Diffuse idiopathic skeletal hyperostosis

Changed by Ciléin Kearns, 17 Jul 2023
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Disclosures - updated 28 Oct 2022: Nothing to disclose

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Diffuse idiopathic skeletal hyperostosis (DISH), also known 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. DISH is defined as flowing bridging anterior osteophytes spanning at least four vertebral levels, with normal disk spaces and sacroiliac 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. 

Associations

Recognised associations include:

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.

Radiographic features

Plain radiograph and CT
Spinal features

  • flowing ossifications: florid, flowing ossification along the anterior or right 7 anterolateral aspects of at least four contiguous vertebrae. The left lateral aspect is usually spared in the thoracolumbar spine, thought due to aortic pulsation inhibiting ossification 5. For the same reason, the right lateral aspect is spared in situs inversus 5.

  • disc spaces are usually well preserved

  • ankylosis is more common in the thoracic than cervical or lumbar spine

    • frequently incomplete

    • can have interdigitating areas of protruding disc material in the flowing ossifications

  • no sacroiliitis or facet joint ankylosis although sacroiliac joint anterior bridging, posterior bridging, entheseal bridging may be present 10

Extraspinal features

  • enthesopathy of the iliac crest, ischial tuberosities, and greater trochanters

  • spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) 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: 

  • acute spinal fractures in low impact trauma

    • inspect the ossified ligaments for disruption, and compare with prior imaging where available to discern fracture from a region without ossification

    • note that fractures can also occur above or below the rigid segment due to altered biomechanics

    • chalk stick fracture

  • rarely

    dysphagia is reported in ~28% of cases involving the cervical spine 12, which may be caused by mechanical compression due to anterior cervical bone production 8

