Diffuse idiopathic skeletal hyperostosis

Dr Craig Hacking and Radswiki et al.

Diffuse idiopathic skeletal hyperostosis (DISH), also referred to as Forestier disease, is a common condition characterized by bony proliferation at sites of tendinous and ligamentous insertion of the spine affecting elderly individuals. On imaging, it is typically characterized by the flowing ossification of the anterior longitudinal ligament involving the thoracic spine and enthesopathy (e.g. at the iliac crest, ischial tuberosities, and greater trochanters). There is no involvement of the sacroiliac synovial joints

DISH most commonly affects the elderly, especially 6th to 7th decades 3. The estimated frequency in the elderly is ~10% 6, with a male predominance. 

The condition is commonly identified as an incidental finding when imaging for other reasons. However, spine stiffness and decreased mobility are referred to as possible symptoms. 

The etiology of DISH is still unknown. Histopathological features of spinal DISH include 5:

  • focal and diffuse calcification and ossification of the anterior longitudinal ligament
  • paraspinal connective tissue and annulus fibrosus
  • degeneration of the peripheral annulus fibrosus fibers
  • anterolateral extensions of fibrous tissue
  • hypervascularity
  • chronic inflammatory cellular infiltration
  • periosteal new bone formation on the anterior surface of the vertebral bodies

The cervical and thoracic (particularly T7-11 5) spines, in particular, are affected. Additionally, enthesopathy may be identified in the pelvis and extremities.

Recognized associations include:

  • florid, flowing ossification is noted along the anterior or right 7 anterolateral aspects of at least four contiguous vertebrae, so-called flowing ossifications
  • disk spaces are usually well preserved
  • ankylosis is more commonly seen in the thoracic than in the cervical or lumbar spine
    • frequently incomplete
    • can have interdigitating areas of protruding disk material in the flowing ossifications
  • no sacroiliitis or facet joint ankylosis
  • enthesopathy of the iliac crest, ischial tuberosities, and greater trochanters and spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) are frequently present
  • 'whiskering' enthesophytes

DISH is generally managed clinically with analgesics and non-steroidal anti-inflammatory drugs when pain and stiffness are related. Possible complications may require specific treatment: 

  • ankylosing spondylitis
    • syndesmophytes: thinner, form over the annulus, and are vertically oriented ("bamboo spine") 
    • sacroiliac joint involvement early on and is in the synovial portion (inferior two-thirds)
    • osteoporosis is prominent
  • degenerative spine disease
    • usually has prominent facet and apophyseal joints degenerative changes as well
    • disk degenerative changes
    • usually, the anterior longitudinal ligament of the thoracic spine is not affected 9
  • retinoid arthropathy 
    • patients using retinoid acid for skin diseases
    • skeletal hyperostosis 
    • predominantly involves the cervical spine
  • fluorosis
    • fluorite intoxication due to long-term ingestion
    • can cause paraspinal ligament calcification
  • if seen in a child, consider juvenile idiopathic arthritis (JIA)
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Article information

rID: 12748
Synonyms or Alternate Spellings:
  • Diffuse idiopathic skeletal hyperostosis (DISH)
  • DISH
  • Forestier disease
  • Forestier's disease
  • Ankylosing hyperostosis

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Cases and figures

  • Case 1
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  • Case 2: MRI
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  •  Case 3: pelvis
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  • 3D SSD
    Case 4: 3D SSD
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  • Case 5: cervical
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  • Case 6
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  • Case 7
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  • Case 8
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  • Case 9
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  • Case 10
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  • Anterior to the C...
    Case 11
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  • Case 14
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  • Case 15
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  • Case 16
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  • Case 17: pelvis
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  • Case 18
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