http://upload.orthobullets.com/topic/2045/images/Lateral neck OITE_moved.jpg
http://upload.orthobullets.com/topic/2045/images/dish.jpg
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Introduction 
  • A very common disorder of unknown etiology that is characterized by back pain and spinal stiffness
    • defined by presence of non-marginal syndesmophytes at three successive levels (involving 4 contiguous vertebrae)
    • also known as Forestier disease
    • can include enthesopathy of the spine, shoulder, elbow, knee and calcaneus
  • Epidemiology
    • demographics
      • overall incidence 6-12%
      • uncommon before 50 years old
      • prevelence
        • > 50 y.o. (25% males; 15% females)
        • > 80 y.o. (28% males; 26% females)
      • less common in Black, Native-American and Asian populations
    • location
      • occurs anywhere in spine
        • most common in the thoracic spine (right side) > cervical > lumbar
          • postulated to be due to the protective effect of the pulsatile aorta on the left of the thoracic spine 
        • symmetrical in the cervical and lumbar spine (syndesmophytes both on left and right of the spine)
    • risk factors
      • gout
      • hyperlipidemia
      • diabetes
  • Diagnostic criteria
    • flowing ossification along the anterolateral aspect of at least 4 contiguous vertebrae
    • preservation of disk height in the involved vertebral segment; relative absence of significant degenerative changes (e.g. marginal sclerosis in vertebral bodies or vacuum phenomenon)
    • absence of facet-joint ankylosis; absence of SI joint erosion, sclerosis or intraarticular osseous fusion
  • Associated conditions
    • lumbar spine
      • lumbar spinal stenosis 
    • cervical spine
      • dysphagia and stridor 
      • hoarseness
      • sleep apnoea
      • difficulty with intubation
      • cervical myelopathy 
    • spine fracture and instability
      • because ankylosis of vertebral segments proximal and distal to the fracture creates long lever arms that cause displacement even in low-energy injuries
      • hyperextension injuries are common
      • seemingly minor, low energy injury mechanisms may result in unstable fracture patterns.  One must have increase vigilance in patients with pain and an ankylosed spine
Presentation
  • Symptoms
    • often asymptomatic and discovered incidentally
    • thoracic and lumbar involvement
      • mild chronic back pain
        • usually pain is minimal because of stabilization of spinal segments through ankylosis
      • stiffness
        • worse in the morning
        • aggravated by cold weather
    • cervical involvement (with large anterior osteophytes)
      • pain and stiffness
      • dysphagia 
      • stridor
      • hoarseness
      • sleep apnea
  • Physical exam
    • decreased ROM of the spine
    • neurologic symptoms of myelopathy or spinal stenosis
Imaging
  • Radiographs
    • recommended views
      • AP and lateral spine radiographs of involved region
    • findings
      • non-marginal syndesmophytes at three successive levels (4 contiguous vertebrae)
      • thoracic spine
        • radiographic findings on the right side  
          • thoracic spine is often involved in isolation
          • particularly T7-T11
          • radiographic examination of this area is helpful when attempting to establish a diagnosis of DISH  
      • cervical spine
        • anterior bone formation with preservation of disc space (best seen on lateral cervical view)  
        • lateral cervical radiographs useful to differentiate from AS 
          • AS will demonstrate disc space ossification (fusion between vertebral bodies)  
      • lumbar spine  
        • symmetrical syndesmophytes (on left and right side of lumbar spine) 
      • other joint involvement e.g. elbow  
  • Technetium bone scan
    • increased uptake in areas of involvement
      • may be confused with metastases
  • CT or MRI
    • patients with DISH, neck pain and history of trauma must be evaluated for occult fracture with CT or MRI
Differential
 
   DISH Ankylosing spondylitis
Syndesmophytes Nonmarginal   Marginal
Radiographs "Flowing candle wax" "Bamboo spine", squaring of vertebral bodies, "shiny corners" at attachment of annulus fibrosus (Romanus lesions)  
Disc space Preservation of disc space   AS in cervical spine will show ossification of disc space 
Osteopenia No osteopenia (rather, there may be increased radiodensity)
Osteopenia present
HLA

No evidence of association with HLA-B27
Associated with HLA-B8 (common in patients with DISH and diabetes)

Strong association with HLA-B27
Age group Older patients (middle aged) Younger patients
SI joint involvement No involvement (SI joint abnormality generally excludes diagnosis of DISH) Bilateral sacroiliitis
 
