Article

Confusion of roentgenographic differential diagnosis between ankylosing hyperostosis (Forestier's disease) and ankylosing spondylitis

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Abstract

A patient with ankylosing hyperostosis (Forestier's disease) initially diagnosed elsewhere as a case of ankylosing spondylitis with bamboo spine, is presented. The characteristic roentgenographic findings of Forestier's disease in the axial skeleton of this patient are described, including computerized tomography of the lower lumbar spine and sacroiliac joints. Major clinical and radiological distinguishing features of Forestier's disease and ankylosing spondylitis are discussed.

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... Both diseases produce bone proliferation in the spine and at the extraspinal entheseal sites in the later phases of their disease course. Although the aspect of these bone proliferations is dissimilar, confusion of radiographic differential diagnosis between the two diseases exists mostly as a consequence of a lack of aware-ness of their characteristic features [2,3]. In fact, Khan [4] pointed out the error when a patient was reported suffering from AS when the published radiographs in a prestigious medical journal strongly supported the diagnosis of ankylosing hyperostosis. ...
... DISH may also affect the sacroiliac joints, which can further result in being mistaken for sacroiliitis of AS. The upper (ligamentous) portion of the joint may show changes, such as vacuum phenomenon, narrowing, sclerosis, and even partial or complete bony ankylosis [2,3,[28][29][30][31]. The lower two-third (synovial) part of the joint is spared. ...
... The lower two-third (synovial) part of the joint is spared. However, ossifi cation of the joint capsule on the anterior surface of the joint may occur, resembling the obliteration of the sacroiliac joints on anteroposterior pelvic radiograph that may erroneously be interpreted as postinfl ammatory ankylosis of the joint [2,3,[28][29][30][31][32]. CT can be useful in these cases by showing the normal aspect of joint space and bony margins, and presence of the anterior capsular ossifi cations [30,31]. ...
Article
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Diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) share involvement of the axial skeleton and peripheral entheses. Both diseases produce bone proliferations in the later phases of their course. Although the aspect of these bone proliferations is dissimilar, confusion of radiologic differential diagnosis between the two diseases exists mostly as a consequence of a lack of awareness of their characteristic clinical and radiographic features. The confusion may extend to the clinical field because both advanced DISH and advanced AS may cause the same limitations of spinal mobility and postural abnormalities. However, the radiologic spinal findings are so different that changes due to each disease can be recognized even in patients in whom both diseases occur. This article reviews the clinical and radiologic characteristics that should help clinicians differentiate between the two diseases without much difficulty.
... One of the hallmarks of SpA, in particular AS, is the involvement of the pelvis, mainly the sacroiliac joints (SIJ) [4]. Involvement of entheseal attachment in the pelvis in both SpA and DISH has long been reported based on plain radiographs [6][7][8][9]. Involvement of the SIJ in DISH typically involves its upper non-synovial portion, while the lower synovial portion is spared. A recent study examined structural changes in patients with DISH using computed tomography (CT) [10] and noted that fusion was observed not only in the entheseal sites but also in the synovial part of the SIJ. ...
Article
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Purpose of Review Diffuse Idiopathic Skeletal Hyperostosis (DISH) is considered a metabolic condition, characterized by new bone formation affecting mainly at entheseal sites. Enthesitis and enthesopathies occur not only in the axial skeleton but also at some peripheral sites, and they resemble to some extent the enthesitis that is a cardinal feature in spondyloarthritis (SpA), which is an inflammatory disease. Recent Findings We review the possible non-metabolic mechanism such as inflammation that may also be involved at some stage and help promote new bone formation in DISH. We discuss supporting pathogenic mechanisms for a local inflammation at sites typically affected by this disease, and that is also supported by imaging studies that report some similarities between DISH and SpA. Summary Local inflammation, either primary or secondary to metabolic derangements, may contribute to new bone formation in DISH. This new hypothesis is expected to stimulate further research in both the metabolic and inflammatory pathways in order to better understand the mechanisms that lead to new bone formation. This may lead to development of measures that will help in earlier detection and effective management before damage occurs.
... In fact, the recognition of sacroiliitis by standard radiographs is more problematic because of changes induced by age (osteoporosis, osteoarthritis, and discarthrosis). DISH and SpA have in common the involvement of axial skeleton and extraspinal entheses but their radiological features are different [35,36]. MRI is a very helpful imaging method for the diagnosis of axial SpA. ...
Conference Paper
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... DISH has been recognised only relatively recently and is not mentioned in contemporary palaeopathological texts.19 25 It can cause fusion of the upper third of the sacroiliac joints26 and causes confusion with AS in medicine today. 27 We have therefore examined previous reports of AS in the palaeopathological literature. ...
