnes s and ting ling o f bo th th igh s , pa in a nd s tiffne ss

Rece i v e d Ju ne 30 , 19 78 ; a cce p te d a fte r rev is io n A ugu st 2 8 , 19 78 .Th is w ork wa s sup po rted in pa rt b y V e te ra ns Adm in is tra t ion g ra n t no . 7406 .D . R esn ick is a P ick e r S cho la r o f the P ic ke r F ounda tion .I Departm en t o f Ra d io logy , U n ive rs ity o f Ca lifo rn ia S cho o l o f M ed ic ine , V e te rans A dm in is tra tion Hosp ita l, 3350 La Jo lla V illage D rive , 5an D iego .

C alifo rn ia 9 21 61 . Add re s s rep rin t re que sts to D . R e sn ick .a Departm en t o f In te rn a l M ed ic ine , H o sp ita l o f S c ripp s C lin ic , S an D ie go , California 92037 .3 Depar tmen t of R ad io lo gy , H osp ita l o f S c rip ps C lin ic , S an D iego , C a lifo rn ia 9 20 37 .

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1050 RE SN IC K ET A L.

Fig . 1 .-C ase 1 . A , F low ing ca lc ific a tion a nd o ss ifica tio n a lon g an te -no r aspe c t o f mi d an d low er tho ra c ic sp ine . B , N ote ca lc if ica tio n andoss ific a tion o f p oste rio r lon g itud ina l l igam en t in ce rv ic a l s p ine (ar row) .

Fig . 2 .-Case 2 . A, La te ra l rad iog rap h o fce rv ic a l sp ine d em on stra tingex te ns ive ca lc ific a tio n an d o ss ifica tio n o f pos te rio r lon g itu d in a l lig a -m en t. O bse rve na d io lucen cy be tw een rad iod en se lig am en t an d po ste rio rsu rface o f second ce rv ica l ve rteb ra l body . B , Tom ogra m d em on stra tin gca lc ifie d a nd o ss ifie d p os te r io r lon g itu d ina l l igam en t. C , CT scan a t le ve lo f o ne ce rv ic a l v e rteb ra l b ody o u tlin in g rad iod en se lig am en t s ep ara te dfrom po ste rio r a sp ec t o f v e rteb ra l bo dy .

in th e ce rv ica l sp ine , a nd m ild d iscom fo r t in the reg io n o f th each illes ten do n asso c ia ted w ith hee l spu rs . P h ys ica l find in g sinc lud ed s ign ific an t re s tric tio n o f c e rv ica l s p in e m otio n , pa na -sp ino us m usc le sp asm of th e ce rv ic a l re g io n , an d res tric t ion o ffo rw a rd fle x io n in th e lum ba r sp in e . N euno lo g ic e xam in a tionand labo ra to ry ana lys is we re w ith in no rm al lim its .

R ad io g raphy ou tlin ed th e changes o f D IS H , inc lu d ing p rom i-n e n t a n te rio r sp in a l new bone fo rm a tion ( fig . 3A ), pa ra ace tab u -Ian os teophy tes , ca lc ific a tion o f ilio lum ban ligam en ts , and pe lv icbon y e xc re scences . C erv ica l s p ine rad io g raph y dem ons tra te dcalc if icat ion and oss ifica tion of the pos te r io r long itud ina l lig a -m ent (fig . 3B ). T he pa tie n t w as re fe rre d fo r ph ys ica l the ra py .

C ase 4A -57 -ye an -o ld w h ite m an wa s eva lu a te d a t the V e te ra ns A d-

m in is tra tion H osp ita l fo r pa in a nd d ec rea se d ra ng e o f m o tio n inth e nec k fo r se ve ra l y ea rs . T he pa tie n t a lso no ted pa in a ndnum bness a long the la te ra l a spec t o f the righ t a rm . P rev iousm ed ica l h is to ry in c lud ed M #{2 33 }n i# {2 32 }ne sise a se . L abo ra to ry ana lys isw as un rewa rd in g , b u t e le c trom yognaph y ou tlin ed absen t se n -sa tio n o f the r igh t a rm a lon g the d is tribu tio n o f the u ln a r ne rve .The re w as no ev idence o f m oto r nad icu lopa thy .R ad iog raph y dem ons tra ted the a lte ra tio ns o f D ISH w ith dep -os itio n o f bo ne a lo ng th e an ten o la ten a l asp ec t o f th e ve r teb ra lco lum n , and e x ten s ive ca lc if ica tio n and o ss ifica tio n o f th epos te rio r lon g itud in a l lig am en t in th e ce rv ica l sp in e (fig . 4 ).A ltho ugh m ye log ra ph y w as re comm ended , the pa tie n t w a s lo s tt o f ol lo w -u p .

