Diffuse idiopathic skeletal hyperostosis

Changed by Craig Hacking, 12 Feb 2019
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Diffuse idiopathic skeletal hyperostosis (DISH), also referred to as Forestier disease, is a common condition characterised by bony 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. 

Epidemiology

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. 

Clinical presentation

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. 

Pathology

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 fibrosus
  • degeneration of 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:

Radiographic features

Plain 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
  • 'whiskering' enthesophytes

Treatment and prognosis

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: 

Differential diagnosis

  • ankylosing spondylitis
    • syndesmophytes: thinner, form over the annulus, and are vertically orientedorientated ("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
    • 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)
  • -<p><strong>Diffuse idiopathic skeletal hyperostosis (DISH)</strong>, also referred to as <strong>Forestier disease</strong>, is a common condition characterised by bony 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 <a href="/articles/anterior-longitudinal-ligament">anterior longitudinal ligament</a> involving the thoracic spine and enthesopathy (e.g. at the iliac crest, ischial tuberosities, and greater trochanters). There is no involvement of the <a href="/articles/sacroiliac-joint">sacroiliac</a> <a href="/articles/synovial-joints">synovial joints</a>. </p><p><!--?xml version="1.0" encoding="UTF-8" standalone="no"?--></p><h4>Epidemiology</h4><p>DISH most commonly affects the elderly, especially 6<sup>th</sup> to 7<sup>th </sup>decades <sup>3</sup>. The estimated frequency in the elderly is ~10% <sup>6</sup>, with a male predominance. </p><h4>Clinical presentation</h4><p>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. </p><h4>Pathology</h4><p>The aetiology of DISH is still unknown. Histopathological features of spinal DISH include <sup>5</sup>:</p><ul>
  • +<p><strong>Diffuse idiopathic skeletal hyperostosis (DISH)</strong>, also referred to as <strong>Forestier disease</strong>, is a common condition characterised by bony 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 <a href="/articles/anterior-longitudinal-ligament">anterior longitudinal ligament</a> involving the thoracic spine and <a title="Enthesopathy" href="/articles/enthesopathy">enthesopathy</a> (e.g. at the iliac crest, ischial tuberosities, and greater trochanters). There is no involvement of the <a href="/articles/sacroiliac-joint">sacroiliac</a> <a href="/articles/synovial-joints">synovial joints</a>. </p><p><!--?xml version="1.0" encoding="UTF-8" standalone="no"?--></p><h4>Epidemiology</h4><p>DISH most commonly affects the elderly, especially 6<sup>th</sup> to 7<sup>th </sup>decades <sup>3</sup>. The estimated frequency in the elderly is ~10% <sup>6</sup>, with a male predominance. </p><h4>Clinical presentation</h4><p>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. </p><h4>Pathology</h4><p>The aetiology of DISH is still unknown. Histopathological features of spinal DISH include <sup>5</sup>:</p><ul>
  • -<li>'whiskering' enthesophytes</li>
  • +<li>'whiskering' <a title="Enthesophytes" href="/articles/enthesophytes">enthesophytes</a>
  • +</li>
  • -<li>syndesmophytes: thinner, form over the annulus, and are vertically oriented ("<a href="/articles/bamboo-spine">bamboo spine</a>") </li>
  • +<li>syndesmophytes: thinner, form over the annulus, and are vertically orientated ("<a href="/articles/bamboo-spine">bamboo spine</a>") </li>

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