Article
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Five hundred and sixty intact skeletons and several thousand disarticulated vertebrae have been examined with special reference to spinal fusion. In period they ranged from a 21st dynasty Egyptian mummy to a mid-19th century skeleton. Osteophytes were found in about half of the specimens, as reported previously. Fifteen skeletons with extensive blocks of spinal fusion were also identified. Sacroiliitis was present in two, but the asymmetrical spinal disease and peripheral joint changes suggested Reiter's disease or psoriatic spondylitis rather than ankylosing spondylitis. The remaining 13 had typical features of Forrestier's disease, and extraspinal findings indicative of diffuse idiopathic skeletal hyperostosis (DISH) were also common. A review of the available literature suggests that many palaeopathological specimens previously reported as anklylosing spondylitis are examples of DISH or other seronegative spondylarthropathies. The antiquity and palaeopathology of AS needs reappraisal.
... Spinal involvement of DISH is characterized by "flowing mantles" of ossification occurring in the anterior longitudinal ligament and to a lesser extent in the paravertebral connective tissue and the peripheral part of the annulus fibrosus. 3 Frequently on lateral view, radiolucency is noted between the new bone and the vertebral body. The thoracic region is predominantly affected, but all levels may be involved. ...
... Diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) are the 2 most common diseases that are characterized by ossification of the ligaments and tendons in both the axial skeleton and peripheral sites (1)(2)(3). Formation of new bone in the spine is most typically seen at the anterior site of the vertebrae, but it does also occur at other sites in both diseases (4,5). The lower part of the thoracic spine and the upper part of the lumbar spine are the most frequently involved regions in both conditions (6)(7)(8). ...
Article
Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are both characterized by new bone formation in the spine but presumably have a different pathogenesis. This study was undertaken to compare the natural course of new bone formation in AS and DISH. Lateral radiographs of the cervical and lumbar spine from AS and DISH patients obtained at ≥2 time points within 6 years were analyzed to quantify osteophyte development. Radiographs were scored in a blinded manner by 2 readers using the modified Stoke AS Spine Score (mSASSS). Bone spurs were categorized as having an angle of <45° or >45°. AS patients (n = 146) were younger than DISH patients (n = 141) (mean ± SD 54.2 ± 12.3 years versus 60.3 ± 7.7 years). Symptom duration (mean ± SD) was 23.6 ± 11.2 years in AS patients and 21.6 ± 12.4 years in DISH patients. The mSASSS at baseline was lower in DISH patients (mean ± SD 14.3 ± 6.7) than in AS patients (20.5 ± 14.5) but had increased by a similar amount at followup (3.3 ± 4.2 versus 4.1 ± 9.5). The mean mSASSS progression rate per year (1.3 units) was also comparable. The mean ± SD number of syndesmophytes per patient was higher in AS (5.7 ± 5.5) than DISH (2.7 ± 2.8) patients (P < 0.001), while degenerative bone spurs (mean ± SD) were more frequent in DISH (1.4 ± 1.8) than AS (1.0 ± 1.4) patients. AS patients developed more new bone spurs with an angle of <45° than >45° per patient (mean ± SD 2.1 ± 2.7 versus 0.6 ± 0.9) (P < 0.001), while similar amounts of both types of bone formation were seen in DISH patients. Our findings indicate that the rates of new bone formation in AS and DISH are largely similar. Both groups show osteophyte development, but as expected, syndesmophytes are more frequent in AS patients while DISH patients have more degenerative bone spurs. The nature of the different mechanisms of bone formation needs further study.
... De igual manera, los pacientes que son HLA-B27 positivos desarrollan la enfermedad a una edad más temprana, presentan una mayor agregación familiar, tienen síntomas articulares más severos y prolongados y además tienen un riesgo mayor de presentar sacroiliítis y espondilitis 1,5,58,132 . La tipificación del HLA-B27 ha sido útil en casos en los cuales se presenta una confusión diagnóstica radiológica, por ejemplo, entre espondilitis anquilosante y la hiperostosis anquilosante (enfermedad de Forestier) 133 . ...
