ArticleLiterature Review

Classification criteria for diffuse idiopathic skeletal hyperostosis: A lack of consensus

March 2017
British Journal of Rheumatology 56(7)

DOI:10.1093/rheumatology/kex056

Authors:

Jonneke Kuperus

University Medical Center Utrecht

Erin De Gendt

University Medical Center Utrecht

Fc Oner

University Medical Center Utrecht

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Objectives.: DISH is a condition characterized by flowing ossifications of the spine with or without ossifications of entheses elsewhere in the body. Studies on the prevalence and pathogenesis of DISH use a variety of partly overlapping combinations of classification criteria, making meaningful comparisons across the literature difficult. The aim of this study was to systematically summarize the available criteria to support the development of a more uniform set of diagnostic/classification criteria. Methods.: A search was performed in Pubmed, Embase, Cochrane Library and Web of Science using the term DISH and its synonyms. Articles were included when two independent observers agreed that the articles proposed a new set of classification criteria for DISH. All retrieved articles were evaluated for methodological quality, and the presented criteria were extracted. Results.: A total of 24 articles met the inclusion criteria. In all articles, spinal hyperostosis was required for the diagnosis of DISH. Peripheral, extraspinal manifestations were included as a (co-)requirement for the diagnosis DISH in five articles. Most discrepancies revolved around the threshold for the number of vertebral bodies affected and to defining different developmental phases of DISH. More than half of the retrieved articles described a dichotomous set of criteria and did not consider the progressive character of DISH. Conclusion.: This systematic review summarizes the available different classification criteria for DISH, which highlights the lack of consensus on the diagnosis of (early) DISH. Consensus criteria, including consecutive phases of new bone formation that characterize DISH, can be developed based upon established diagnostic/classification criteria.

Case report: a rare combination of diffuse idiopathic skeletal hyperostosis and cervical septic spondylodiscitis

Article

Full-text available

Mar 2024

Ossification of the anterior longitudinal ligament of the spine is a rare pathology with still unclear etiopathogenesis, although some authors associate it with metabolic diseases such as diabetes. Another rare disorder whose etiopathogenesis is also closely related to immunological disorders in diabetes is spinal epidural empyema. We present a case of a 62-year-old man with comorbidities of arterial hypertension and type II diabetes mellitus, with complaints of dysphagia and throat discomfort one and a half years prior to hospitalization. About a month before hospitalization, the patient reports pain with limited cervical mobility, followed by episodes of fever up to 38°C, with developing upper extremity muscle weakness and self-care incapacity. After imaging and laboratory studies, the patient was diagnosed with Forestier disease according to Resnick and Niwayama criteria, with ossification of the anterior longitudinal ligament and spondylodiscitis with epidural empyema in the cervical compartment. The patient was started on empiric antibiotic therapy and emergency surgery was undertaken for osteophytectomy, median corpectomy with medullar decompression and vertebrodesis. Postoperatively, the patient had improvement in dysphagia and upper extremity muscle strength - MRC 5/5 at the 6-month follow-up. Timely diagnosis and operative treatment with adequate decompression, anterior vertebrodesis and subsequent targeted antibiotic therapy are essential for a good outcome in the management of patients with this combined pathology.

Síndrome de Forestier: caso clínico y revisión de la literatura

Article

Jan 2021

Antecedentes: El síndrome de Forestier también conocido como Hiperostosis Esquelética Idiopática Difusa (DISH, por sus siglas en inglés), es una enfermedad de etiología desconocida que se caracteriza por osificación del ligamento espinal anterior, siendo las porciones cervicales y torácicas las que se afectan más frecuentemente. Esta enfermedad es más frecuente en hombres y se asocia con diabetes, hipertensión arterial, dislipidemia y trastornos endocrinos. Descripción del caso clínico: Paciente femenina de 63 años con antecedente de dolor cervical desde hace 32 años, que 6 años después del inicio del cuadro, presentó limitación en la movilidad del cuello; presentando varios episodios de disfonía desde hace 10 años; al momento de la consulta la paciente presentó limitación de la movilidad del cuello y dolor cervical. La imagen de resonancia magnética reportó: presencia de crecimiento óseo anterior de los cuerpos vertebrales, este hallazgo está en relación con el síndrome de Forestier. Conclusiones: Por ser una enfermedad poco conocida es subdiagnosticada y a menudo confundida con otras patologías. Los pacientes son diagnosticados muchos años después de que aparecieron los primeros síntomas que incluyen dolor, limitación de la movilidad, disfagia y dificultad respiratoria. El tratamiento incluye manejo sintomático, terapia física y manejo quirúrgico.

Is spinal sagittal alignment of diffuse idiopathic skeletal hyperostosis relevant to thoracolumbar pain? A controlled study

Article

Full-text available

Dec 2022
BMC MUSCULOSKEL DIS

Objectives: The extension of diffuse idiopathic skeletal hyperostosis (DISH) from the low thoracic spine to the lumbar spine result in adjustment of spinal sagittal alignment in surgical patients. The aim of this study was to investigate changes in sagittal alignment and back pain in the thoracolumbar spine in nonsurgical DISH and control participants selected from a radiological database. Methods: Participants in the DISH and the control group were selected by searching for "DISH or degenerative changes in the thoracic spine" in the radiology database of Taizhou Hospital between 2018 and 2021 using Resnick and Niwayama's criteria. The subjects with spinal tumors, previous spinal surgery, vertebral fractures, inflammatory diseases, poor-quality radiographs, or loss of follow-up were excluded. Demographic and clinical characteristics were recorded retrospectively via the hospital information system and telephone follow-up. Segmental disc angles (SDAs), lumbar lordosis (LL), and bridge scores were analyzed using images of three-dimensional CT. Results: The final participants consisted of 51 individuals with DISH (DISH group) and 102 individuals without DISH (control group). Depending on the presence of thoracolumbar pain, the DISH group was divided into the DISH group with thoracolumbar pain (DISH+Pain) and the DISH group without thoracolumbar pain (DISH-Pain). The LL and SDAs of T11-T12 and T12-L1 were significantly greater in the DISH group than in the control group. In addition, the SDA of L1-L2 was significantly smaller in the DISH+Pain group than in the DISH-Pain group, whereas there was no significant difference in lumbar lordosis between the DISH+Pain group and the DISH-Pain group. The bridge scores in DISH+Pain group was larger in T10-T11 (p = 0.01) and L1-L2 (p < 0.01) spine segments than those in DISH-Pain group. Conclusion: The extension of DISH from thoracic to lumbar spine may increase lumbar lordosis and SDAs in the thoracolumbar spine. The DISH patients with more bony bridging and small L1-L2 SDA may be more likely have thoracolumbar pain. Adjustment of sagittal alignment of the spine in the development of DISH may be of clinical importance.

The role of diffuse idiopathic skeletal hyperostosis (DISH) in positive identification

Article

Dec 2021

The use of skeletal pathologies in establishing positive identifications via radiographic comparison is often avoided—and thus understudied—due to the dynamic nature of the skeleton in response to pathological conditions. Using an online survey, this study tests the accuracy of diffuse idiopathic skeletal hyperostosis (DISH), a relatively common vertebral pathology, in making positive identifications through radiographic comparison. Three digital radiographic images from 51 DISH-positive individuals were obtained from the Boston Medical Center: one image taken at a baseline date (Group A), one image taken within 2 years from baseline (Group B), and one image taken greater than 4.5 years from baseline (Group C). Survey participants were tasked with comparing between simulated lateral “antemortem” and “postmortem” images from living patients and identifying which pair represented the same individual at different time intervals. A total of 40 responses were recorded and analyzed by measuring accuracies, sensitivities, and specificities. Information about survey participants’ field, degree, experience working with radiographs, and familiarity with DISH was also recorded. Series 1 compared Group A to Group B images and resulted in an accuracy of 87.3%, sensitivity of 46.9%, and specificity of 94.3%. Series 2 compared Group A to Group C images and resulted in an accuracy of 83.4%, sensitivity of 34.3%, and specificity of 95.8%. The results indicate that the progressive changes associated with DISH render the condition unreliable for making positive identifications but suggest that DISH could be used to winnow potential matches.

