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Paper text:
diffuse idiopathic skeletal hyperostosis ( dish ) is a common disease in which tendons and capsules are subject to calcification leading to hyperostosis and functional impairment .
diagnosis of dish is established by the presence of both spinal and extraspinal radiographic characteristics .
typical appearance of the cervical spine includes irregular and pointed osseous appositions of the superior and inferior vertebral margin .
the key organ is the enthesis , where calcification occurs under yet incompletely identified circumstances . among the abnormal conditions occurring in patients suffering from dish , the elevated levels of insulin - like growth factor i and hyperinsulinaemia are observed .
dickkopf-1 ( dkk-1 ) , a recently identified inhibitor of osteoblast differentiation , may be a key player in the formation of osseous appositions .
epidemiologically , dish is associated with metabolic syndrome and a risk of coronary heart disease .
interestingly , the presence of radiographical features of dish does not correlate with back pain . in severe cases ,
a study observing the long - term outcome of surgical treatment showed recurrent dysphagia 10 and 11 years after surgery in 2 of 7 patients , one of them requiring renewed surgery .
while only two patients were symptomatic , radiological follow - up showed recurrent hyperostosis in all patients who had undergone surgical resection .
heterotopic ossification after orthopaedic trauma is a common problem following accidental or surgical trauma to joint regions .
so far , there has been no report of radiotherapy for prophylaxis of relapse in diffuse idiopathic skeletal hyperostosis .
a 77-old - female with type 2 diabetes , arterial hypertension , obstructive sleep apnoea syndrome , atrial fibrillation and chronic kidney disease presented to the hospital with progressive dysphagia over a period of 6 months , currently of mellow grade 2 .
she complained neither of neck pain , nor pharyngeal pain . also , the history of present illness was negative for symptoms of malignant disease , trauma , cerebral ischaemia and surgical intervention .
clinical examination showed a mildly overweight female at a bmi of 33 with no external signs of obstructed oesophageal passage or respiratory distress .
the x - ray and ct scan of the cervical spine revealed significant hyperostosis of the ventral cervical spine segments c3c7 .
hyperostosis was most extensive at segments c3c5 causing stenosis of the pharyngeal lumen at the level of the larynx ( fig .  1 ) . due to accompanying joint pain , additional radiological examinations were performed .
ct of the right shoulder showed extensive osseous proliferation of the medial humeral head reducing the articular space of the glenohumeral joint , as well as calcification of the rotator cuff ( fig .  2 ) .
in the left ankle , the ct scan revealed ossification of the deltoid ligament , and kellgren grade 4 arthrosis of the tibiotalar and talocalcaneal joints ( fig . 
hyperostosis is present at the medial side of the humeral head , as well as at the humeral insertion of the rotator cuff . 

hyperostosis is present at the medial side of the humeral head , as well as at the humeral insertion of the rotator cuff .
surgical access to the cervical spine through a right - sided standard anterolateral approach showed osseous vegetations , which were strongly attached to the ventral spine and caused ventral displacement of the oesophagus .
a control ct examination showed successful removal of hyperostosis from segments c3 to c5 with intact vertebrae and proper configuration of the cervical lordosis without signs of instability ( fig . 
after 18 months dysphagia had regressed to grade 0 and there were no radiological signs of recurrence .
the patient in this case presented with a medical history common in dish patients : obesity , arterial hypertension and type 2 diabetes mellitus . the symptoms  dysphagia and absence of neck pain  as well as the presence of extraspinal hyperostosis were typical .
diagnostics were conducted with x - ray and ct scan according to the current standard .
surgical treatment is a standard procedure in severe dysphagia ; it was performed without complications .
this was crucial since instability of spine segments after surgical resection of hyperostosis is a risk factor for recurrent ossification .
radiotherapy of the affected segments was performed within 24 h. this has been described as a prophylaxis of formation of heterotopic ossification after orthopaedic trauma .
what makes this case unusual is the application of radiotherapy for prophylaxis from recurrence of ossification .
however , further research is required in order to examine whether there is statistical significance .
in diffuse idiopathic skeletal hyperostosis ( dish ) , recurrence of hyperostosis after surgical removal is common . 
 while both non - steroidal anti - inflammatory drugs ( nsaids ) and radiotherapy have been used in the prevention of heterotopic ossification , only nsaids have been applied for prophylaxis in dish . as a previously undescribed prophylaxis of recurrence in dish 
 , we report a case treated with local radiotherapy .