Article
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Resumen Las espondiloartropatías son un grupo de enfer-medades inflamatorias crónicas, de las cuales se des-tacan especialmente la espondilitis anquilosante, artritis reactiva, artritis psoriásica, artritis asocia-da con la enfermedad inflamatoria intestinal y las espondiloartropatías indiferenciadas. Los subgrupos más comunes de espondiloartropatías son la espondilitis anquilosante y la espondiloartropatía indiferenciada. El diagnóstico de la espondilitis anquilosante se basa especialmente en los hallazgos radiológicos inequívocos de sacroiliítis de grado 2 bilateralmente o grado 3 unilateralmente. Sin em-bargo en la fase temprana de la enfermedad, los es-tudios radiológicos no son lo suficientemente sensibles como para mostrar la presencia de sacroiliítis y por lo general pueden tardar varios años para detectar la presencia de sacroiliitis radiológica; de esta ma-nera el diagnóstico de espondilitis anquilosante pue-de tardar hasta 8 a 11 años luego del inicio de los síntomas; como consecuencia de ello, el diagnóstico de espondiloartropatía con compromiso axial en au-sencia de sacroiliítis radiológica es de gran dificul-tad para el reumatólogo. En los estadíos tempranos, el test de HLA B27 y la resonancia magnética de articulaciones sacroiliacas son útiles en el diagnósti-co temprano. En presencia de dolor crónico de es-palda la probabilidad de espondiloartropatía axial es de un 5% y aumenta a un 14% en presencia de dolor de espalda inflamatorio; la probabilidad de espondiloartropatía axial aumenta a un 90% en pre-sencia de = 3 hallazgos de espondiloartropatías (talagia, uveítis, dactilitis, historia familiar positiva, dolor glúteo alternante, psoriasis, enfermedad inflamatoria intestinal, artritis asimétrica, respues-ta favorable a los antiinflamatorios no esteroideos). De otra parte, la positividad del HLA B27 y la reso-nancia magnética aumentan la probabilidad de la en-fermedad, en especial en aquellos casos que no presentan otros hallazgos de espondiloartropatías o que presentan 1 a 2 manifestaciones de espondilo-artropatías. En pacientes con espondiloartropatía psoriásica o asociada con la enfermedad inflamatoria intestinal el uso del HLA B27 es de valor limitado, ya que estas entidades por lo general tienen una aso-ciación negativa con el HLA B27. También se debe tener en cuenta, que la utilidad del HLA B27 y sus diferentes subtipos difiere entre los diferentes gru-pos étnicos y su valor en el diagnóstico depende de la probabilidad pre-test individual de cada caso. Palabras Clave: espondiloartropatías seronega-tivas, espondilitis anquilosante, diagnostico temprano.
... Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are two different diseases sharing the involvement of axial skeleton and peripheral entheses [1,2]. Symptoms of AS start at a young age, usually in late adolescence and early adulthood, and consist of inflammatory spinal pain and stiffness, decreasing range of spinal motion, and after many years the illness can result in characteristic postural abnormalities ('Bechterew stoop'). ...
Article
Full-text available
To describe a case-series of patients who presented with the typical postural abnormalities of long-standing advanced ankylosing spondylitis (AS) but were instead found to suffer from diffuse idiopathic skeletal hyperostosis (DISH). We enrolled consecutive patients who showed postural abnormalities, which at first suggested to us the diagnosis of long-standing advanced AS, although the diagnostic process led us to the correct diagnosis of DISH. Each patient had a complete physical examination and radiographs of the spine and pelvis, and was investigated for HLA-B27 locus typing. From 15 June 1998 to 15 June 2006, 15 patients with DISH were seen who presented with the typical postural abnormalities of long-standing advanced AS. All patients were males with a median age of 69 yrs (range 51-91). All lacked HLA-B27 and denied personal or family history of spondyloarthritis. All measurements assessing cervical, thoracic and lumbar spinal movement were abnormal. Patients suffering from DISH can occasionally have severe limitations of spinal mobility, along with postural abnormalities that resemble long-standing advanced AS. Thus, the differential diagnosis between DISH and advanced AS is not limited to the radiological findings and can also extend to the clinical findings in the two diseases, as is highlighted by our report.
... DISH needs to be distinguished from ankylosing spondylitis. Diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) are the two most common diseases that are characterized by ossification of the ligaments in both the axial skeleton and peripheral sites 12,13,14 . Both diseases produce bone proliferations in the later phases of their course and in advanced stages cause the same limitations of spinal mobility and postural abnormalities. ...
Article
Full-text available
The ossification of the anterior longitudinal ligament may be a part of diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier’s disease. We are describing a case of ossification of the anterior longitudinal ligament in the region of thoracic spine, found on routine examination of dry bones.
... AS and DISH are two separate enthesitis-related diseases, in which bony ankylosis of the axial skeleton and peripheral enthesopathies occur. Although the spinal radiographic findings differ, in AS, the ankylosis involves the annulus fibrosus of the intervertebral discs while in DISH, the ALL is the primary anatomical site of ossification; the distinction between the two entities may be difficult [11]. SIJ damage caused by sacroiliitis is the radiographic hallmark of AS, and though DISH was initially classified by the absence of SIJ involvement [1], it became evident that the anterior capsule of the SIJ can ossify and thus be confused with the post-inflammatory sacroiliac fusion characteristic of advanced AS on anteroposterior pelvic radiographs [12]. ...
Article
Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory condition that involves calcification and ossification of the spinal ligaments and entheses. While, characteristic magnetic resonance imaging (MRI) lesions of the spine in patients with axial spondyloarthritis, another enthesitis-related disease, have been described and defined, there is a paucity of information regarding the MRI findings in DISH. The aim of this study was to describe the MRI findings of patients with DISH. We collected computed tomography studies with findings characteristic of DISH and that also had corresponding and concurrent MRI studies of the spine. For each patient, sagittal T1-weighted and STIR MRI sequences were evaluated for anterior/posterior vertebral corners of bone marrow edema (BME) and fat deposition. In total, we assessed 156 vertebral units in 10 patients that had both radiographic evidence of DISH and available MRI studies of the spine. Lesions consistent with BME corners were detected in five patients, and in three of them, three separate sites were involved, a finding that is suggestive of axial spondyloarthritis (SpA) according to the ASAS/OMERACT consensus statement. Fat deposition corners were detected in eight patients and in seven of them, several sites were involved. Spinal MRI lesions that are characteristic of axial SpA were commonly observed in a cohort of patients with DISH. This bears relevance to cases with diagnostic uncertainty and may imply overlapping pathogenetic mechanisms for new bone formation in both SpA and DISH. Further study is indicated to better characterize the similarities and differences between the MRI lesions of DISH and SpA.