Incidental finding: Ossification of the anterior longitudinal ligament of the spine depicted on a panoramic radiograph – A case report with narrative review of the literature

Article

Full-text available

Jan 2021

Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance

Article

Full-text available

May 2020
BEST PRACT RES CL RH

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic bone-forming condition characterized by the presence of at least three bony bridges at the anterolateral spine. The aim of this review was to address the present state of pathophysiological knowledge, the clinical relevance, and diagnosis of DISH. The pathogenesis of DISH is currently unknown. The presence of DISH has been associated with older age, male sex, obesity, hypertension, atherosclerosis, and diabetes mellitus. Because the new bone forms mainly at entheseal sites, local fibroblasts, chondrocytes, collagen fibers, and calcified matrix are probably influenced by genetic, vascular, metabolic, and mechanical factors. Diagnosing the presence of DISH is of clinical importance, because the risk of a spinal fracture increases and associations with the metabolic syndrome, coronary and aortic disease, and respiratory effects are strong. Unravelling the pathogenesis of DISH can impact the field of regenerative medicine and bone tissue regeneration.

Back to the beginning: Identifying lesions of diffuse idiopathic skeletal hyperostosis prior to vertebral ankylosis

Article

Jan 2020

Objective: To better understand the pathogenesis of DISH, identifying early or pre-DISH lesions in the spine and investigating the relationship between spinal and extra-spinal manifestations of DISH. Material: 44 skeletonized individuals with DISH from the WM Bass Donated Skeletal Collection. Methods: For each vertebra, location, extension, point of origin and appearance of vertebral outgrowths were recorded. The size of the enthesophytes at the olecranon process, patella and calcaneal tuberosity was measured with digital callipers. Results: At either end of the DISH-ankylosed segment, isolated vertical outgrowths arising from the central third of the anterior aspect of the vertebral body can usually be observed. These bone outgrowths show a well-organized external cortical layer, an internal structure of trabecular bone and usually are unaccompanied by or show minimal associated endplate degeneration. Analysis of the relationship between spinal and extra-spinal manifestations (ESM) suggests great inter-individual variability. No correlation between any ESM and the stage of spinal DISH was found. Conclusions: Small isolated outgrowths represent the earliest stages of the spinal manifestations of DISH. The use of ESM as an indicator of DISH should be undertaken with great caution until the relationship between these two features is understood. Significance: Improved accuracy of paleopathological diagnostic criteria of DISH. Limitations: Small sample comprised of only individuals with DISH. FUTURE RESEARCH: micro-CT analysis to investigate the internal structure of the spinal lesions. Analysis of extra-spinal enthesophytes in individuals with and without DISH to understand their pathogenesis and association with the spinal lesions in individuals with DISH.

Criteria for Early-Phase Diffuse Idiopathic Skeletal Hyperostosis: Development and Validation

Article

Apr 2019

Background Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by the formation of new bone along the anterolateral spinal column at four adjacent vertebral bodies. Purpose To propose and validate criteria for the early phase of DISH by using CT data from two large-scale retrospective cohorts, each with 5-year follow-up. Materials and Methods For this retrospective study, CT data at baseline and follow-up in 1367 patients (cohort I) from 2004 to 2011 were evaluated by two observers to define no DISH, early-stage DISH, and definite DISH on the basis of interval development of consecutive complete or incomplete bone bridges. An independent group of 2267 participants from the COPDGene cohort from 2008 to 2016 was used to validate the early DISH criteria (cohort II). The sensitivity and specificity of early DISH criteria were based on findings in the last CT study as the reference standard by using a nested case-control design. κ Values were calculated between seven readers and with a 3-month interval for one reader. Results Cohort I consisted of 100% men, with a mean age of 60.0 years ± 5.6 (standard deviation) and a mean time between baseline and follow-up CT of 5.0 years ± 1.1. Cohort II consisted of 51% men, with a mean age of 59.9 years ± 8.6 and a mean time between baseline and follow-up CT of 5.4 years ± 0.5. In the derivation cohort, 55 patients comprised the early DISH group. Early DISH was defined as the presence of a spinal segment with a complete bone bridge with an adjacent segment of at least a near-complete bone bridge and another adjacent segment with at least the presence of newly formed bone or when three or more adjacent segments were recorded as showing a near-complete bone bridge. In the validation cohort, sensitivity for early DISH (vs no DISH) was 96% (99 of 103 participants; 95% confidence interval [CI]: 90%, 99%). The corresponding specificity was 83% (1695 of 2034 participants; 95% CI: 82%, 85%). The Fleiss κ for interrater reliability was 0.78 (95% CI: 0.77, 0.78), and the κ for intrarater reliability was 0.89 (95% CI: 0.82, 0.96). Conclusion Early diffuse idiopathic skeletal hyperostosis (DISH) criteria had high sensitivity and specificity for predicting the development of DISH. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Block in this issue.

Ectopic Spinal Calcification Associated with Diffuse Idiopathic Skeletal Hyperostosis (DISH): A Quantitative Micro‐CT Analysis

Article

Feb 2019

Diffuse idiopathic skeletal hyperostosis (DISH) is a non‐inflammatory spondyloarthropathy identified radiographically by calcification of the ligaments and/or entheses along the anterolateral aspect of the vertebral column. The etiology and pathogenesis of calcifications are unknown, and the diagnosis of DISH is currently based on radiographic criteria associated with advanced disease. To characterize the features of calcifications associated with DISH, we used micro‐computed tomographic imaging to evaluate a cohort of 19 human cadaveric vertebral columns. Fifty‐three percent of the cohort (n = 10; 3 females, 7 males, mean age of death = 81 years, range 67‐94) met the radiographic criteria for DISH, with calcification of four or more contiguous vertebral segments. In almost all cases, the lower thoracic regions (T8‐12) were affected by calcifications, consisting primarily of large, horizontal outgrowths of bony material. In contrast, calcifications localized to the upper thoracic regions demonstrated variability in their presentation and were categorized as either “continuous vertical bands” or “discontinuous‐patchy” lesions. In addition to the variable morphology of the calcifications, our analysis demonstrated remarkable heterogeneity in the densities of calcifications, ranging from internal components below the density of cortical bone to regions of hyper‐dense material exceeded cortical bone. These findings establish that the current radiographic criteria for DISH capture heterogeneous presentations of ectopic spine calcification that can be differentiated based on the morphology and densities. These findings may indicate a naturally heterogenous disease, potential stage(s) in the natural progression of DISH, or distinct pathologies of ectopic calcifications. This article is protected by copyright. All rights reserved

Bioanthropological study of human remains from UF 221 of the Santa Caterina Convent site (1243-1836) in Barcelona

Thesis

Sep 2022

Antony Cevallos

The aim of this study is the bioanthropological analysis of the bone remains of the Funerary Unit (UF) 221 of the Santa Caterina Convent site in Barcelona. This UF is divided into secondary burial (medieval, 13th-14th centuries) and primary burial (modern, early 16th century). To carry out the study, standard anthropological methods were applied, and possible pathologies were observed macroscopically and radiologically. The results indicate a minimum number of 27 individuals from the medieval period (15♂, 7♀ and 5 immature) and 35 individuals from the modern period (12 ♂, 8♀ and 15 immature). Individuals from the medieval period are robust and taller than other peninsular series (169.02 cm ♂, 154.53 cm ♀). The results indicate that they belonged to guild who performed a heavy work, since they present multiple enthesopathies in the upper and lower limbs, of which those of the flexor and extensor muscles of the phalanges of the hand stand out, a high frequency of septal opening (55.20%) and high fractures frequencies possibly associated with their daily work. Individuals from the modern period are less robust, with a lower prevalence of physical activity patterns compared to medieval ones, and with a stature like other contemporary series (163.02 cm ♂, 156.75 cm). The immature individuals of the modern series present a high frequency of caries and the adults present pathologies compatible with DISH. The results of this study agree with archaeological observations, which indicate that they are laypeople belonging to some guild, with family relationships, and with a good social status. This study allows us to learn about the living conditions, demography, and diseases suffered by individuals who lived in the city of Barcelona from the 13th to the early 16th century, giving us more information about the medieval and modern history of Barcelona. MonBones: PID2020-118194RJ-100 AEI / MINECO.

Is there a place for magnetic resonance imaging in diffuse idiopathic skeletal hyperostosis?

Article

Full-text available

Apr 2023

Iris Eshed

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the new bone formation and enthesopathies of the axial and peripheral skeleton. The diagnosis of DISH currently relies upon the end-stage radiographic criteria of Resnick and Niwayama, in which bridging osteophytes are present over at least four thoracic vertebras. The pathogenesis of DISH is not well understood, and it is currently considered a non-inflammatory condition with an underlying metabolic derangement. However, an inflammatory component was suggested due to the similarities between DISH and spondyloarthritis (SpA) in spinal and peripheral entheseal new bone formation. Magnetic resonance imaging (MRI) is the imaging modality of choice in the diagnostic work-up and follow-up of patients with SpA, as well as in understanding its pathogenesis. The aims of the current review were to evaluate the current and future role of MRI in imaging DISH.