C e rv ic a l S p in e C hanges in D ISHR ev iew o f c e rv ica l sp in e ra d io g ra phs in 7 4 pa tie n ts

w ho m e t o u r p re v io u s ly pub lis he d c rite ria fo r D ISH [2 ]docum en ted de fin ite abno rm a litie s a long the pos te rio ra spec t o f th e ve rte b ra l b od ie s in 5 5 pa tien ts (74% ). T he seabno rm a litie s cou ld be d iv ided in to th ree types wh ichfreq uen tly w ere fou nd tog e th e r :

1 . Bony hype ros tos is (fig . 5 ) . B on y ebu rn a tio n o r sc le -ro s is a lo n g th e po s te rio r as pe c t o f th e ve rteb ra l b od ie sw as appa ren t in 30 pa tien ts (41% ). Th is abno rm a lity w asm ost appa ren t in the uppe r ce rv ica l ve rteb rae and p ro -duced h igh ligh ting o r w h iten ing o f the pos te r io rcortex.

2 . O steophy tos is . O steophy tes p ro trud ing from thepos te rio r a sp ec t o f th e ve rte b ra l b o d ies w ere no te d in 25pa tien ts (34% ). T hey we re m os t frequen t in the m id andlowe r ce rv ica l reg ion w he re they p roduced bony excres-cen ce s , typ ica lly sm a ll, w h ich p ro trud ed in to the sp in a lcana l .

3 . P os te r io r long itud ina l lig am en t ca lc ifica tion andos s ifica tion . L ig am en tou s ca lc if ica tio n and o ss ifica tio nwe re apparen t in 3 7 pa tien ts (50% ). T he se depo s its ,pa rtic u la r ly frequen t in the uppe r ce rv ic a l s p ine , w ere o fva r iab le s iz e , lin ear in d is tribu tion , bum py in contou r,and typ ica lly w e re sepa ra ted from the sub jacen t ve rteb ra lbody by a rad io lu cency o f va riab le th ic kness .

T hese th ree types o f rad iog raph ic abno rm a litie s w e recomm on ly , bu t n o t in va r ia b ly , a ss oc ia te d w ith a lte ra tio nsa lo ng the an te rio r a sp ec t o f th e ce rv ica l sp in e wh ic hin c lu ded o s te ophy te s and flow in g o ss ifica tion an te rio r tothe ve rte b ra l bo d ies a nd in te rv e rte b ra l d iscs . A lth o ughtho raco lum ba r changes we re in va riab ly p resent a llow ing

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F ig . 4 .-Ca se 4 . A and B , La te ra l an d fron ta l na d io g rap hs o f ce rv ic a lsp ine d em on stra tin g w id esp re ad ca lc ifica tio n a nd oss ific a t ion o f po s te -n or long itud ina l ligam en t (a rrow s ). C a nd D , La te ra l an d fron ta l tom o -g ram s be tte r d e lin e a ting th ese f i nd ings.

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D ISH /C ALC IF IC AT ION AND OSS IF IC AT IO N O F PO STER IOR L IGAM ENT 1051

the d iagnos is o f D ISH , the re w as no de fin ite co rre la tionbe tween the ex ten t o f abno rm a lity a long the pos te r io raspec t o f the ce rv ica l ve rteb rae and tha t in the tho raco -lum ba r reg ion .

