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diffuse idiopathic skeletal hyperostosis (DISH, Forestier disease, ankylosing hyperostosis of the spine, spondylosis hyperostotica)
Variant of primary osteoarthritis.
Etiology:
- idiopathic
Epidemiology:
1) occurs primarily in men > 50 years of age [6]
2) up to 10-27% of elderly persons [6]
Pathology:
- non-inflammatory flowing ossification along anterolateral aspect of vertebral bodies (>= 4)
- may occur with or without osteoarthritis of the spine or inflammatory arthritis [2]
- represents a separate finding of ectopic calcification of spinal ligaments & entheses [2]
Clinical manifestations:
1) generally asymptomatic or minimally symptomatic
2) occasional back pain
- case of 76-year-old man with 10-year history of progressive pain & stiffness in the thoracic & lumbar spine.
3) patients are frequently obese
4) diabetes or glucose intolerance (60%)
5) mild back stiffness
- reduced range of motion, esp. at the thoracic spine [2]
- difficulty bending
6) dysphagia may result from anterior osteophytes in the cervical spine compressing the esophagus [7]
7) airway obstruction may result from anterior osteophytes in the cervical spine compressing the trachea [7]
Radiology:
- radiograph of spine
- no vertically bridging syndesmophytes
- osteophytes connecting 4 or more vertebrae
- along anterolateral aspect
- most easily seen in the thoracic spine [2]
- preservation of disk space [1,2]; narrowing of disk space [2]
- preservation of vertebral height [2]
- usually on right side of spine [2]
- hyperostosis in the cervical spine occurs the anterior inferior lip of the vertebra, resulting in a downward-pointing spur
- hyperostosis in the lumbar spine results in spurs tending to point upward
- complete bridging of the lumbar disk space is unusual
- calcification of anterior longitudinal ligaments [2]
- encroachment of intervertebral foramina by osteophytes
- bridging horizontal syndesphophytes [2]
- calcification of pelvic & spinal ligaments
- radiograph of saroiliac joint
- absence of sacroiliac joint inflammatory changes (erosions)
- radiographs
- calcification of enthesis (where tendons & ligaments insert into bone)
- osteophytes at sites of osteoarthritis
- acetabular, olecranon, calcaneus & patellar spurs
- hypertrophic bone formation after joint arthroplasty
Differential diagnosis:
- ankylosing spondylitis (vertically bridging syndesmophytes) [2,3]
- generally begins in 2nd or 3rd decade of life
- onset after age 40 is unusual
Complications:
- dysphagia (see Pathology above)
- airway obstruction (see Pathology above)
- unstable vertebral fractures
- spinal stenosis
- myelopathy
Management:
- no treatment, none usually necessary
Related
osteoarthritis of the spine
osteophyte (bone spur)
General
exostosis; hyperostosis; osteoma; osteoncus
References
- Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed)
Lippincott-Raven, Philadelphia, 1998, pg 832
- Medical Knowledge Self Assessment Program (MKSAP) 11, 16,17, 19.
American College of Physicians, Philadelphia 1998, 2012, 2015, 2022
- Medical Knowledge Self Assessment Program (MKSAP) 19
Board Basics. An Enhancement to MKSAP19.
American College of Physicians, Philadelphia 2022
- Olivieri I, D'Angelo S, Palazzi C, Padula A, Mader R, Khan MA.
Diffuse idiopathic skeletal hyperostosis: differentiation from
ankylosing spondylitis.
Curr Rheumatol Rep. 2009 Oct;11(5):321-8.
PMID: 19772826
- Mader R, Verlaan JJ, Buskila D.
Diffuse idiopathic skeletal hyperostosis: clinical features
and pathogenic mechanisms.
Nat Rev Rheumatol. 2013 Dec;9(12):741-50.
PMID: 24189840
- Westerveld LA, van Ufford HM, Verlaan JJ, Oner FC.
The prevalence of diffuse idiopathic skeletal hyperostosis in
an outpatient population in The Netherlands.
J Rheumatol. 2008 Aug;35(8):1635-8. Epub 2008 Jun 1
PMID: 18528963
- Fournier DE, Leung AE, Battie MC, Seguin CA.
Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) and early-phase DISH
across the lifespan of an American population.
Rheumatology (Oxford). 2024 Apr 2;63(4):1153-1161.
PMID: 37481711 PMCID: PMC10986808 Free PMC article.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10986808/
- Harlianto NI, Kuperus JS, Mohamed Hoesein FAA, et al.
Diffuse idiopathic skeletal hyperostosis of the cervical spine causing dysphagia
and airway obstruction: an updated systematic review.
Spine J. 2022;22(9):1490-1503
PMID: 35283294
https://www.thespinejournalonline.com/article/S1529-9430(22)00100-0/fulltext
- Le HV, Wick JB, Van BW, Klineberg EO.
Diffuse idiopathic skeletal hyperostosis of the spine: pathophysiology, diagnosis,
and management.
J Am Acad Orthop Surg. 2021;29(24):1044-1051
PMID: 34559699 Review