"Importance of Conventional Radiography in the Diagnosis of Diffuse Idiopathic Skeletal Hyperostosis"

Article

Apr 2021

M Geneva Popova

Hiperostosis esquelética difusa idiopática, una causa infrecuente de disfagia y disfonía

Article

Full-text available

Dec 2020

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic disease characterized by ossi- fication of the anterior longitudinal ligament of the spine. Patients are usually asympto- matic, or present mild pain or stiffness, however cervical compromise can cause dysphagia, dyspnea and dysphonia. We present the case of a 63-year-old patient with hoarseness and dysphagia. Studies revealed anterior displacement of the arytenoid cartilage and collapse of the pyriform sinus secondary to an osteophyte at C4 level. The patient showed improvement with conservative management. We present a discussion about this case and the available scientific evidence on the diagnosis and treatment of this pathology.

DISH vs Spondyloarthritides

Article

Full-text available

Jan 2019

Mimics of axial spondyloarthritis

Article

Full-text available

Apr 2019

Purpose of review: Although axial spondyloarthritis (AxSpA) is a distinct clinical entity with characteristics clinic and radiographic features, however, multitude of other metabolic, infectious and inflammatory disorders mimic it both clinically and radiographically. Recent findings: We present in this review article recent updates about the various disease entities and conditions that may mimic AxSpA and how to differentiate among them. The sensitivity and specificity of MRI in diagnosing AxSpA has limitations and needs to be interpreted in the context of the clinical picture. Interestingly, some recent studies have highlighted that a relatively high prevalence of bone marrow edema on pelvic MRIs in healthy volunteers which could even be categorized as having a ‘positive MRI’ as defined by Assessment of Spondyloarthritis International Society. Another study revealed that a substantial proportion of patients with suspected sacroiliitis were more commonly diagnosed with diseases other than inflammatory sacroiliitis. On the basis of these reports, it is prudent to request MRIs in the appropriate clinical context and interpreted with caution taking into considerations the wide differential diagnosis of such MRI changes. Summary: Highlighting the clinical pearls that differentiate disorders suspected of having sacroiliitis will lead to earlier and correct diagnosis and management; however, one must always take into considerations the radiographic and MRI findings in addition to the clinical presentations in order to make the appropriate diagnosis. Keywords: ankylosing spondylitis, axial spondyloarthritis, bone marrow edema, clinical diagnosis and imaging, inflammatory arthritis, inflammatory back pain, mimics, sacroiliitis, spondyloarthropathy

An example of a favorable outcome of a cervical spine injury occurring on a background of diffuse idiopathic skeletal hyperostosis: the result of an anthropological finding in the church of St. Peter in the town of Domashevo (Bosnia and Herzegovina)

Article

Full-text available

Dec 2023

The article provides a description of the anthropological finding-human remains discovered in the church of St. Peter (Domashevo, Bosnia and Herzegovina, burial at the turn of the 15th and 16th centuries AD). The available morphological data most likely indicate the presence of diffuse idiopathic skeletal hyperostosis. This disease resulted in trauma to the cervical vertebrae, which altered their morphology. However, the injury did not lead to death; the person lived for a long time afterwards, as post-traumatic skeletal changes with the development of torticollis were noted.

Association between serum interleukin-17 levels and ectopic bone formation in OPLL patients with DISH

Article

Oct 2023

Objective To investigate the relationship between the severity and morphology of heterotopic ossification in the spinal ligaments including sacroiliac (SI) joints, and serum interleukin-17 (IL-17) levels in patients with ossification of the posterior longitudinal ligament (OPLL) with or without diffuse idiopathic skeletal hyperostosis (DISH), as well as a non-OPLL group. Methods A total of 103 patients with OPLL (DISH (−), n = 50; DISH (+), n = 53) and 53 age- and gender-matched controls were included. The serum levels of IL-17 were analyzed, and the severity of ectopic ossification and the morphology of ectopic bone formation were evaluated. The SI joint morphological variations were categorized into four types. Results No significant differences were found in serum IL-17 levels between the OPLL and control groups. However, the DISH (+) group showed higher IL-17 levels than the DISH (−) group, especially in female patients (p = 0.003). Additionally, IL-17 levels were positively correlated with the number of Flat vertebral units, meaning one of the characteristics of DISH ossification type (R2 = 0.199, p = 0.012). IL-17 levels in type 4 were significantly higher in the DISH (+) group than in the DISH (−) group. Conclusions The morphological characteristics of paravertebral bone formation in the entire spine, including the SI joint, are likely associated with serum IL-17 levels in OPLL. These findings provide pathological and serological evidence of local inflammation contributing to paravertebral ossification of OPLL patients.

High Circulating FGF-23 and Its Relationship with Severity of Spinal Involvement in Diffuse Idiopathic Skeletal Hyperostosis

Article

Full-text available

Sep 2023
CALCIFIED TISSUE INT

The primary objective of this study was to determine the role of fibroblast growth factor 23 (FGF-23) in the pathogenesis of diffuse idiopathic skeletal hyperostosis (DISH). A total of 61 patients with DISH and 61 age- and sex-matched control patients without DISH were included in this study. The serum FGF-23, creatinine, inorganic phosphate, calcium, albumin, albumin-adjusted calcium and alkaline phosphatase, and C-reactive protein were assessed in both groups. Based on the extent of ossification, DISH group was further divided into T-DISH and L-DISH subgroups. Data were comparatively analyzed between DISH and Non-DISH groups and among T-DISH, L-DISH, and Non-DISH groups, respectively. Besides, the number of ossification segments of all DISH patients was quantified and the correlation between the number of ossification segments and the serum concentration of FGF-23 was analyzed. The results revealed that serum FGF-23 was significantly higher in DISH group than in Non-DISH group, regardless of gender. Interestingly, serum Pi was significantly lower in DISH group than in Non-DISH group. Moreover, a significant difference in serum FGF-23 among T-DISH, L-DISH, and Non-DISH groups was also observed. In contrast to Non-DISH group, both T-DISH and L-DISH subgroups displayed significantly higher serum FGF-23 level. Although the mean value was relatively higher in L-DISH subgroup, no statistically significant difference was found between T-DISH and L-DISH subgroups. In addition, a moderately positive correlation was identified between the number of ossification segments and the serum level of FGF-23. It can be concluded that serum FGF-23 could serve as a positive biomarker for DISH and may play a significant role in ectopic ossification in DISH.

Axial Spondyloarthritis and Diagnostic Challenges: Over-diagnosis, Misdiagnosis, and Under-diagnosis

Article

Full-text available

Jan 2023
Curr Rheumatol Rep

Purpose of Review This article aims to review the challenges in axial spondyloarthritis diagnosis and identify the possible contributing factors. Recent Findings The inability to reach an accurate diagnosis in a timely fashion can lead to treatment delays and worse disease outcomes. The lack of validated diagnostic criteria and the misuse of the currently available classification criteria could be contributing. There is also significant inter-reader variability in interpreting images, and the radiologic definitions of axial spondyloarthritis continue to be re-defined to improve their positive predictive value. The role of inflammatory back pain features, serologic biomarkers, genetics, and their diagnostic contribution to axial spondyloarthritis continues to be investigated. Summary There is still a significant amount of delay in the diagnosis of axial spondyloarthritis. Appreciating the factors that contribute to this delay is of utmost importance to close the gap. It is similarly important to recognize other conditions that may present with symptoms that mimic axial spondyloarthritis so that misdiagnosis and wrong treatment can be avoided.

Hiperostose esquelética idiopática difusa – critérios de classificação

Article

Jun 2022

A hiperostose esquelética difusa idiopática (DISH) é uma condição sistêmica caracterizada pela progressiva calcificação de ligamentos e ênteses, tanto axiais quanto periféricas, e com fisiopatogenia ainda desconhecida. Os principais fatores de risco associados são envelhecimento, obesidade e síndrome metabólica. Na maioria das vezes, o diagnóstico é incidental e realizado por meio de métodos de imagem solicitados por outras condições não relacionadas à DISH. A evolução dos sintomas é lenta, mas pode ser progressiva, incluindo dor torácica, lombar e/ou cervical; rigidez axial e articular; sintomas de compressão radicular (parestesia, claudicação e fraqueza em membros inferiores) e dor mono ou poliarticular. O principal método de imagem na DISH é a radiografia da coluna vertebral, que caracteristicamente mostra a presença de calcificação do ligamento longitudinal anterior, com aspecto ondulante, sobretudo no lado direito da coluna torácica. A entesopatia periférica ou extra-axial também pode ser encontrada, particularmente em pés e joelhos. Neste artigo os autores revisam os diversos critérios de classificação vigentes, sobretudo os propostos por Resnick e Niwayama. Unitermos: hiperostose esquelética difusa idiopática; quadro clínico; diagnóstico; critérios de classificação.