... Whereas findings in the WB-MRI reformed the classification criteria for SpA 3 and became part of the new diagnosis of nonradiographic SpA, the Resnick criteria for DISH are still based on findings from conventional radiographs of the spine 4 . In clinical practice, later stages of the 2 illnesses may overlap both clinically and radiologically, because patients with back pain from an axial form of psoriatic arthritis (PsA) may present with coarse parasyndesmophytes and patients with back pain diagnosed with DISH may show hyperostotic excrescences on spine radiographs 5,6 . To make it even more complicated, both diseases may occur in the same patient, as 1 study showed 7 . ...
Article
Full-text available
Objective: Discrimination of diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) can be challenging. Usefulness of whole-body magnetic resonance imaging (WB-MRI) in diagnosing spondyloarthritis has been recently proved. We assessed the value of clinical variables alone and in combination with WB-MRI to distinguish between DISH and AS. Methods: Diagnostic case-control study: 33 patients with AS and 15 patients with DISH were included. All patients underwent 1.5 Tesla WB-MRI scanning. MR scans were read by a blinded radiologist using the Canadian-Danish Working Group's recommendation. Imaging and clinical variables were identified using the bootstrap. The most important variables from MR and clinical history were assessed in a multivariate fashion resulting in 3 diagnostic models (MRI, clinical, and combined). The discriminative capacity was quantified using the area under the receiver-operating characteristic (ROC) curve. The strength of diagnostic variables was quantified with OR. Results: Forty-eight patients provided 1545 positive findings (193 DISH/1352 AS). The final MR model contained upper anterior corner fat infiltration (32 DISH/181 AS), ankylosis on the vertebral endplate (4 DISH/60 AS), facet joint ankylosis (4 DISH/49 AS), sacroiliac joint edema (11 DISH/91 AS), sacroiliac joint fat infiltration (2 DISH/114 AS), sacroiliac joint ankylosis (2 DISH/119 AS); area under the ROC curve was 0.71, 95% CI 0.64-0.78. The final clinical model contained patient's age and body mass index (area under the ROC curve 0.90, 95% CI 0.89-0.91). The full diagnostic model containing clinical and MR information had an area under the ROC curve of 0.93 (95% CI 0.92-0.95). Conclusion: WB-MRI features can contribute to the correct diagnosis after a thorough conventional workup of patients with DISH and AS.
Article
Spinal involvement in spondyloarthropathy is characterized by inflammation concentrated at the site of bony insertion of ligaments and bones. These inflammatory sites show a peculiar tendency towards prominent fibrosis, ossification and new bone formation (syndesmophytes). The syndesmophytes arise either at the margins of intervertebral disc and these are called marginal syndesmophytes as in ankylosing spondylitis, or from the vertebral bodies beyond their corners and are called nonmarginal syndesmophytes as in psoriatic arthritis and Reiter's syndrome (1,2). In some references and in the European literature, the term 'syndesmophyte' is usually reserved for the vertical ossification that bridges two adjacent vertebrae in ankylosing spondylitis (3). Syndesmophytes predominate on the anterior and lateral aspect of the spine (1-3). We report a patient with undifferentiated spondyloarthropathy with posterior syndesmophytes resulting in symptomatic spinal stenosis.
Article
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Conventional radiography and magnetic resonance imaging (MRI) are currently the most widely used imaging methods for the initial diagnostic evaluation and follow-up of patients with ankylosing spondylitis (AS). Scintigraphy, computed tomography (CT), and positron emission tomography (PET) only play minor roles, although some are being further developed. AS is characterized by inflammatory changes to the sacroiliac joints (SIJs) and spine, as well as asymmetrical arthritis of the peripheral joints and joints near the trunk. The diagnosis of AS is based on clinical parameters and the presence of chronic inflammatory changes to the SIJs on conventional radiographs. Typical radiographic changes also involve the spine. MRI depicts not only chronic changes, but also active inflammatory lesions, which are important for the diagnosis of early disease and precursors of AS. The scoring system of choice for quantifying spinal changes depicted by conventional radiography is the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). MRI allows the quantitative evaluation of changes involving the SIJs and the spine. Various MRI scoring systems have been proposed to quantify these changes, but they require further validation. This review article presents the imaging modalities used in AS patients, typical findings, and relevant methods of analysis. The most recent developments are discussed.
