Diffuse idiopathic skeletal hyperostosis

Radswiki et al.

Diffuse idiopathic skeletal hyperostosis (DISH), also referred to as Forestier disease, is a common condition characterised by bone proliferation at sites of tendinous and ligamentous insertion of the spine affecting elderly individuals.

On imaging, it is typically characterised 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 at ~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 as possible symptoms. 

The aetiology 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 fibrosis
  • degeneration in the peripheral annulus fibrosus fibres
  • anterolateral extensions of fibrous tissue
  • hypervascularity
  • chronic inflammatory cellular infiltration
  • periosteal new bone formation on the anterior surface of the vertebral bodies
Location

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

Associations

Recognised associations include:

Radiograph and CT
Spinal features
  • florid, flowing ossification is noted along the anterior or right 7 anterolateral aspects of at least four contiguous vertebrae, so-called flowing ossifications
  • disc 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 disc material in the flowing ossifications
  • no sacroiliitis or facet joint ankylosis
Extraspinal features
  • enthesopathy of the iliac crest, ischial tuberosities, and greater trochanters and spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) are frequently present

DISH is generally managed clinically with analgesics and nonsteroidal 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
    • disc degenerative changes
  • 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
Section: Pathology
Synonyms or Alternate Spellings:
  • Diffuse idiopathic skeletal hyperostosis (DISH)
  • DISH
  • Forestier disease
  • Forestier's disease
  • Ankylosing hyperostosis

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Cases and Figures

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    Case 2: MRI
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     Case 3: pelvis
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    Case 5: cervical
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    Diffuse idiopathic skeletal hyperostosis (DISH)
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