Diffuse Idiopathic Skeletal Hyperostosis and Ankylosing Spondylitis: A Challenging Case and Review of the Literature

Article

Full-text available

Nov 2022
J Radiol Case Rep

Background: Diffuse idiopathic skeletal hyperostosis and spondyloarthritis share similarities in clinical and radiological findings. In this article, we report a case of overlapping of these two hyperostotic diseases followed by an extensive narrative review of the literature focusing on the gray areas in the diagnosis of diffuse idiopathic skeletal hyperostosis. Case description: We report the case of simultaneous diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis in a 57-year-old man. The diagnosis was made after many collegial meetings based on solid radiological arguments. Conclusion: Review of the literature reveals many uncertainties in the diagnosis of diffuse idiopathic skeletal hyperostosis, especially in the radiological evaluation of sacroiliac joints. Diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis frequently overlap in important radiological features leading to diagnostic ambiguity and they can also co-exist in the same patient.

Patients with diffuse idiopathic skeletal hyperostosis have an increased burden of thoracic aortic calcifications

Article

Full-text available

Aug 2022

Objectives: DISH has been associated with increased coronary artery calcifications and incident ischaemic stroke. The formation of bone along the spine may share pathways with calcium deposition in the aorta. We hypothesized that patients with DISH have increased vascular calcifications. Therefore we aimed to investigate the presence and extent of DISH in relation to thoracic aortic calcification (TAC) severity. Methods: This cross-sectional study included 4703 patients from the Second Manifestation of ARTerial disease cohort, consisting of patients with cardiovascular events or risk factors for cardiovascular disease. Chest radiographs were scored for DISH using the Resnick criteria. Different severities of TAC were scored arbitrarily from no TAC to mild, moderate or severe TAC. Using multivariate logistic regression, the associations between DISH and TAC were analysed with adjustments for age, sex, BMI, diabetes, smoking status, non-high-density lipoprotein cholesterol, cholesterol lowering drug usage, renal function and blood pressure. Results: A total of 442 patients (9.4%) had evidence of DISH and 1789 (38%) patients had TAC. The prevalence of DISH increased from 6.6% in the no TAC group to 10.8% in the mild, 14.3% in the moderate and 17.1% in the severe TAC group. After adjustments, DISH was significantly associated with the presence of TAC [odds ratio (OR) 1.46 [95% CI 1.17, 1.82)]. In multinomial analyses, DISH was associated with moderate TAC [OR 1.43 (95% CI 1.06, 1.93)] and severe TAC [OR 1.67 (95% CI 1.19, 2.36)]. Conclusions: Subjects with DISH have increased TACs, providing further evidence that patients with DISH have an increased burden of vascular calcifications.

The prevalence of diffuse idiopathic skeletal hyperostosis in England and Catalonia from the Roman to the post-medieval periods

Article

Jun 2022

Objective Evaluate the prevalence of DISH through time from the Roman to the post-Medieval period in England and Catalonia. Material 281 individuals from England and 247 from Catalonia were analyzed. Methods Adult individuals with at least three well-preserved lower thoracic vertebral bodies were analyzed. DISH was assessed considering the early stages of development. Diachronic and geographical dietary shifts were investigated using reported light isotope data, archaeological reports and historical documentation. Results Males and older individuals showed consistently higher prevalence of DISH, however, only the English sample showed a significant difference between males and females in the prevalence of DISH. No significant difference was found in the prevalence of DISH though time (from Roman to post medieval periods) nor across regions (England and Catalonia). Conclusion The development of DISH is probably influenced by a combination of factors including increasing age and sex. Significance This is the first exhaustive analysis of DISH in ancient Catalan populations and the first that considers the early stages of DISH. Limitations Reduced sample size, particularly in post-medieval samples, as a result of the available excavated samples and the inclusion criteria adopted. Future Research Include rural, religious and high-status samples in the analysis of DISH. Re-assess the prevalence of DISH in post-medieval populations.

An isotope signature for diffuse idiopathic skeletal hyperostosis?

Article

Full-text available

Mar 2022

Objectives: Diffuse idiopathic skeletal hyperostosis (DISH) has recurrently been associated with a rich diet (high in protein and higher trophic level foods); however, very few studies have investigated this link using carbon and nitrogen (δ13C and δ15N) stable isotope analysis. This paper explores the relationship between DISH and diet in two Roman urban communities by analyzing individuals with and without DISH. Materials and methods: δ13C and δ15N analysis carried out on collagen from 33 rib samples (No DISH: 27; early DISH: 4; DISH: 2) selected from individuals buried at the Romano-British site of Baldock (UK), 41 rib samples (No DISH: 38; early DISH: 3) from individuals from the Catalan Roman site of Santa Caterina (Barcelona, Spain). Additionally, six faunal samples from Baldock and seven from Santa Caterina were analyzed. Results: Standardized human isotope data from Santa Caterina show high δ15N probably associated to a diet combining terrestrial resources and freshwater fish. In contrast, isotope results from Baldock suggest a terrestrial-based diet. Individuals with DISH do not show isotopic ratios indicative of rich diet and there is no correlation between stage of DISH development and δ13C and δ15N. Conclusion: The results of this study suggest that individuals with DISH followed a similar or isotopically similar diet as those individuals without DISH in Baldock and in Santa Caterina and therefore, while DISH may have been influenced by individual's dietary habits, this is not reflected in their isotopic signature.

Diffuse Idiopathic Skeletal Hyperostosis with Cervical Vertebra Involvement: A Case Report

Article

Full-text available

Dec 2021

Diffuse idiopathic skeletal hyperostosis is a non-inflammatory disease characterized by ossification and calcification in soft tissues, such as enthesis and joint capsules. The thoracic vertebra is often affected; however, cervical vertebra involvement can also be seen. Diagnosis is made by observing ossifications in the anterior surface of the four vertebrae and excluding spinal degenerative and inflammatory diseases. Pain and movement limitation is frequently observed in cervical vertebra involvement, but symptoms, such as dysphagia, hoarseness, and snoring, may also occur. This study aimed to present a 69-year-old male patient with pain in the neck and back, movement limitations, and swallowing difficulties, mostly with solid foods. The cervical imaging of the patient revealed anterior ossifications that compress the esophagus and posterior ossifications without myelomalacia. Surgery was recommended to the patient for his progressive dysphagia but was refused. Partial improvement was achieved in the patient’s complaints with exercise and swallowing training in pain, movement limitation, and swallowing difficulties.

Diffuse idiopathic skeletal hyperostosis is associated with incident stroke in patients with increased cardiovascular risk

Article

Full-text available

Nov 2021

Objectives Earlier retrospective studies have suggested a relation between diffuse idiopathic skeletal hyperostosis [DISH] and cardiovascular disease, including myocardial infarction. The present study assessed the association between DISH and incidence of cardiovascular events and mortality in patients with high cardiovascular risk. Methods In this prospective cohort study, we included 4624 patients (mean age 58.4 years, 69.6% male) from the Second Manifestations of ARTerial disease cohort. The main end point was major cardiovascular events [MACE: stroke, myocardial infarction, and vascular death]. Secondary endpoints included all-cause mortality and separate vascular events. Cause specific proportional hazard models were used to evaluate the risk of DISH on all outcomes, and subdistribution hazard models were used to evaluate the effect of DISH on the cumulative incidence. All models were adjusted for age, sex, body mass index, blood pressure, diabetes, non-HDL cholesterol, packyears, renal function, and C-reactive protein. Results DISH was present in 435 (9.4%) patients. After a median follow-up of 8.7 (IQR 5.0–12.0) years, 864 patients had died and 728 patients developed a MACE event. DISH was associated with an increased cumulative incidence of ischaemic stroke. After adjustment in cause specific modelling, DISH remained significantly associated with ischaemic stroke (HR 1.55; 95%CI : 1.01–2.38), but not with MACE (HR 0.99; 95%CI : 0.79–1.24), myocardial infarction (HR 0.88; 95%CI : 0.59–1.31), vascular death (HR 0.94; 95%CI : 0.68–1.27), or all-cause mortality (HR 0.94; 95%CI : 0.77–1.16). Conclusion The presence of DISH is independently associated with an increased incidence and risk for ischaemic stroke, but not with MACE, myocardial infarction, vascular death, or all-cause mortality.