  • cervical DISH can make intubation more difficult 11

  • lumbar dish can cause radiculopathy 11

    •

Differential diagnosis

  • -<p><strong>Diffuse idiopathic skeletal hyperostosis (DISH)</strong>, also known 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 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>. DISH is defined as flowing bridging anterior osteophytes spanning at least four vertebral levels, with normal disk spaces and sacroiliac joints</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><h5>Associations</h5><p>Recognised associations include:</p><ul>
  • -<li>
  • -<a href="/articles/ossification-of-the-posterior-longitudinal-ligament">ossification of the posterior longitudinal ligament</a>, which may be a cause of spinal stenosis</li>
  • -<li>hyperglycaemia</li>
  • -<li>approximately one-third of patients test positive for <a href="/articles/hla-b27">HLA-B27</a>
  • -</li>
  • -</ul><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>focal and diffuse calcification and ossification of the <a href="/articles/anterior-longitudinal-ligament">anterior longitudinal ligament</a>
  • -</li>
  • -<li>paraspinal connective tissue and annulus fibrosus</li>
  • -<li>degeneration of the peripheral annulus fibrosus fibres</li>
  • -<li>anterolateral extensions of fibrous tissue</li>
  • -<li>hypervascularity</li>
  • -<li>chronic inflammatory cellular infiltration</li>
  • -<li>periosteal new bone formation on the anterior surface of the vertebral bodies</li>
  • -</ul><h5>Location</h5><p>The <a href="/articles/cervical-spine">cervical</a> and thoracic (particularly T7-11 <sup>5</sup>) spines, in particular, are affected. Additionally, <a href="/articles/enthesopathy">enthesopathy</a> may be identified in the <a href="/articles/pelvis-1">pelvis</a> and extremities.</p><h4>Radiographic features</h4><h5>Plain radiograph and CT</h5><h6>Spinal features</h6><ul>
  • -<li>
  • -<a href="/articles/flowing-ossifications">flowing ossifications</a>: florid, flowing ossification along the anterior or right <sup>7</sup> anterolateral aspects of at least four contiguous vertebrae</li>
  • -<li>disc spaces are usually well preserved</li>
  • -<li>ankylosis is more common in the thoracic than cervical or lumbar spine<ul>
  • -<li>frequently incomplete</li>
  • -<li>can have interdigitating areas of protruding disc material in the flowing ossifications</li>
  • -</ul>
  • -</li>
  • -<li>no <a href="/articles/sacroiliitis-differential">sacroiliitis</a> or facet joint ankylosis although sacroiliac joint anterior bridging, posterior bridging, entheseal bridging may be present <sup>10</sup>
  • -</li>
  • -</ul><h6>Extraspinal features</h6><ul>
  • -<li>
  • -<a href="/articles/enthesopathy">enthesopathy</a> of the iliac crest, ischial tuberosities, and greater trochanters</li>
  • -<li>spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) frequently present</li>
  • -<li>'whiskering' <a href="/articles/enthesophyte-2">enthesophytes</a>
  • -</li>
  • -</ul><h4>Treatment and prognosis</h4><p>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: </p><ul>
  • -<li>
  • -<a title="acute spinal fractures" href="/articles/spinal-fractures">acute spinal fractures</a><ul><li><a href="/articles/chalk-stick-fracture">chalk stick fracture</a></li></ul>
  • -</li>
  • -<li>rarely <a href="/articles/dysphagia">dysphagia</a> caused by mechanical compression due to anterior cervical bone production <sup>8</sup>
  • -</li>
  • -</ul><h4>Differential diagnosis</h4><ul>
  • -<li>
  • -<a href="/articles/ankylosing-spondylitis-1">ankylosing spondylitis</a><ul>
  • -<li>syndesmophytes: thinner, form over the annulus, and are vertically orientated ("<a href="/articles/bamboo-spine-ankylosing-spondylitis">bamboo spine</a>") </li>
  • -<li>sacroiliac joint involvement early on and is in the synovial portion (inferior two-thirds)</li>
  • -<li>osteoporosis is prominent</li>
  • -</ul>
  • -</li>
  • -<li>
  • -<a href="/articles/spondylosis">degenerative spine disease</a><ul>
  • -<li>usually has prominent facet and apophyseal joints degenerative changes as well</li>
  • -<li>disc degenerative changes</li>
  • -<li>usually, the <a href="/articles/anterior-longitudinal-ligament">anterior longitudinal ligament</a> of the thoracic spine is not affected <sup>9</sup>
  • -</li>
  • -</ul>
  • -</li>
  • -<li>
  • -<a href="/articles/retinoid-arthropathy">retinoid arthropathy</a> <ul>
  • -<li>patients using <a href="/articles/vitamin-a-1">retinoid acid</a> for skin diseases</li>
  • -<li>skeletal hyperostosis </li>
  • -<li>predominantly involves the <a href="/articles/cervical-spine">cervical spine</a>
  • -</li>
  • -</ul>
  • -</li>
  • -<li>
  • -<a href="/articles/fluorosis">fluorosis</a><ul>
  • -<li>fluorite intoxication due to long-term ingestion</li>
  • -<li>can cause paraspinal ligament calcification</li>
  • -</ul>
  • -</li>
  • -<li>if seen in a child, consider <a href="/articles/juvenile-idiopathic-arthritis">juvenile idiopathic arthritis (JIA)</a>
  • -</li>
  • +<p><strong>Diffuse idiopathic skeletal hyperostosis (DISH)</strong>, also known 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 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>. DISH is defined as flowing bridging anterior osteophytes spanning at least four vertebral levels, with normal disk spaces and sacroiliac joints</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><h5>Associations</h5><p>Recognised associations include:</p><ul>
  • +<li><p><a href="/articles/ossification-of-the-posterior-longitudinal-ligament">ossification of the posterior longitudinal ligament</a>, which may be a cause of spinal stenosis</p></li>
  • +<li><p>hyperglycaemia</p></li>
  • +<li><p>approximately one-third of patients test positive for <a href="/articles/hla-b27">HLA-B27</a></p></li>
