No evidence of association with HLA-B27 Associated with HLA-B8 (common in patients with DISH and diabetes)
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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?
Ossification of the posterior longitudinal ligament
Diffuse idiopathic skeletal hyperostosis
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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.
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.
Belanger TA, Rowe DE
J Am Acad Orthop Surg. 9(4):258-67. PMID: 11476536 (Link to Abstract)
Resnick D, Niwayama G.
Radiology. 1976 Jun;119(3):559-68. PMID: 935390 (Link to Abstract)
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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?
Congenital spinal stenosis
Diffuse idiopathic skeletal hyperostosis
Ossification of posterior longitudinal ligament
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.
di Girolamo C, Pappone N, Rengo C, Miniero E, Crisci C, Olivieri I.
Clin Exp Rheumatol. 2001 May-Jun;19(3):310-2. PMID: 11407085 (Link to Abstract)
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