Identifying Clinicoradiological Phenotypes in Diffuse Idiopathic Skeletal Hyperostosis: A Cross-Sectional Study

Article

Full-text available

Sep 2021

Background and objectives: Diffuse idiopathic skeletal hyperostosis (DISH) is a bone formation disease in which only skeletal signs are considered in classification criteria. The aim of the study was to describe different phenotypes in DISH patients based on clinicoradiological features. Materials and Methods: We evaluated 97 patients who met the Resnick or modified Utsinger classification criteria for DISH and were diagnosed at our hospital from 2004 to 2015. Patients were stratified into: (a) peripheral pattern (PP)—Resnick criteria not met but presenting ≥3 peripheral enthesopathies; (b) axial pattern (AP)—Resnick criteria met but <3 enthesopathies; and (c) mixed pattern (MP)—Resnick criteria met with ≥3 enthesopathies. Statistical analysis was carried out to identify variables that might predict classification in a given group. Results: Fifty-six of the 97 patients included (57.7%) were male and 72.2% fulfilled the Resnick criteria. Applying our classification, 39.7% were stratified as MP, 30.9% as AP and 29.4% as PP. Clinical enthesopathy was reported in 40.2% of patients during the course of the disease. Sixty-eight patients were included in a comparative analysis of variables between DISH patterns. The results showed a predominance of women (p < 0.004), early onset (p < 0.03), hip involvement (p < 0.003) and enthesitis (p < 0.001) as hallmarks of PP. Asymptomatic patients were most frequently observed in AP (28.6%, MP 3.8%, PP 5.0%) while MP was characterized by a more extensive disease. Conclusions: We believe DISH has distinct phenotypes and describe a PP phenotype that is not usually considered. Extravertebral manifestations should be included in the new classification criteria in order to cover the entire spectrum of the disease.

Dystrophic calcification and heterotopic ossification in fibrocartilaginous tissues of the spine in diffuse idiopathic skeletal hyperostosis (DISH)

Article

Full-text available

Apr 2020

Diffuse idiopathic skeletal hyperostosis (DISH) is a prevalent noninflammatory spondyloarthropathy characterized by ectopic mineral formation along the anterolateral aspect of the vertebral column, yet little is known about its underlying pathogenesis. Our objective was to evaluate the histopathological features and composition of ectopic mineral within spinal tissues affected by DISH in humans. Thoracic spine segments from six embalmed cadaveric donors (one female and five males; median age 82 years) meeting the radiographic diagnostic criteria for DISH were evaluated using radiological, histological, and physical analyses. Overall, the histological features of ectopic mineralization at individual motion segments were heterogeneous, including regions of heterotopic ossification and dystrophic calcification. Heterotopic ossifications were characterized by woven and lamellar bone, multifocal areas of metaplastic cartilage, and bony bridges along the anterior aspect of the intervertebral disc space. Dystrophic calcifications were characterized by an amorphous appearance, a high content of calcium and phosphorus, an X-ray diffraction pattern matching that of hydroxyapatite, and radiodensities exceeding that of cortical bone. Dystrophic calcifications were found within the anterior longitudinal ligament and annulus fibrosus in motion segments both meeting and not meeting the radiographic criteria for DISH. In summary, our findings indicate that in DISH, ectopic mineral forms along the anterior aspect of the spine by both heterotopic ossification and dystrophic calcification of fibrocartilaginous tissues. Although both types of ectopic mineralization are captured by current radiographic criteria for DISH, dystrophic calcification may reflect a distinct disease process or an early stage in the pathogenesis of DISH.

Diffuse idiopathic skeletal hyperostosis: Imaging findings with special focus on extraspinal involvement

Article

Sep 2024

Diffuse Idiopathic Skeletal Hyperostosis (IDHS) is a multifactorial disease with a high prevalence and that is frequently detected incidentally in imaging tests. Most of its diagnostic criteria are focused on axial involvement and more specifically the spine. However, peripheral involvement in DISH is less well known despite its non insignificant frequency. DISH can be associated with serious complications, the most severe being vertebral fractures in low energy trauma and dysphagia or airway obstruction in cervical involvement. Knowing how to identify the patterns of peripheral involvement of DISH and its complications helps in the radiological and clinical management of patients with this disease.

Bone and Entheseal Targets for Growth Factors in Diffuse Idiopathic Skeletal Hyperostosis

Article

Aug 2024
SEMIN ARTHRITIS RHEU

Geoffrey Owen Littlejohn

Diffuse idiopathic skeletal hyperostosis (DISH): Detection on dental radiologic examinations in two older adults and overview of the literature

Article

May 2024
Spec Care Dent

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is a potentially serious osteopathic disorder associated with coalescing ossifications of the anterior vertebrae and may be concomitant with a constellation of symptomatology and systemic comorbidities. There is limited dental literature describing this finding on panoramic radiographs and cone beam computed tomography (CBCT) scans. Case presentations: Two case reports of DISH are provided. One patient manifested extensive ossifications along the cervical vertebrae and consequent episodes of dysphagia and hoarseness. The other affected patient's cervical ossification was found at an earlier stage of formation and without symptomatology. Panoramic radiography, cervical spine radiography, and CBCT examinations have been provided. Conclusion: Attending dental healthcare practitioners should carefully evaluate all areas of interest and surrounding fields of view when taking panoramic radiographs and CBCT scans for manifestations of DISH and other potential disorders of the cervical vertebrae. A suspected radiologic finding of DISH should prompt timely referral for comprehensive medical assessment to mitigate neurologic deficits and other comorbidities.

Diffuse idiopathic skeletal hyperostosis (DISH): review of comorbidities and detection on dental radiologic examinations in 2 older adults

Article

Sep 2024
Spec Care Dent

How does diffuse idiopathic skeletal hyperostosis affect the sagittal spinopelvic alignment in lumbar spinal stenosis patients?

Article

Aug 2023
CLIN NEUROL NEUROSUR

Objective: To compare the differences of spinopelvic morphology among patients with DISH, patients without DISH and normal elderly and to assess the impact of ossification extent on sagittal alignment. Methods: Patients with and without DISH aged > 50 years who required surgery because of lumbar spinal stenosis were enrolled in this cohort(DISH and Non-DISH groups). Also, we collected age-matched normal old outpatients as the control group(Normal group). According to ossification extent, DISH group were divided into two subgroups(T-DISH and L-DISH subgroups). Spinopelvic parameters were measured. Distribution differences of Roussouly classification were analyzed between DISH and Non-DISH group, T-DISH and L-DISH subgroup, respectively. Additionally, distribution difference of kyphotic apex vertebrae between T-DISH and L-DISH subgroup was also investigated. Results: A total of 429 patients (300 males and 129 females) were enrolled in our study, with a mean age of 64.1 ± 5.8 years. Compared to the Normal group, DISH and Non-DISH groups both had significantly higher CSVA, PT, OH, SVA, TPA and lower LL, SS, C7 Tilt, SSA, SPA. Compared to Non-DISH group, DISH group, regardless of ossification extent, had significantly higher T1 slope, CSVA, TK and SVA. Besides, T-DISH subgroup showed significant higher LL, PI, SS and SSA than L-DISH subgroup. There were significant differences of Roussouly classification distribution between T-DISH and L-DISH subgroup. In terms of kyphotic apex location, compared to relatively higher locations in T-DISH subgroup, L-DISH subgroup had apical locations predominantly in the lower thoracic. Conclusion: Sagittal spinopelvic alignment is influenced by the presence of DISH and the extent of ossification. Patients with L-DISH have not only increased thoracic kyphosis and forward trunk, but also insufficient lumbar lordosis.