Article
In recent years, great progress has been made in the development of diagnostic tools, therapeutic approaches, and validated outcome measures in the understanding of the pathogenesis of ankylosing spondylitis (AS). The purpose of this review was to summarize these developments. We performed a PubMed search for the period 1978 to 2005, using the keyword, "ankylosing spondylitis," resulting in a total of 4878 publications, including 778 reviews. Articles were then selected based on their discussion of recent diagnostic tools and new treatment approaches in the pathogenesis of AS, leading to a final total of 104 articles. In recent years, there have been 2 major developments in the management of AS that make earlier diagnosis possible and offer the hope of alleviating pain and preventing structural changes that result in loss of function. These developments include the use of magnetic resonance imaging to visualize the inflammatory changes in the sacroiliac joint and the axial spine, and the demonstration that tumor necrosis factor blocking agents are highly efficacious in reducing spinal inflammation and possibly in slowing radiographic progression. There have been major advances in both the diagnostic tools and the therapeutic regimens available for patients with AS.
Article
To challenge the diagnosis of ankylosing spondylitis in the mummy of Ramesses II that was suggested about 30 years ago and to propose a differential diagnosis for the changes that were detected in the mummy's spine and pelvis. We read and interpreted both the published and unpublished radiographs of the mummy. Changes in the mummy's spine and pelvis included ossification of the anterior longitudinal ligament at the cervical spine level, ossified enthesopathy of both the right and left rectus femoris tendons as well as the right ischial tuberosity, a large osteophyte at both acetabula margins, no ankylosis of the cervical apophyseal joints and no ankylosis of the right sacroiliac joint. The radiologic evidence does not support the claim that Ramesses II had ankylosing spondylitis. Our radiologic reappraisal suggests instead the diagnosis of diffuse idiopathic skeletal hyperostosis. This new diagnosis needs to be validated by a computed tomographic scan of the mummy.
Article
Full-text available
Patients with ankylosing spondylitis (AS) are characterised by a wide range of clinical presentations, radiographic profiles, and outcomes, which are not well differentiated by current diagnostic and classification systems for the disorder. Inadequacies in these systems may limit clinicians' ability to manage their patients with AS appropriately and act as an obstacle to reasonable comparison of therapeutic trial results. A standardised staging system for AS is therefore proposed that would provide a more detailed categorisation of patients based on assessment of structural damage, peripheral joint and organ involvement, presence of concomitant diseases, and the severity and extent of disease activity and functional impairment. The proposed system needs to be evaluated closely and amended as needed to assure its usefulness in clinical and research settings.
Article
Sacroiliitis is an indispensable condition for the diagnosis of ankylosing spondylitis according to the present criteria and is usually diagnosed on standard anteroposterior radiographs of the pelvis. In cases with suspicious abnormalities (grade 1 of the New York criteria) CT permits the diagnosis since it shows a higher degree of sacroiliitis. MRI is superior to CT in the early diagnosis as it can detect the cartilage abnormalities which precede bony changes. 'Romanus lesions' with 'shiny corners', 'squaring' of the vertebral bodies, syndesmophytes, spondylodiscitis and osteoporosis are the radiological findings of ankylosing spondylitis. The nonmarginal, asymmetric, coarse and broad syndesmophytes of psoriatic spondylitis and spondylitis associated with Reiter's syndrome resemble the flowing bone outgrowths of diffuse idiopathic skeletal hyperostosis (DISH). The ossification of the posterior longitudinal ligament and of the flavum ligament are rare manifestations of ankylosing spondylitis. Peripheral extra-articular enthesitis is a clinical hallmark of seronegative spondylarthropathies. Plain film radiography shows erosions and spurs but only in advanced phases. US shows the swelling of the entheses and the peritendinous soft tissues and the distension of adjacent bursae by fluid collection. MRI shows the inflammation of the bone adjacent to the insertion as well as the soft tissue changes. Dactylitis is another typical manifestation of seronegative spondylarthropathies. In the past it was thought to be due to concomitant tenosynovitis and arthritis. Recently, however, we have demonstrated with US and MRI that the 'sausage-like' appearance is due to the flexor tenosynovitis and that joint capsule distension is not indispensable.
Article
Bioarchaeological research of ancient Amerindians was undertaken to test the hypothesis that seronegative spondyloarthropathies (SNS) and diffuse idiopathic skeletal hyperostosis (DISH) existed in prehistoric South Americans. An osteological-radiographic model was developed from clinical literature and systematically applied to 504 archaeological human remains housed at the Universidad de Tarapacá in Arica, Chile, to search for evidence of these arthritides. The results showed that SNS existed with an average frequency of 7% for the adult sample and DISH averaged 4% in individuals over 40 years old. It was found that the antiquity of SNS date back at least 5,000 years in both New World and Old World populations. In contrast, the antiquity of DISH in the Americas is not clear because no previous studies have dealt with this subject; however, this research finds mild DISH cases dating back 4,000 years in northern Chile. It was also found that SNS and DISH exhibit a trend of increasing incidence with the advent of agro-pastoral activities and village formation.
Article
The paleopathological study of human osteological remains from the site of Semna South, of northern Sudan, revealed that about thirteen percent of this ancient Nubian population had diffuse idiopathic skeletal hyperostosis (DISH). As in modern cases, males were more affected than females. Two thousand years ago, ancient Nubian males had the same spinal problems elderly men have today.