Treatment
  • Nonoperative
    • activity modification, physical therapy, brace wear, NSAIDS and bisphosphonate therapy
      • indications
        • most cases
    • cervical traction
      • indications
        • cervical spine fracture
          • use with caution because traction may result in excessive distraction due to lack of ligamentous structures
  • Operative
    • spinal decompression and stabilization
      • indications
        • reserved for specific sequelae (e.g., lumbar stenosis, cervical myelopathy, adult spinal deformity)
Complications
  • Mortality
    • for cervical spine trauma in DISH
      • 15% for those treated operatively
      • 67% for those treated nonoperatively
  • Heterotopic ossification
    • increased risk of HO after THA
      • 30-50% for THA in patients with DISH
      • <20% for THA in patients without DISH
 

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Questions (2)

(OBQ07.233) A 67-year-old male presents with chronic low back and neck pain. A lateral cervical radiographs is shown in Figure A. An AP and lateral of the thoracic spine is shown in Figure B and C. What is the most likely diagnosis? Review Topic

QID:894
FIGURES:
1

Ossification of the posterior longitudinal ligament

5%

(126/2345)

2

Rheumatoid arthritis

0%

(8/2345)

3

Ankylosing spondylitis

12%

(285/2345)

4

Osteoarthritis

1%

(35/2345)

5

Diffuse idiopathic skeletal hyperostosis

80%

(1872/2345)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The clinical presentation and radiographic findings are consistent with diffuse idiopathic skeletal hyperostosis (DISH).

DISH is a common disorder of unknown etiology that is characterized by back pain and spinal stiffness. The condition is recognized radiographically by the presence of "flowing" ossification along the anterolateral margins of at least four contiguous vertebrae and the absence of changes of spondyloarthropathy or degenerative spondylosis. It is a challenge to differentiate between DISH and ankylosing spondylitis. In the cervical spine, anterior bone formation with preservation of disc space can help differentiate from AS (in AS bone formation is typically seen between vertebral bodies).

Resnick et al. investigated the radiographic and pathologic features of DISH. Pathologic features included diffuse calcification and ossification in the anterior longitudinal ligament, degeneration in the peripheral annulus fibrosis fibers, chronic inflammatory cellular infiltration, and periosteal new bone formation on the anterior surface of the vertebral bodies.

Belanger et al. reviewed the diagnosis and treatment of both spinal and extraspinal manifestations of DISH. They report in patients with DISH, even in patients who present with either lumbar or cervical symptoms, almost universally flowing osteophytes are seen on the right side of the thoracic spine. Thus, they emphasize that radiographic examination of this area is critical when attempting to establish a diagnosis of DISH.

Figure A shows typical cervical radiographs of DISH with anterior bone formation with preservation of disc space. Illustration A shows the typical lateral cervical radiographs seen with ankylosing spondylitis with bone formation within the intervertebral space. Illustration B shows a lateral in a patient with ossification of the posterior longitudinal ligament (OPLL). Notice the longitudinal "bar" posterior to the vertebral bodies. Illustration C shows basilar invagination which is one form of rheumatoid spondylitis. Illustration D shows the osteophytes consistent with osteoarthritis.

Incorrect Answers:
Answer 1: Ossification of the posterior longitudinal ligament is consistent with the radiographs in Illustration B.
Answer 2: Rheumatoid arthritis is consistent with the radiograph in Illustration C.
Answer 3: Ankylosing spondylitis is consistent with radiographs in Illustration A.
Answer 4: Osteoarthritis is consistent with the radiographs in Illustration D.

ILLUSTRATIONS:

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(OBQ05.155) A 60-year-old man presents with neck stiffness and difficulty swallowing. A lateral radiograph is shown in Figure A. What is the most likely diagnosis? Review Topic

QID:1041
FIGURES:
1

Ankylosing spondylitis

8%

(120/1446)

2

Cervical myelopathy

0%

(5/1446)

3

Congenital spinal stenosis

0%

(3/1446)

4

Diffuse idiopathic skeletal hyperostosis

90%

(1300/1446)

5

Ossification of posterior longitudinal ligament

1%

(13/1446)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of unknown etiology that is characterized by back pain and spinal stiffness.

The condition is recognized radiographically by the presence of "flowing" ossification along the anterolateral margins of at least four contiguous vertebrae and the absence of changes of spondyloarthropathy or degenerative spondylosis. It is a challenge to differentiate between DISH and ankylosing spondylitis.

Features that help distinguish DISH from AS include: 1) nonmarginal syndesmophytes as shown in Illustration A (AS is marginal). 2) no involvement of SI joint (biliateral sacroiliitis in AS). 3) anterior cervical bone formation with preservation of disc space as seen in Illustration B (AS will typicall show bone formation between vertebral bodies as seen in Illustration C). 4) Radiographic findings on the right side of the thoracic spine.

The reference by Belanger et al is a review article that discusses the diagnosis and treatment of both spinal and extraspinal manifestations of DISH.

The reference by di Girolamo et al found an increased prevalence of vertebral osteochondrosis (degenerative disc disease) in younger DISH patients with respect to controls.

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