Diffuse idiopathic skeletal hyperostosis (DISH) and trabecular bone score (TBS) in postmenopausal women: the Camargo Cohort

Article

May 2023
SEMIN ARTHRITIS RHEU

Objectives The potential relationship between diffuse idiopathic skeletal hyperostosis (DISH) and bone microstructure has not been studied in women. We aimed to assess the association between the trabecular bone score (TBS) and DISH in postmenopausal women, as well as the role of other parameters related to bone metabolism, such as bone mineral density (BMD), calciotropic hormones, and bone remodeling markers. Methods Cross-sectional study, nested in a prospective population-based cohort (Camargo cohort). Clinical covariates, DISH, TBS, vitamin D, parathormone, BMD and serum bone turnover markers, were analyzed. Results We have included 1545 postmenopausal women (mean age, 62±9 years). Those with DISH (n=152; 8.2%) were older and had a significantly higher prevalence of obesity, metabolic syndrome, hypertension, and type 2 diabetes mellitus (p<0.05). Moreover, they had lower TBS values (p=0.0001) despite having a higher lumbar spine BMD (p<0.0001) and a higher prevalence of vertebral fractures than women without DISH (28.6% vs. 15.1%; p=0.002). When analyzing DISH through Schlapbach grades, women without DISH had a median TBS value consistent with a normal trabecular structure while the values for women with DISH from grades 1 to 3 were consistent with a partially degraded trabecular structure. Women with vertebral fractures and DISH had a mean TBS corresponding to a degraded trabecular structure (1.219±0.1). After adjusting for confounders, the estimated TBS means were 1.272 (1.253-1.290) in the DISH group, and 1.334 (1.328-1.339) in the NDISH group (p<0.0001). Conclusion An association between DISH and TBS has been shown in postmenopausal women, in which hyperostosis has been significantly and consistently related to trabecular degradation and, therefore, to deterioration in bone quality after adjusting for confounding variables.

Stiffness and axial pain are associated with the progression of calcification in a mouse model of diffuse idiopathic skeletal hyperostosis

Article

Full-text available

Apr 2023
ARTHRITIS RES THER

Background Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by progressive calcification of spinal tissues; however, the impact of calcification on pain and function is poorly understood. This study examined the association between progressive ectopic spine calcification in mice lacking equilibrative nucleoside transporter 1 (ENT1−/−), a preclinical model of DISH, and behavioral indicators of pain. Methods A longitudinal study design was used to assess radiating pain, axial discomfort, and physical function in wild-type and ENT1−/− mice at 2, 4, and 6 months. At endpoint, spinal cords were isolated for immunohistochemical analysis of astrocytes (GFAP), microglia (IBA1), and nociceptive innervation (CGRP). Results Increased spine calcification in ENT1−/− mice was associated with reductions in flexmaze exploration, vertical activity in an open field, and self-supporting behavior in tail suspension, suggesting flexion-induced discomfort or stiffness. Grip force during the axial stretch was also reduced in ENT1−/− mice at 6 months of age. Increased CGRP immunoreactivity was detected in the spinal cords of female and male ENT1−/− mice compared to wild-type. GFAP- and IBA1-immunoreactivity were increased in female ENT1−/− mice compared to wild-type, suggesting an increase in nociceptive innervation. Conclusion These data suggest that ENT1−/− mice experience axial discomfort and/or stiffness and importantly that these features are detected during the early stages of spine calcification.

Early stages of diffuse idiopathic skeletal hyperostosis (DISH) and chronic inflammation: the Camargo Cohort Study

Article

Full-text available

Mar 2023

Introduction/objectives DISH has traditionally been considered a non-inflammatory rheumatic disorder. Currently, an inflammatory component has been theorized in the early phases of this condition (EDISH). The study is aimed at investigating a possible relationship between EDISH and chronic inflammation. Method Analytical-observational study. Participants from the Camargo Cohort Study were enrolled. We collected clinical, radiological, and laboratory data. C-reactive protein (CRP), albumin-to-globulin ratio (AGR), and triglyceride-glucose (TyG) index were assessed. EDISH was defined by Schlapbach’s scale grades I or II. A fuzzy matching with tolerance factor = 0.2 was performed. Subjects without ossification (NDISH), sex- and age-matched with cases (1:4), acted as controls. Definite DISH was an exclusion criterion. Multivariable analyses were performed. Results We evaluated 987 persons (mean age 64 ± 8years; 191 cases with 63.9% women). EDISH subjects presented more frequently obesity, T2DM, MetS, and the lipid pattern [↑TG ↓TC]. TyG index and alkaline phosphatase (ALP) were higher. Trabecular bone score (TBS) was significantly lower (1.310 [0.2] vs. 1.342 [0.1]; p = 0.025). CRP and ALP showed the highest correlation (r = 0.510; p = 0.0001) at lowest TBS level. AGR was lower, and its correlations with ALP (r = − 0.219; p = 0.0001) and CTX (r = − 0.153; p = 0.022), were weaker or non-significant in NDISH. After adjustment for potential confounders, estimated CRP means for EDISH and NDISH were 0.52 (95% CI: 0.43–0.62) and 0.41 (95% CI: 0.36–0.46), respectively (p = 0.038). Conclusions EDISH was associated with chronic inflammation. Findings revealed an interplay between inflammation, trabecular impairment, and the onset of ossification. Lipid alterations were similar to those observed in chronic-inflammatory diseases.

A Multicenter Allelic Analysis of Diffuse Idiopathic Skeletal Hyperostosis: Nature Versus Nurture?

Article

Feb 2023
NEUROSURGERY

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is an incompletely defined disease process with no known unifying pathophysiological mechanism. Objective: To our knowledge, no genetic studies have been performed in a North American population. To summarize genetic findings from previous studies and to comprehensively test for these associations in a novel and diverse, multi-institutional population. Methods: Cross-sectional, single nucleotide polymorphism (SNP) analysis was performed in 55 of 121 enrolled patients with DISH. Baseline demographic data were available on 100 patients. Based on allele selection from previous studies and related disease conditions, sequencing was performed on COL11A2, COL6A6, fibroblast growth factor 2 gene, LEMD3, TGFB1, and TLR1 genes and compared with global haplotype rates. Results: Consistent with previous studies, older age (mean 71 years), male sex predominance (80%), a high frequency of type 2 diabetes (54%), and renal disease (17%) were observed. Unique findings included high rates of tobacco use (11% currently smoking, 55% former smoker), a higher predominance of cervical DISH (70%) relative to other locations (30%), and an especially high rate of type 2 diabetes in patients with DISH and ossification of the posterior longitudinal ligament (100%) relative to DISH alone (100% vs 47%, P < .001). Compared with global allele rates, we found higher rates of SNPs in 5 of 9 tested genes (P < .05). Conclusion: We identified 5 SNPs in patients with DISH that occurred more frequently than a global reference. We also identified novel environmental associations. We hypothesize that DISH represents a heterogeneous condition with both multiple genetic and environmental influences.

Comparison of radiological characteristics between diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: a multicenter study

Article

Full-text available

Feb 2023

To evaluate the radiological differences between diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) using whole spine computed tomography (CT), including the spine and sacroiliac joint (SIJ). The ossification and bridging of spinal ligament and fusion of the facet joint and SIJ were evaluated in 111 patients who were diagnosed with DISH and 27 patients with AS on the whole spine CT. The number of anterior bridging and shape of bridging (candle-wax-type/ smooth-type) were also evaluated. We further evaluated patients with DISH and AS by matching their age and sex. Complete SIJ fusion was more common in AS, whereas anterior and posterior bony bridging around SIJ was more common in DISH. However, 63% of patients with DISH had a partial or complete fusion. In spinal anterior bony bridging, the majority of patients with AS had the smooth-type, whereas those with DISH had the candle-wax-type. However, some of the patients with DISH (11%) had smooth-type. Intervertebral facet joint fusion is more common in AS. The number of anterior spinal bony bridging was greater in AS than in DISH, especially in the lumbar spine. These results are useful in differentiating DISH from AS and should therefore be considered when making a diagnosis.

Diagnóstico diferencial das entesopatias. Parte 4 – Hiperostose esquelética idiopática difusa

Article

Dec 2020

A hiperostose esquelética idiopática difusa (DISH) é uma condição sistêmica caracterizada pela progressiva calcificação de ligamentos e ênteses, tanto axiais quanto periféricas, e com fisiopatogenia ainda desconhecida. Os principais fatores de risco associados são envelhecimento, obesidade e síndrome metabólica. Na maioria das vezes, o diagnóstico é incidental e realizado por meio de métodos de imagem solicitados por outras condições não relacionadas à DISH. A evolução dos sintomas é lenta, mas pode ser progressiva, incluindo dor torácica, lombar e/ou cervical; rigidez axial e articular; sintomas de compressão radicular (parestesia, claudicação e fraqueza em membros inferiores) e dor mono ou poliarticular. Com relação aos exames laboratoriais, os reagentes de fase aguda estão dentro da normalidade, em geral, e a prevalência do Human Leukocyte Antigen (HLA)-B27 é semelhante à população geral. Embora sem biomarcadores específicos, os marcadores de síndrome metabólica, como elevação da ferritina e insulina, podem estar presentes. O principal método de imagem na DISH é a radiografia da coluna vertebral, que caracteristicamente mostra a presença de calcificação do ligamento longitudinal anterior, com aspecto ondulante, sobretudo no lado direito da coluna torácica. A entesopatia periférica ou extra-axial também pode ser encontrada, particularmente em pés e joelhos. O tratamento é sintomático e baseia-se em analgesia, modulação da dor e reabilitação, bem como o controle do estado de resistência periférica à insulina. Unitermos: Hiperostose esquelética idiopática difusa. Condições patológicas. Quadro clínico. Diagnóstico. Diagnóstico diferencial. Classificação. Tratamento.