Article
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To the best of our knowledge, only two patients with concurrent diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) have been reported so far. Here we present 3 patients in whom clinical and radiological findings indicative of DISH and AS coexisted. Two of these cases exhibited HLA B27. Although the presence of sacroiliitis would appear to exclude DISH, calcification and ossification of the anterior common vertebral ligament (ACVL) confirmed diagnosis of the latter disease.
Article
Objectives: AS and DISH are both spinal ankylosing conditions with a 4-fold increased risk of spinal fractures. The most commonly used criteria for DISH were designed to exclude radiographic signs of spondyloarthritis. However, case reports describing the presence of both conditions exist. In this study, the co-occurrence of AS and DISH were reviewed in the literature to explore the potential need to revise the criteria for DISH. Methods: A search was conducted in Pubmed, Embase, Web of Science and the Cochrane library using the terms 'spondyloarthritis' and 'DISH' and their matching synonyms. Full-text articles describing the coexistence of both conditions in the same patient were included. A quality assessment was performed, and the case descriptions were extracted. Results: Twenty articles describing simultaneous occurrence of AS and DISH in 39 cases were retrieved. All articles were case reports or series of moderate quality. Back or neck pain was present in 97% of the patients (mean age 61.2 years, 90% male) and HLA-B27 was positive in 9/27 documented measurements. Radiographic abnormalities were described in the SI joint (82% AS, 13% DISH) and in the spine (49% AS, 100% DISH). Conclusion: Simultaneous occurrence of AS and DISH has been reported in the literature in at least 39 cases. AS and DISH should not be seen as mutually exclusive. If the results of the current study are confirmed in a large observational study, revision of the current criteria to include the co-existence of both conditions should be considered.
Article
The spondyloarthropathies are strongly associated with the HLA-B27 gene. The diagnosis is based primarily on clinical findings. Ankylosing spondylitis often involves the sacroiliac joints and spine. Psoriatic arthritis occurs in up to one-third of patients with psoriasis. Reactive arthritis must be distinguished from other arthropathies. Arthritis occurs in about 30% of patients with inflammatory bowel disease. Undifferentiated spondyloarthropathy includes several related disorders. Radiographic evidence of sacroiliitis is a characteristic feature of ankylosing spondylitis. Management of spondyloarthropathies should include patient education and regular exercise. NSAIDs are the first line of treatment. The tumor necrosis factor-α inhibitors are highly effective in patients with active ankylosing spondylitis and in those with psoriatic arthritis that is unresponsive to conventional therapy.
Article
Diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) are 2 clearly different disease entities having in common the involvement of the axial skeleton and the peripheral entheses1,2. Both diseases produce bone proliferation in the spine and at the extraspinal entheseal sites in the later phases of their course. Although the aspects of the bone proliferations of the 2 diseases are dissimilar, confusion …
Article
To the Editor: I read with great interest the recent editorial on diffuse idiopathic skeletal hyperostosis (DISH) by Dr. Mader1. The author affirms the clinical relevance of this skeletal disorder because of its various complications, some of which are very important in clinical practice (e.g., dysphagia, spinal fracture, spinal lumbar stenosis, neurologic complications, postsurgical heterotopic ossifications, etc). He also emphasizes the need of updating diagnostic criteria (at least 3 sets are used) to obtain a more accurate and timely diagnosis of this condition in its early phases. Dr. Mader is to be congratulated for his interesting paper; however, while defining the still insufficient current diagnostic criteria, he omits comment on possible explanations for this critical diagnostic phase. I would like to express some considerations on the causes of the limited availability of diagnostic tools for DISH. Forestier’s disease, a common name for DISH, particularly in European countries of Latin origin, is an ancient skeletal disorder whose pathologic alterations were described in human skeletons going back to 5000 years ago …
Article
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Die konventionelle Röntgendiagnostik und die Magnetresonanztomographie (MRT) werden für die Diagnostik und Verlaufskontrolle von Patienten mit ankylosierender Spondylitis (AS) bevorzugt eingesetzt. Szintigraphie, Computertomographie (CT) und Positronenemissionstomographie (PET) spielen heutzutage eine untergeordnete Rolle, werden aber teilweise weiterentwickelt. Merkmale der AS sind entzündliche Veränderungen der Sakroiliakalgelenke (SIG) und der Wirbelsäule sowie asymmetrische Arthritiden von stammnahen oder peripheren Gelenken. Die Diagnose der AS wird neben klinischen Parametern anhand chronisch entzündlicher Veränderungen der SIG in den konventionellen Röntgenaufnahmen gestellt. Auch an der Wirbelsäule werden typische Röntgenveränderungen der AS beobachtet. Die MRT kann neben den chronischen Veränderungen auch aktive entzündliche Läsionen abbilden, die wichtig für die Diagnostik der Frühformen und Vorläufererkrankungen der AS sind.Scoringmethode der Wahl für konventionelle Röntgenveränderungen der AS an der Wirbelsäule ist der modifizierte Stokes Ankylosing Spondylitis Spine Score (mSASSS). Mit der MRT können Veränderungen an den SIG und an der Wirbelsäule quantifiziert werden. Es existieren Vorschläge für verschiedene MR-Scoringsysteme bei AS, deren Zuverlässigkeit weiter evaluiert werden muß. Dieser Übersichtsartikel stellt die verwendeten Methoden der Bildgebung, typische Befunde und relevante Auswertemethoden vor. Die neuesten Entwicklungen auf diesem Gebiet werden berücksichtigt.
