Diffuse idiopathic skeletal hyperostosis
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Diffuse idiopathic skeletal hyperostosis (DISH) or Forestier disease is a common condition characterised by bone proliferation at sites of tendinous and ligamentous insertion of the spine affecting elderly individuals.
Epidemiology
DISH most commonly affects the elderly (especially 6th to 7th decades 3). Its estimated frequency in the elderly is at ~10% 6.
Pathology
Pathological 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 fibrosis fibers
- 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) spine in particular are affected. Additionally, enthesopathy may be identified in the pelvis and extremities.
Associations
Recognised associations include:
- ossification of the posterior longitudinal ligament (OPLL)
- hyperglycaemia
- approximately one-third of patients test positive for
human leukocyte antigen (HLA)B27HLA-B27
If seen in a child, consider juvenile rheumatoid arthritis (JRA).
Radiographic features
Plain film/CTradiograph / 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 disk 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
.
Complications
- acute spinal fractures
- rarely dysphagia 8
Differential diagnosis
- ankylosing spondylitis
- if seen in a child, consider juvenile idiopathic arthritis (JIA)
-</ul><h5>Location</h5><p>The cervical and thoracic (particularly T7-11 <sup>5</sup>) spine in particular are affected. Additionally, <a title="enthesopathy" href="/articles/enthesopathy">enthesopathy</a> may be identified in the pelvis and extremities.</p><h5>Associations</h5><p>Recognised associations include:</p><ul>- +</ul><h5>Location</h5><p>The cervical and thoracic (particularly T7-11 <sup>5</sup>) spine in particular are affected. Additionally, <a href="/articles/enthesopathy">enthesopathy</a> may be identified in the pelvis and extremities.</p><h5>Associations</h5><p>Recognised associations include:</p><ul>
-<li>approximately one-third of patients test positive for human leukocyte antigen (HLA)B27 </li>-</ul><p>If seen in a child, consider <a href="/articles/juvenile-idiopathic-arthritis">juvenile rheumatoid arthritis</a> (JRA).</p><h4>Radiographic features</h4><h5>Plain film/CT</h5><h6>Spinal features</h6><ul>- +<li>approximately one-third of patients test positive for <a title="HLA-B27" href="/articles/hla-b27">HLA-B27</a>
- +</li>
- +</ul><h4>Radiographic features</h4><h5>Plain radiograph / CT</h5><h6>Spinal features</h6><ul>
-<li>no sacroiliitis or facet joint ankylosis</li>- +<li>no <a title="Sacroiliitis" href="/articles/sacroiliac-joint-disease-differential">sacroiliitis</a> or facet joint ankylosis</li>
-<a href="/articles/enthesopathy">enthesopathy</a> of the iliac crest, ischial tuberosities, and greater trochanters and spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) are frequently present.</li></ul><h4>Complications</h4><ul>- +<a href="/articles/enthesopathy">enthesopathy</a> of the iliac crest, ischial tuberosities, and greater trochanters and spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) are frequently present</li></ul><h4>Complications</h4><ul>
-</ul><h4>Differential diagnosis</h4><ul><li><a href="/articles/ankylosing-spondylitis">ankylosing spondylitis</a></li></ul>- +</ul><h4>Differential diagnosis</h4><ul>
- +<li><a href="/articles/ankylosing-spondylitis">ankylosing spondylitis</a></li>
- +<li>if seen in a child, consider <a href="/articles/juvenile-idiopathic-arthritis">juvenile idiopathic arthritis</a> (JIA)</li>
- +</ul>
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