Updated: 6/13/2021

DISH (Diffuse Idiopathic Skeletal Hyperostosis)

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https://upload.orthobullets.com/topic/2045/images/Lateral neck OITE_moved.jpg
https://upload.orthobullets.com/topic/2045/images/dish.jpg
https://upload.orthobullets.com/topic/2045/images/cervical dish.jpg
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  • SUMMARY
    • 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
  • ETIOLOGY
    • 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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(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?

QID: 894
FIGURES:
1

Ossification of the posterior longitudinal ligament

4%

(141/3949)

2

Rheumatoid arthritis

0%

(18/3949)

3

Ankylosing spondylitis

13%

(506/3949)

4

Osteoarthritis

1%

(52/3949)

5

Diffuse idiopathic skeletal hyperostosis

81%

(3203/3949)

L 2 C

Select Answer to see Preferred Response

(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?

QID: 1041
FIGURES:
1

Ankylosing spondylitis

7%

(241/3448)

2

Cervical myelopathy

0%

(11/3448)

3

Congenital spinal stenosis

0%

(14/3448)

4

Diffuse idiopathic skeletal hyperostosis

91%

(3137/3448)

5

Ossification of posterior longitudinal ligament

1%

(29/3448)

L 1 D

Select Answer to see Preferred Response

Evidence (12)
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