Article
Since diffuse idiopathic skeletal hyperostosis (DISH) is frequently difficult to differentiate radiologically from the axial involvement of ankylosing spondylitis and osteoarthrosis, some features of these 3 different diseases were compared. The predominantly horizontal nature of the enthesiophyte in DISH and its right preponderance in the thoracic region were demonstrated. This right preponderance was due to the presence of the thoracic aorta located in the left thoracic side. A midthoracic notch was described in DISH which seemed to be confined to noninflammatory conditions, but was not found in ankylosing spondylitis. The importance of sacroiliac computerized tomography to differentiate sacroiliac joint abnormalities associated with DISH from the sacroiliitis of spondylarthropathies was stressed.
Article
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Radiographs of 175 patients with diffuse idiopathic skeletal hyperostosis (DISH) of the spine or ankylosing spondylitis were reviewed. DISH most frequently began in the middle and lower portions of the thoracic spine; it was rare in the upper portion. A few vertebrae were first affected, and then involvement extended, sometimes throughout the thoracic spine. The anterior and lateral aspects of vertebral bodies were mainly affected. Hyperostosis vertically spanning the anterior aspects of the vertebrae varied in thickness up to 10 mm, and the rate at which the hyperostosis proliferated was not specific for any vertebra. Males were 12 times more frequently affected than females, especially in the older age groups. Diabetes mellitus and hypertension have reportedly been associated with DISH, but no such correlation was found in this study. Despite the existence of criteria for differential diagnosis, it is sometimes difficult to distinguish ankylosing spondylitis from DISH radiologically. The radiologic features helpful in the differential diagnosis are described, and a review of the pertinent literature is included.
Article
Nine radiodiagnostic rules are drawn from the X-rays of 2125 ankylosing spondylitis patients. The significance of early diagnosis of the 'multicolored' saroiliac X-ray is looked onto; the syndesmophyte, squaring-phenomenon, barrel-shaped vertebra, Romanus and Andersson lesions, and the ossification of ligaments are discussed. The changes at the apophyseal and the costovertebral joints, unimportant for early diagnosis, are explored.
Article
HLA antigens were studied in three different groups of 50 patients each. These included (a) Forestier's disease, (b) ankylosing spondylitis, and (c) polyarthrosis of the hands. HLA typing included 12 specificities from locus A and 15 from locus B, the frequencies being compared to those in 700 normal controls. No significant differences were found in the frequency of distribution between the polyarthrosis patients and the normal population. In patients with Forestier's disease, B5 was increased, but this was not a significant difference. The antigen B27 was present in 94 per cent of patients with ankylosing spondylitis, confirming previous studies.
Article
Degenerative disease of the sacroiliac joint is common in middle-aged and elderly patients. Its radiographic features simulate those of ankylosing spondylitis. Interosseous space narrowing, subchondral sclerosis, and osteophytosis are apparent. Although intraarticular bony ankylosis is generally absent, anterior paraarticular bridging osteophytes resemble true osseous fusion of the joint cavity on frontal radiographs. Focal sclerosis in degenerative disease is most common on the superior and inferior margins of the articular cavity and can usually be differentiated from that accompanying ankylosing spondylitis and osteitis condensans ilii.
Article
In a review of 131 patients with psoriatic arthritis, spondylitis was noted in 40%. Sacro-iliitis was observed in 21% and was present either when axial disease was predominant (7 patients) or in association with peripheral polyarthritis (15 patients). The groups differed in that most of those with axial disease were males who had developed psoriasis later in life. In those with disease of the axial skeleton, nail dystrophy was less common, and iritis, chronic back pain and restriction of spinal mobility were more common. They had higher values of E.S.R. In both cases there was a high incidence of the histocompatibility antigen B27. The axial group resembled idiopathic ankylosing spondylitis and the New York criteria were fulfilled by 86% compared with 27% of those who had peripheral arthritis as well. This latter group was frequently without symptoms or signs of spondylitis. Syndesmophytes are accepted as a radiological manifestation of spondylitis. They were noted in 25% of patients and in 60% of these the sacroiliac joints were normal radiologically. Anterior syndesmophytes alone were found only in the cervical spine and were more common in patients without sacro-iliitis. Lateral syndesmophytes were most commonly found in the lumbar and lower dorsal vertebrae and were slightly less common in patients without sacro-iliitis. Patients with syndesmophytes and normal sacro-iliac joints had a small male preponderance. They were no more likely to have symptoms or signs of spinal disease than those with normal spine radiographs.
