Updated: 11/1/2021

DISH (Diffuse Idiopathic Skeletal Hyperostosis)

Review Topic
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    • 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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Questions (8)
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(SBQ12SN.80.1) Figure A and Figure B show two distinct hyperostotic conditions of the spine. Which of the following statements is true?

QID: 9101

Patients with the condition shown in FIGURE A have higher rates of neurologic injury with trauma than patients with the condition in FIGURE B



Patients with the condition shown in FIGURE A have a lower rate of surgical treatment with trauma than patients with the condition in FIGURE B



Patients with the condition shown in FIGURE A have a higher mortality rate with trauma than patients with the condition in FIGURE B



Patients with the condition shown in FIGURE A have a higher association with HLA-B8 than patients with the condition in FIGURE B



Patients with the condition shown in FIGURE A have an increased rate isolated disease on the right side of the thoracic spine compared to patients with the condition in FIGURE B



L 4 B

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(SBQ12SP.80) A 57-year-old male with a history of neck stiffness presents after a fall from standing height. He reports severe neck pain but denies subjective weakness in his extremities. Neurological examination reveals normal motor strength in the upper and lower extremities without sensory changes. Figure A is the sagittal CT scan of the cervical spine on presentation. Which of the following is true regarding his clinical presentation and treatment?

QID: 3778

The is a 90% probability that he is HLA-B27 positive



A nondisplaced fracture can be treated with a hard cervical collar and immediate discharge so long as there is close follow up.



The underlying condition is associated with increased morbidity and mortality compared to individuals without the condition



The patient is unlikely to have diabetes or coronary artery disease



The condition usually presents in patients young than 50 years of age



L 2 B

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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

Ossification of the posterior longitudinal ligament



Rheumatoid arthritis



Ankylosing spondylitis






Diffuse idiopathic skeletal hyperostosis



L 2 C

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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?

QID: 1041

Ankylosing spondylitis



Cervical myelopathy



Congenital spinal stenosis



Diffuse idiopathic skeletal hyperostosis



Ossification of posterior longitudinal ligament



L 1 D

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Evidence (15)
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