Discuss ionA lthough D ISH and poste r io r long itud ina l lig am en t

ca lc if ica tio n and o ss ifica tion have re ce ive d cons id e ra b lea tten tion in the m ed ica l lite ra tu re , the ir poss ib le assoc i-a tion has ra re ly been m en tioned . A rle t e t a l. [16 ] ana lyzed40 pa tien ts w ith ce rv ic a l m ye lopa thy and no ted thefrequency o f ve rteb ra l hypenos tos is in these pa tien ts . O fthe 40 patien ts , 17 (43% ) had bo th D ISH and acqu ireds tenos is o f the ce rv ica l cana l re la ted to bony p ro lifena-t io n a lo n g the pos te rio r a sp ec t o f th e ve rte b ra l b o d ies .The pa tte rn o f p ro life ra tion in c luded find ings s im ila r tothose no ted in ou r in ves tiga tion , such as hype ros tos is ,o s teophy tos is , and ligam en t ca lc ifica tion and oss ifica -t ion .

O no e t a l. [17 ] in ves tiga ted 166 pa tien ts w ith oss ifica -tion o f the pos te rio r long itud ina l lig am en t. S ym p tom s inthese pa tien ts , in c lud ing m oto r and sensory d is tu rb -ances in the low e r ex trem ity , w e re pa rticu la rly p rom inen tw hen the oss ified pos te r io r long itud ina l lig am en t occu -p ied 60% o f the sag itta l d iam ete r o f the ce rv ica l s p ine .O f 160 pa tien ts in tha t repo rt, 71 (44% ) dem onstra tedconcom itan t hype ros tos is on the an te r io r aspec t o f theve rteb ra l c o lum n . P ostm o rtem exam ina tion o f tw o pa -tien ts w ith bo th pos te r io r long itud ina l lig am en t ca lc ifi-ca tion and D ISH revea led tha t the oss ifica tion o f thepos te rio r long itud ina l lig am en t w as pa rticu la rly p rom i-nen t in its supe rfic ia l la ye r, w he reas the unoss ified deeplaye r w as th ickened , c rea ting a rad io lu cency be tw eenthe o ss ified ligam en t a nd unde rly in g ve r te b ra l bo d y . A tthe c ran ioce rv ica l junc tion , h is to lo g ic e va lu a tion ou t-l in ed p ro life ra tion o f ca rtilage like ce lls and hype rp la s iao f the m atrix w ith in the po s te rio r lon g itud in a l l ig am en t.These find ings d id no t docum en t the sequence o f even tsw hich occu rs in th is cond ition , bu t sugges ted tha t a l-though an te rio r and pos te r io r long itud ina l lig am en t ca l-c ific a tion and o ss ifica tio n fre quen tly c oe x is t , defin iteand rem a rkab le d iffe rences in the ir pa tho logy can beno ted .

A ltho ugh pa tie n ts w ith p o s te rio r lo ng itu d ina l l ig am en toss ific a tio n m ay be a sym ptom a tic [1 3 ], a va rie ty o f sym p -tom s and s ig ns have been as soc ia ted w ith th is d is o rd e r[4 -12 ]. P a ra s the s ia s m ay va ry from in te rm itten t s en sa -tio ns , in c lu d ing num bness o r ting lin g o f se ve ra l d ig its o fone o r bo th uppe r ex trem itie s , to ex tens ive and seve reanes thes ia o f the trunk and lowe r ex trem itie s [6 ]. M o to rd is tu rbances , such as w eakness , in coo rd ina tion , and in -s tab ility , m a y be encoun te re d in u ppe r a nd low er ex trem -tie s . A dd itio na l sym ptom s m ay in c lu de head and nec kpa in and s tiffness , u r ina ry and rec ta l in con tinence and

F ig . 3 .-C ase 3 . A, Typ ica l flow ing o ss ifica tio n in tho ra c ic sp ine . B ,Ca lc if ic a tio n and o ss ifica tio n o f po s te r io r lo ng itu d ina l l ig am en t a t leve lo f seco nd and th ird ce rv ica l ve rteb ra l bod ies (ar row) .

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F ig . 5 .-H ype ros to s is o f p o s te rio r s u rfa ce o f sec -o nd , th ird , a nd fo u rth ce rv ic a l v e rteb ra l bo d ies .

1052 RESN ICK ET AL .

d ys fu n c tio n , a nd lo ss o f lib ido . O n ph ys ica l ex am in a tio n ,pa tie n ts m ay revea l m us c le a tro p hy , fa sc ic u la tion s , h y -pe rre fle x ia , a n d sen so ry loss . The re po rte d inc id en ce o fth ese find in gs has va ried cons ide ra b ly , an d th e sym p -tom s and s ign s a re , in g enera l, no n spec ific , be in g p res -e n t in o the r d iso rd e rs o f the sp in a l ca na l an d co rd .