Comparison of radiological characteristics between diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: A multicenter study

Preprint

Full-text available

Oct 2022

Objective: To evaluate the radiological differences between diffuse idiopathic skeletal hyperostosis (DISH) and ankylosing spondylitis (AS) using whole spine computed tomography (CT), including the spine and sacroiliac joint (SIJ) Methods: The ossification and bridging of spinal ligament and fusion of the facet joint and SIJ were evaluated in 111 patients who were diagnosed with DISH and 28 patients with AS on the whole spine CT. The number of anterior bridging and shape of bridging (candle-wax-type/ smooth-type) were also evaluated. We further evaluated patients with DISH and AS by matching their age and sex. Results: Complete SIJ fusion was more common in AS, whereas anterior and posterior bony bridging around SIJ was more common in DISH. However, 63% of patients with DISH had a partial or complete fusion. In spinal anterior bony bridging, the majority of patients with AS had the smooth-type, whereas those with DISH had the candle-wax-type. However, some of the patients with DISH (11%) had smooth-type. Intervertebral facet joint fusion is more common in AS. The number of anterior spinal bony bridging was greater in AS than in DISH, especially in the lumbar spine. Conclusion: These results are useful in differentiating DISH from AS and shouldtherefore be considered when making a diagnosis.

The natural course of bridging osteophyte formation on MRI-A pictorial illustration ✩ , ✩✩

Article

Full-text available

Jan 2023

Diffuse skeletal hyperostosis is a common spinal disorder, but its pathophysiology is mostly unclear. The disorder can lead to a variety of symptoms, but many patients remain relatively asymptomatic. We present a case demonstrating the development of bridging osteophytes on a series of magnetic resonance images. An elderly person's spine was scanned repeatedly due to non-specific back pain during the last 4 years and the consecutive images revealed the formation of a bony bridge in the lumbar spine. Extensive bone marrow edema was seen during the formation of the osteophyte, suggestive of an ongoing inflammatory process. This case underlines that the inflammatory reaction in diffuse skeletal hyperostosis can be intense and prolonged, and its role might be worth studying further.

Diagnostic Imaging in the Degenerative Diseases of the Cervical Spine

Chapter

Jan 2022

The aim of this chapter would be to help the clinician, with the support of imaging, in the diagnosis of patients whith degenerative changes of the cervical spine, and to make differential diagnoses with other specific diseases.The knowledge of the anatomy of the osteo-discal-ligamentous complex, with particular focus to the intervertebral joints, that represent the primary targets of degeneration and cause of symptoms, is fundamental, as is the capability of how to choose the best imaging modality, in order to make a correct diagnostic evaluation of the cervical spine and also to follow and understand the evolution of the disease. In this scenario, MRI certainly represents the best imaging modality, especially in the cervical segment where other investigation methods, such as radiography and computed tomography, do not have the same diagnostic accuracy.In this chapter the basic findings in the degenerative diseases (disk degeneration, spondylosis, cervical facet joint arthropathy and the ligament degeneration), and how to recognize the evolution towards the phase of instability of the cervical spine will be explained. We will also illustrate the main findings, combining data from Rx, TC and MRI, of the degenerative disease of cranio-cervical junction and cervical axial segments with the support of images from clinical cases, focusing on the cervical disk herniation and the spinal stenosis.Finally, specific degenerative disease that may have elements in common with each other but which require specific therapies will be discussed. The clinician will therefore find the major pathological signs in the various imaging modalities about the rheumatoid arthritis, the Crowned dens syndrome, the retro-odontoid pseudotumor, the diffuse idiopathic skeletal hyperostosis, the ossification of the posterior longitudinal ligament and flaval ligaments, the destructive spondyloarthropaty in long-term hemodialyzed patients and the calcium pyrophosphate deposition disease.KeywordsCervical spineDegenerative diseasesRadiographic imagesComputed tomography imagesMagnetic resonance images

Galectin-3 Enhances Osteogenic Differentiation of Precursor Cells From Patients With Diffuse Idiopathic Skeletal Hyperostosis via Wnt/β-Catenin Signaling

Article

Jan 2022

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory skeletal disease characterized by the progressive ectopic ossification and calcification of ligaments and enthuses. However, specific pathogenesis remains unknown. Bone marrow mesenchymal stem cells (BMSCs) are a major source of osteoblasts and play vital roles in bone metabolism and ectopic osteogenesis. However, it is unclear whether BMSCs are involved in ectopic calcification and ossification in DISH. The current study aimed to explore the osteogenic differentiation abilities of BMSCs from DISH patients (DISH‐BMSCs). Our results showed that DISH‐BMSCs exhibited stronger osteogenic differentiation abilities than NC‐BMSCs. Human cytokine array kit analysis showed significantly increased secretion of Galectin‐3 in DISH‐BMSCs. Furthermore, Galectin‐3 downregulation inhibited the increased osteogenic differentiation ability of DISH‐BMSCs, while exogenous Galectin‐3 significantly enhanced the osteogenic differentiation ability of NC‐BMSCs. Notably, the increased Galectin‐3 in DISH‐BMSCs enhanced the expression of β‐catenin as well as TCF‐4, whereas attenuation of Wnt/β‐catenin signaling partially alleviated Galectin‐3‐induced osteogenic differentiation and activity in DISH‐BMSCs. In addition, our results noted that Galectin‐3 interacted with β‐catenin and enhanced its nuclear accumulation. Further in vivo studies showed that exogenous Galectin‐3 enhanced ectopic bone formation in the Achilles tendon in trauma‐induced rats by activating Wnt/β‐catenin signaling. The current study indicated that enhanced osteogenic differentiation of DISH‐BMSCs was mainly attributed to the increased secretion of Galectin‐3 by DISH‐BMSCs, which enhanced β‐catenin expression and its nuclear accumulation. Our study helps illuminate the mechanisms of pathological osteogenesis and sheds light on the possible development of potential therapeutic strategies for DISH treatment.

Historical bioarcheological aspects of Diffuse Idiopathic Skeletal Hyperostosis in humans

Article

Dec 2021
SEMIN ARTHRITIS RHEU

Geoffrey O Littlejohn

Objective : To identify diffuse idiopathic skeletal hyperostosis (DISH) in the human bioarcheological record to seek out temporal, geographic and dietary information to enhance better understanding of this common condition. Materials and Methods : A review of available literature was conducted. Results : DISH has been identified in hominin populations over millions of years, including several different human species. The distribution of DISH in ancient populations is diverse, both temporally and geographically. Where available, dietary intake of subjects with DISH, in contrast to those without DISH, suggests that metabolic factors associate with DISH. Conclusion : DISH is a ubiquitous human disorder over the ages. Metabolic factors appear important in ancient populations of those with DISH.

Probable Diffuse Idiopathic Skeletal Hyperostosis (DISH) in Pre-Pottery Neolithic Cyprus: Evidence from Khirokitia

Article

Oct 2021

Clinical Correlations to Specific Phenotypes and Measurements With Classification Systems: Lumbosacral Spine

Chapter

Apr 2021

This chapter examines the various classification schemes utilized to categorize alignment, assess boney anomalies, and assess disc vitality to identify potential lumbosacral disease and injury. Spinal pathophysiology is often multifactorial. On occasions, the severity of pathology and treatment is clear. In other instances, the pathology is more nuanced, requiring additional clinical and radiographic assessments. These cases have led to the development of multiple imaging-based classification systems in an attempt to identify which patients will respond appropriately to a specific intervention. An understanding of the classification schemes currently utilized is invaluable as it further solidifies their clinical significance and continues to drive research forward.

Musculoskeletal disorders associated with diabetes

Chapter

Jan 2020

Several musculoskeletal diseases are prevalent in individuals with diabetes. These include ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. In both, heterotopic ossification near the spine underlies neurological injury. These related conditions are common in individuals with obesity and type 2 diabetes; and, in both, abnormal mesenchymal cell differentiation secondary to altered growth factor milieu has been implicated in pathogenesis. Similarly, two shoulder disorders—rotator cuff tendinopathy and adhesive capsulitis—cause tendon injury and fibrosis. Common in those with type 1 and 2 diabetes, they are respectively thought to be caused by advanced glycation end product deposition and myofibroblastic differentiation of tendon mesenchymal cells. Finally, diabetic amyotrophy is rare, painful diabetic neuropathy associated with muscle wasting and likely caused by immune-mediated microvasculitis. Better understanding of their relationships with metabolic dysfunction may further elucidate the pathogenic mechanism of these conditions and inform future treatment options.