  • +</ul><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><p>focal and diffuse calcification and ossification of the <a href="/articles/anterior-longitudinal-ligament">anterior longitudinal ligament</a></p></li>
  • +<li><p>paraspinal connective tissue and annulus fibrosus</p></li>
  • +<li><p>degeneration of the peripheral annulus fibrosus fibres</p></li>
  • +<li><p>anterolateral extensions of fibrous tissue</p></li>
  • +<li><p>hypervascularity</p></li>
  • +<li><p>chronic inflammatory cellular infiltration</p></li>
  • +<li><p>periosteal new bone formation on the anterior surface of the vertebral bodies</p></li>
  • +</ul><h5>Location</h5><p>The <a href="/articles/cervical-spine">cervical</a> and thoracic (particularly T7-11 <sup>5</sup>) spines, in particular, are affected. Additionally, <a href="/articles/enthesopathy">enthesopathy</a> may be identified in the <a href="/articles/pelvis-1">pelvis</a> and extremities.</p><h4>Radiographic features</h4><h5>Plain radiograph and CT</h5><h6>Spinal features</h6><ul>
  • +<li><p><a href="/articles/flowing-ossifications">flowing ossifications</a>: florid, flowing ossification along the anterior or right <sup>7</sup> aspects of at least four contiguous vertebrae. The left lateral aspect is usually spared in the thoracolumbar spine, thought due to aortic pulsation inhibiting ossification <sup>5</sup>. For the same reason, the right lateral aspect is spared in situs inversus <sup>5</sup>.</p></li>
  • +<li><p>disc spaces are usually well preserved</p></li>
  • +<li>
  • +<p>ankylosis is more common in the thoracic than cervical or lumbar spine</p>
  • +<ul>
  • +<li><p>frequently incomplete</p></li>
  • +<li><p>can have interdigitating areas of protruding disc material in the flowing ossifications</p></li>
  • +</ul>
  • +</li>
  • +<li><p>no <a href="/articles/sacroiliitis-differential">sacroiliitis</a> or facet joint ankylosis although sacroiliac joint anterior bridging, posterior bridging, entheseal bridging may be present <sup>10</sup></p></li>
  • +</ul><h6>Extraspinal features</h6><ul>
  • +<li><p><a href="/articles/enthesopathy">enthesopathy</a> of the iliac crest, ischial tuberosities, and greater trochanters</p></li>
  • +<li><p>spur formation in the appendicular skeleton (olecranon, calcaneum, patellar ligament) frequently present</p></li>
  • +<li><p>'whiskering' <a href="/articles/enthesophyte-2">enthesophytes</a></p></li>
  • +</ul><h4>Treatment and prognosis</h4><p>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: </p><ul>
  • +<li>
  • +<p><a href="/articles/spinal-fractures" title="acute spinal fractures">acute spinal fractures</a> in low impact trauma</p>
  • +<ul>
  • +<li><p>inspect the ossified ligaments for disruption, and compare with prior imaging where available to discern fracture from a region without ossification</p></li>
  • +<li><p>note that fractures can also occur above or below the rigid segment due to altered biomechanics </p></li>
  • +<li><p><a href="/articles/chalk-stick-fracture">chalk stick fracture</a></p></li>
  • +</ul>
  • +</li>
  • +<li><p><a href="/articles/dysphagia">dysphagia</a> is reported in ~28% of cases involving the cervical spine <sup>12</sup>, which may be caused by mechanical compression due to anterior cervical bone production <sup>8</sup></p></li>
  • +<li><p>cervical DISH can make intubation more difficult <sup>11</sup></p></li>
  • +<li><p>lumbar dish can cause radiculopathy <sup>11</sup></p></li>
  • +</ul><h4>Differential diagnosis</h4><ul>
  • +<li>
  • +<p><a href="/articles/ankylosing-spondylitis-1">ankylosing spondylitis</a></p>
  • +<ul>
  • +<li><p>syndesmophytes: thinner, form over the annulus, and are vertically orientated ("<a href="/articles/bamboo-spine-ankylosing-spondylitis">bamboo spine</a>") </p></li>
  • +<li><p>sacroiliac joint involvement early on and is in the synovial portion (inferior two-thirds)</p></li>
  • +<li><p>osteoporosis is prominent</p></li>
  • +</ul>
  • +</li>
  • +<li>
  • +<p><a href="/articles/spondylosis">degenerative spine disease</a></p>
  • +<ul>
  • +<li><p>usually has prominent facet and apophyseal joints degenerative changes as well</p></li>
  • +<li><p>disc degenerative changes</p></li>
  • +<li><p>usually, the <a href="/articles/anterior-longitudinal-ligament">anterior longitudinal ligament</a> of the thoracic spine is not affected <sup>9</sup></p></li>
  • +</ul>
  • +</li>
  • +<li>
  • +<p><a href="/articles/retinoid-arthropathy">retinoid arthropathy</a> </p>
  • +<ul>
  • +<li><p>patients using <a href="/articles/vitamin-a-1">retinoid acid</a> for skin diseases</p></li>
  • +<li><p>skeletal hyperostosis </p></li>
  • +<li><p>predominantly involves the <a href="/articles/cervical-spine">cervical spine</a></p></li>
  • +</ul>
  • +</li>
  • +<li>
  • +<p><a href="/articles/fluorosis">fluorosis</a></p>
  • +<ul>
  • +<li><p>fluorite intoxication due to long-term ingestion</p></li>
  • +<li><p>can cause paraspinal ligament calcification</p></li>
  • +</ul>
  • +</li>
  • +<li><p>if seen in a child, consider <a href="/articles/juvenile-idiopathic-arthritis">juvenile idiopathic arthritis (JIA)</a></p></li>

References changed:

  • 11. Shah N, Keraliya A, Nunez D et al. Injuries to the Rigid Spine: What the Spine Surgeon Wants to Know. Radiographics. 2019;39(2):449-66. <a href="https://doi.org/10.1148/rg.2019180125">doi:10.1148/rg.2019180125</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30707647">Pubmed</a>
  • 12. Rustagi T, Drazin D, Oner C et al. Fractures in Spinal Ankylosing Disorders: A Narrative Review of Disease and Injury Types, Treatment Techniques, and Outcomes. J Orthop Trauma. 2017;31(4):S57-74. <a href="https://doi.org/10.1097/bot.0000000000000953">doi:10.1097/bot.0000000000000953</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/28816877">Pubmed</a>

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