O u r p re v iou s in ve s tig a tio n s o f p a tien ts w ith D ISH d idno t em pha s ize abno rm a lit ie s o f th e po s te r io r a sp ec t o fthe ce rv ica l ve rtebrae , a lthough we d id no te som e pa -t ie n ts w ith D ISH who revea le d pos te rio r lon g itud in a lligam en t oss ific a tio n , a n d o th e rs w ho dem ons tra te dsm a ll p o s te rio r ce rv ica l s p ine os te oph y tes and h ype ro s -to s is [1 8 ]. It is a ppa ren t from ou r c lo se r e va lu a tion o fth ese and add itio na l pa tie n ts w ith D ISH th a t su ch a lte ra -tion s a re freq uen t in th e d ise ase . F u rth e rm o re , o u rre cen t expe rie nce w ith th e fo u r p a tien ts rep o r te d he resugge s ts tha t po s te rio r lon g itud in a l l ig am en t ca lc ifica -tio n and o ss ifica tion in th e ce rv ic a l sp ine m ay becom eex te ns ive in th is d iso rde r.

T h is o b se rva tion is im po rtan t, a s d epos itio n o f ca lc iumand bone a lon g the po s te r io r a sp ec t o f the ve rte b ra lb o d ies a nd in te rv e rte b ra l d isc s m ay com prom ise th ein te g r ity o f th e sp in a l c o rd , lea d ing to s ig n ifica n t ne u ro -log ic fin d in gs . S om e o f th e neu ro log ic a bnorm a lit ies inth ree o f these fou r pa tien ts (cases 1 , 3 , and 4) m ay in -deed have resu lted from such oss ific a tion ; it is the re -fo re im pe ra tiv e tha t the rad io log is t sea rch d ilig en tly fo rthese changes. Thus , lowe r ex trem ity m usc le a trophy

and seno sry los s in c ase 1 , num bne ss and tin g lin g o fth e th ig h in c ase 3 , an d uppe r ex trem ity num bness andsenso ry lo ss in ca se 4 m ay have been re ia te d to p os te rio rlon g itud in a l l ig am en t o ss ifica tion . Tom og raph y o f thesp ine m ay be ne ce ssa ry fo r a deq ua te e va lua t ion ; in o neo f o u r pa tie n ts , com pu te d tom ogra ph y re vea led no t o n lythe p res en ce o f p o s te rio r lon g itud in a l ligam en t c a lc if i-ca tion and o ss ifica tion bu t th e e x ten t o f sp in a l ca na lim p ing em en t. H um an e t a l. [1 9 ] p rev io us ly d esc rib ed apa tie n t w ith ce rv ic a l m ye lop a th y in w hom com pu tedtom ogra phy do cum en te d the p res en ce and e x ten t o fo ss ifica tion w ith in th e po s te r io r lo n g itu d in a l lig am en t.

It is a ppa ren t from th is rev iew th a t a g re a t n um be r o fp a tie n ts w ith D IS H w ill rev ea l s ig n ifica n t po s te rio r ve rte -b ra l a b no rm a lit ie s . A ltho ugh w e have no t a na ly zed ce r-v ica l sp in e ra d io g ra phs in a n age- a nd se x -m a tch edno rm a l co n tro l p opu la tion , ou r b rie f rev iew o f a bou t2 0 ce rv ica l s p ine e xam in a tion s in e ld e rly pa tie n ts y ie lde dsom e w ith b ony h yperos to s is and m in o r deg ree s o fo s teo ph y to s is . P os te rio r lo ng itu d ina l ligam en t ca lc if ica -tion and oss ific a tio n we re no t a ppa ren t, su gge s tin g th a tth ese la tte r c hange s a re in deed as soc ia te d w ith D ISH . IfD ISH is cons ide red a frequen t d is ease in th is coun tryw ith a n inc ide n ce tha t m ay re ach 12% o f m idd le -ag edand e lde r ly pa tien ts [18 ], c a lc ific a tion and oss ifica tion o fthe pos te rio r long itud ina l lig am en t shou ld no longe r bereg a rded a s fin d in gs a lm os t con fin ed to Japaneseind iv idua ls .

