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Updated: Jul 2 2023

DISH (Diffuse Idiopathic Skeletal Hyperostosis)

Images neck OITE_moved.jpg dish.jpg ap.jpg lateral.jpg
    • DISH, also known as Forestier disease, is a common disorder of unknown etiology characterized by enthesopathy of the spine and extremities, that usually presents with back pain and spinal stiffness. 
    • Diagnosis can be confirmed with radiographs of the cervical and thoracic spine. A CT scan should be performed whenever there is concern for a fracture following low energy trauma. 
    • Treatment is usually activity modification, physical therapy, and bisphosphonate therapy. Associated spine fractures are treated with long spinal fusion. 
  • 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
    • 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
  • Differential
      • DISH vs AS Table
      • 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
      • Diabetes
      • Yes
      • No
  • Diagnosis
    • 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
  • 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
      • higher mortality rates than cervical spine trauma with ankylosing spondylitis
      • similar mortality rates to patients with ankylosing spondylitis overall
    • 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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