Article
All known A, B, and C HLA antigens were determined in 50 white patients with vertebral ankylosing hyperostosis. A statistically significant decrease was found for the A9 and A11 specificities. Only three (6%) of the patients possessed the B27 antigen, a frequency which is not different from that of a control population. B27 therefore does not seem to be linked to abundant new bone formation.
Article
Due to its unique bicompartmental anatomy and spatial configuration, the sacroiliac joint can be more accurately defined by computed tomography (CT) than conventional radiography. Using a tilted gantry and paraaxial scanning technique, the synovial portion of the joint is oriented vertically on the CT image, while the ligamentous portion is oriented oblique-horizontally. The tilted CT gantry technique allows full ventral-dorsal imaging of the synovial portion of the sacroiliac joint. We have found the accuracy of CT to be superior to conventional radiography in the detection of early erosive sacroiliitis and joint space narrowing. In all patients with discrepancy between the two radiologic techniques, the changes were either only demonstrated or better demonstrated by CT than conventional radiography.
Article
We studied 63 consecutive patients with ankylosing hyperostosis to investigate any possible difference in clinical or roentgenographic features between whites and blacks. Our data suggest that (a) the disease may not be less common among blacks, (b) presence of extraspinal hyperostosis in this disease may be more frequent in black patients, and (c) the known male preponderance of the disease among whites may not occur among blacks.
Article
Sacroiliitis is often difficult to diagnose with certainty using conventional radiographs and radionuclide scanning. Computed tomography was used to study the sacroiliac joints in 20 consecutive patients clinically suspected of having sacroiliitis on initial evaluation. Of these 20 patients, 17 fulfilled conventional clinical criteria for sacroiliitis; computed tomography demonstrated changes of sacroiliitis in 12 of these 17 patients. CT revealed no changes of sacroiliitis in the three patients who failed to meet conventional clinical criteria for sacroiliitis. Conventional radiography demonstrated diagnostic changes of sacroiliitis in only five patients. Seven patients with CT changes of sacroiliitis had equivocal or negative conventional films. CT therefore seems superior to conventional radiography in detecting sacroiliitis.
Article
Radiographs of selected peripheral entheseal regions from 32 patients with axial diffuse idiopathic skeletal hyperostosis (DISH) were examined for the presence of new bone formation. The prevalence of entheseal new bone in the various regions was as follows: 98% of tibial spines, 91% of posterior heel regions and about 80% of superior patella, olecranon and inferior heel regions. The new bone showed characteristic solid well defined cortical margins without features of inflammatory change. We suggest that further attention to these readily accessible and easily interpretable peripheral entheseal regions, particularly the posterior heel, may be useful to extend the diagnostic criteria of DISH.
Article
Typing for histocompatibility antigen (HLA)-B27 has been suggested as a clinically valuable diagnostic test for ankylosing spondylitis and Reiter's syndrome, although some decry its use for this purpose. Diagnoses can be made in most patients with these diseases on the basis of the history, physical examination, and roentgenographic findings. The B27 test cannot be used to screen an asymptomatic population to detect these diseases and should not be thought of as a routine diagnostic test. We present probability graphs derived from Bayes' theorem, which show that for certain patients the B27 test, when used properly, is of clinical value as an aid to diagnosis. Proper application of the B27 test in clinical medicine is discussed. The test result does not absolutely confirm or exclude the presence of these diseases; it merely provides a probability statement on their existence in the patient. The test is therefore most useful to physicians who understand the use of probability reasoning in clinical decision making.
Article
A radiological study of the sacroiliac joints was undertaken in 54 patients (32 males, 22 females) with vertebral ankylosing hyperostosis (VAH) and in 46 control patients (24 males, 22 females) matched for age and sex. The ages ranged from 38 to 90 years. The radiographs were taken in anteroposterior, oblique, and craniocaudal projections. The films were read for cranial, ventral, and caudal capsular ossifications, for ventral and caudal osteophytes, and for bone sclerosis. Cranial and/or ventral capsular ossifications were found in 28 (87.5%) males with VAH and in 4 (16.6%) control males (p less than 0.0005), but only in 2 females with VAH and no control female. Sacroiliac capsular ossifications in males with VaH are frequent from the onset, but complete bridging of the joint is not reached before the sixth decade. Women, either VAH or control, have more sacroiliac osteophytes than men. There were 11 out of 22 control women with osteophytes versus 4 out of 24 men (p less than 0.025). The incidence of osteophytes does not seem to increase with age after 50 years. Our findings support the idea of VAH being a distinct entity and not a major form of osteophytosis.
HLA-antigens in Forestier's disease, ankylosing spondylitis and polyarthroses of the hands
  • M G Ercilla
  • M A Brancos
  • Y Breysse
  • M.G. Ercilla
Diffuse idiopathic skeletal hyperostosis
  • D Resnick
  • R F Shapiro
  • K B Weisner
  • D. Resnick