REFERENCES1 . R esn ick D , S hau l SR , R ob in s JM : D iffu se id io pa th ic ske le ta l

h yp e ro s to s is (D ISH ) : F o res tie r s d ise ase w ith e x tra sp in a lman i fes ta t ions . Rad io logy 1 1 5 : 5 1 3 -524 , 1975

2 . R e sn ick D , N iw a yam a C : R ad iog ra ph ic and pa tho lo g icfe a tu re s o f sp in a l inv o lvem en t in d iffus e id iop a th ic ske le ta lh yp e ro s to s is (D IS H). Rad io logy 119 :5 59 -5 68 , 1 976

3 . Fo re s tie r J , R o tes -Q ue ro l J : S en ile a nk y lo s ing h ypero s to s iso f th e sp ine . Ann R heum D is 9 :3 21 -3 30 , 19 50

4. N akan ish i T , M annen T , T oyo ku ra Y . S a kagu ch i R , T suyam aN : S ym ptom a tic o ss ifica tion o f the po s te rio r lon g itud in a ll ig am en t o f th e ce rv ica l sp ine . Neuro logy 24 :1139-1143 ,1 9 74

5 . B akay L , C a re s H L , Sm ith R J : O s s ific a tio n in the re g ion o fthe pos te rio r lo ng itu d ina l l ig am en t a s a cause o f ce rv ic a lmye lopa thy . J N eu ro l N eu ros u rg P sych ia tr 3 3 : 2 6 3- 26 8,1 9 70

6 . T a kaha sh i M , K aw anam i H , T om onaga M , K itam u ra K :O ss ifica tio n o f the pos te rio r lo ng itu d ina l ligam en t. A ro en t-ge no log ic and c lin ica l in ve s tig a tion . Acta R ad io ! [D iag n ](S toc kh ) 13 :25 -36 , 1 9727 . S oo Y S , S a chde v A S : C a lc if ica tion in the po s te rio r lon g itu -d ina l ligam en t a s a cause o f c e rv ica l m ye lo pa thy . M ed JAu s t 1 :743 -744 , 1 971

8 . O p den O rth JO : D ie V e rka lku ng bzw . V e rkn oche rung desL ig am en tum Long itu d ina le P os te n iu s den Ha lsw irbe lsau le .For ts ch r G eb R oen tg e ns tr N u k !ea rm ed 1 2 2 : 4 42 -4 45 , 197

9 , Lagem ann V K : H in te re L angsband ve rka lk ungen kom b in ie rtm i t v i rb e lk o rp e r ex k a va t io n e n . Fo rtsch r G ob Roen tge n s trNu k le a rmed 116 :834 -835 , 1 9 72

10 . M inag i H , G ro nner AT : C a lc if ica tio n o f th e po s te rio r lo ng i-tud in a l ligam en t: a ca use o f ce rv ica l m ye lo p a th y . Am JRoen tg e no ! 105 :365 -369 , 19 69

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ii . H iram a ts u Y , N obech i T : C a lc if ic a tio n o f the pos te rio rlo ng itud ina l lig am en t o f the sp ine am ong Japanese . Rad io l -og y 100 :30 7 -312 , 1 97 1

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14 . Y anag i T : O ss ifica tion o f th e pos te rio r lo n g itud in a l l ig a -m en t. A c lin ica l and rad io log ica l ana lys is o f fo rty -s ixcases . B ra in N erve 22 : 909-921 , 1970

15 . P a la c ios E , B ra cke tt CE , L ean y D J : O s s ific a tio n o f th epos te rio r lo ng itu d ina l ligam en t a sso c ia te d w ith a he rn ia tedin te rve rte bra l d isc . Rad io logy 1 00 : 31 3 -3 1 4 , 1971

i6 . A n le t P J , P u jo l M , B uc A , G enaud G , G aynand M , La to rze ff S :R o le d e lhy pe ros tose ve rteb ra le d an s es m ye lop a th ie scerv ica les . Rev Rhum M a l O s teo a rtic 43 : 1 6 7 -1 75 , 1 976

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