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 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 Diabetes Yes No 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
QUESTIONS 1 of 4 1 2 3 4 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Ankylosing spondylitis 8% (195/2514) 2 Cervical myelopathy 0% (7/2514) 3 Congenital spinal stenosis 0% (8/2514) 4 Diffuse idiopathic skeletal hyperostosis 90% (2275/2514) 5 Ossification of posterior longitudinal ligament 1% (20/2514) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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: A B C 1 Ossification of the posterior longitudinal ligament 4% (139/3345) 2 Rheumatoid arthritis 1% (17/3345) 3 Ankylosing spondylitis 13% (423/3345) 4 Osteoarthritis 1% (46/3345) 5 Diffuse idiopathic skeletal hyperostosis 81% (2695/3345) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK