Occult osteophyte fracture as an atypical source of massive hemothorax in diffuse idiopathic skeletal hyperostosis: illustrative case.

backgroundDiffuse idiopathic skeletal hyperostosis (DISH) limits spinal mobility, predisposing patients to unstable fractures even following minor trauma. While spinal fractures are a well-documented complication, massive hemothorax remains a rare presentation, particularly when the bleeding source is from the osteophyte fracture site. OBSERVATIONS: An 84-year-old man with DISH, currently on a factor Xa inhibitor, presented after a 2-m fall. Initial imaging revealed a T11 reverse Chance-type fracture and a right hemothorax, notably without associated rib fractures or pulmonary contusions. Over the next 10 hours, chest tube drainage precipitously increased to more than 2400 mL, prompting emergency video-assisted thoracoscopic surgery. Exploration revealed no active bleeding at the primary T11 injury. Instead, the hemorrhage originated from an isolated, occult osteophyte fracture at T7-8. Hemostasis was successfully achieved with electrocautery, human thrombin, and fibrin glue, followed by delayed posterior spinal fusion. LESSONS: In patients with DISH, life-threatening hemothorax can arise from occult osteophyte fractures situated far from the spinal injury diagnosed at initial presentation. When bleeding is continuous or progressive, clinicians must maintain a high index of suspicion for remote bleeding sources. Surgical intervention should be considered for hemostasis, especially in the setting of concurrent anticoagulation therapy. https://thejns.org/doi/10.3171/CASE26279.