Radiographic/MR Imaging Correlation of Paravertebral Ossifications in Ligaments and Bony Vertebral Outgrowths: Anatomy, Early Detection, and Clinical Impact

Article

Nov 2019

Monique Reijnierse

This article focuses on the variety of imaging features of paravertebral ossifications that are of practical interest in the diagnosis of diseases. The spinal anatomy is reviewed and correlated to paravertebral ligamentous ossifications and their potential clinical impact. A vertebral bony outgrowth is secondary to inflammation or degeneration and can be characterized based on its origin and growth direction, in addition to appreciation of intervertebral disc space preservation or loss. Imaging in rheumatology patients is highlighted because early detection of disease is of increasing importance. A correlation between radiographs and MR imaging is made.

Enfermedad de Forestier-Rotes-Querol

Article

Full-text available

May 2019

Redefining DISH: A Catalyst for Advancement of Research?

Article

Apr 2019

John J. Block

Diagnosis of diffuse idiopathic skeletal hyperostosis with chest computed tomography: inter-observer agreement

Article

Full-text available

Apr 2016
EUR RADIOL

Objective To evaluate and improve the interobserver agreement for the CT-based diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). Methods Six hundred participants of the CT arm of a lung cancer screening trial were randomly divided into two groups. The first 300 CTs were scored by five observers for the presence of DISH based on the original Resnick criteria for radiographs. After analysis of the data a consensus meeting was organised and the criteria were slightly modified regarding the definition of ‘contiguous’, the definition of ‘flowing ossifications’ and the viewing plane and window level. Subsequently, the second set of 300 CTs was scored by the same observers. κ ≥ 0.61 was considered good agreement. ResultsThe 600 male participants were on average 63.5 (SD 5.3) years old and had smoked on average 38.0 pack-years. In the first round κ values ranged from 0.32 to 0.74 and 7 out of 10 values were below 0.61. After the consensus meeting the interobserver agreement ranged from 0.51 to 0.86 and 3 out of 10 values were below 0.61. The agreement improved significantly. Conclusions This is the first study that reports interobserver agreement for the diagnosis of DISH on chest CT, showing mostly good agreement for modified Resnick criteria. Key Points• DISH is diagnosed on fluoroscopic and radiographic examinations using Resnick criteria• Evaluation of DISH on chest CT was modestly reproducible with the Resnick criteria• A consensus meeting and Resnick criteria modification improved inter-rater reliability for DISH• Reproducible CT criteria for DISH aids research into this poorly understood entity

Metabolic Factors in Diffuse Idiopathic Skeletal Hyperostosis – A Review of Clinical Data

Article

Full-text available

Dec 2014
Open Rheumatol J

We aimed to review the literature linking metabolic factors to Diffuse Idiopathic Skeletal Hyperostosis (DISH), in order to assess associations between growth factors and DISH. We identified studies in our personal database and PubMed using the following keywords in various combinations: "diffuse idiopathic skeletal hyperostosis", "ankylosing hyperostosis", "Forestier's disease", "diabetes", "insulin", "obesity", "metabolic", "growth factors", "adipokines", "glucose tolerance" and "chondrocytes". We were not able to do a systematic review due to variability in methodology of studies. We found positive associations between obesity (especially abdominal obesity), Type 2 diabetes mellitus, glucose intolerance, hyperinsulinemia and DISH. Current research indicates that certain metabolic factors associate with DISH. More precise studies deriving from these findings on these and other newly identified bone-growth factors are needed.

Diffuse idiopathic skeletal hyperostosis: Clinical features and pathogenic mechanisms

Article

Full-text available

Nov 2013
NAT REV RHEUMATOL

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the ossification and calcification of ligaments and entheses. DISH is observed on all continents and in all races, but most commonly in men over 50 years of age. Although DISH is asymptomatic in most individuals, the condition is often an indicator of underlying metabolic disease, and the presence of spinal or extraspinal ossifications can sometimes lead to symptoms including pain, stiffness, a reduced range of articular motion, and dysphagia, as well as increasing the risk of unstable spinal fractures. The aetiology of DISH is poorly understood, and the roles of the many factors that might be involved in the development of excess bone are not well delineated. The study of pathophysiological aspects of DISH is made difficult by the formal diagnosis requiring the presence of multiple contiguous fully formed bridging ossifications, which probably represent advanced stages of DISH. In this Review, the reader is provided with an up-to-date discussion of the epidemiological, aetiological and clinical aspects of DISH. Existing classification criteria (which, in the absence of diagnostic criteria, are used to establish a diagnosis of DISH) are also considered, together with the need for modified criteria that enable timely identification of early phases in the development of DISH.

Spondyloarthritis and Diffuse Idiopathic Skeletal Hyperostosis: Two Different Diseases That Continue to Intersect

Article

Full-text available

Aug 2013

Spondyloarthritis (SpA) and diffuse idiopathic skeletal hyperostosis (DISH) are different diseases obliged to converge1. SpA is an inflammatory disease involving the axial skeleton and the peripheral entheses and joints and showing a wide clinical spectrum that encompasses ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), arthritis related to inflammatory bowel disease (IBD), and forms that do not meet established criteria for these definite categories and are designated as undifferentiated SpA (uSpA)2,3. Recently, classification criteria have been suggested by ASAS (Assessment in Spondyloarthritis International Society) for axial and peripheral SpA4,5. In contrast, DISH is a degenerative condition characterized by calcification and ossification of ligaments and entheseal sites in the axial and the peripheral skeleton6. Classification criteria for DISH used so far require involvement of the spine6 although extravertebral bone proliferations are frequent and characteristic and may precede axial changes7,8. An international study for the development of new criteria is in progress8. At the beginning of the story, AS and DISH resembled each other only on radiographs because of the bony outgrowths they produce in the spine1. Clinically, they were considered very different diseases. Symptoms of AS begin at a young age, frequently in second and third decades, and consist of inflammatory back pain and buttock pain, reduced spinal movement, and progressive typical postural abnormalities known as “Bechterew stoop.” In contrast, DISH was considered a disease with an asymptomatic course or with mild dorsolumbar pain and/or some restriction of spinal motion. Radiographically, DISH is characterized by “flowing mantles” of ossifications occurring in the anterior longitudinal … Address correspondence to Dr. Olivieri, Rheumatology Department of Lucania-San Carlo Hospital, Contrada Macchia Romana, 85100-Potenza, Italy. E-mail: ignazioolivieri{at}tiscalinet.it

Developing new classification criteria for diffuse idiopathic skeletal hyperostosis: Back to square one

Article

Full-text available

Sep 2012

Objective: To revise the definition of DISH and suggest a classification that may better represent our current knowledge of this entity allowing earlier diagnosis. Methods: Seven rheumatologists and an orthopaedic surgeon suggested a list of 63 parameters that might be included in a future classification of DISH. Participants rated their level of agreement with each item, expressed in percentages. In a second session, participants discussed each item again and re-rated all parameters. Thirty items that were granted ≥50% support on average were considered valid for a third round. A questionnaire listing these 30 items was mailed to 39 rheumatologists and orthopaedic surgeons worldwide with a request to answer categorically if they agreed on an item to be included as a criterion for a future classification of DISH. Items were regarded as perfect consensus when at least 95% of the respondents agreed and were regarded as consensus when at least 80% agreed. Results: There was perfect consensus for 2 (6.7%) of the 30 parameters and consensus for another 2 parameters. These items were ossification and bridging osteophytes in each of the three segments of the spine and exuberant bone formation of bone margins. Conclusion: At present there is no agreement about the inclusion of extraspinal, constitutional and metabolic manifestations in a new classification of DISH. Investigators with an interest in this condition should be encouraged to restructure the term DISH in an attempt to establish a more sophisticated definition.

Diffuse idiopathic skeletal hyperostosis: Differentiation from ankylosing spondylitis

Article

Full-text available

Oct 2009
Curr Rheumatol Rep

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.

Diffuse Idiopathic Skeletal Hyperostosis Is Associated with Lower Lung Volumes in Current and Former Smokers

Article

Jul 2016

Prevalence, Concomitance, and Distribution of Ossification of the Spinal Ligaments: Results of Whole Spine CT Scans in 1500 Japanese Patients

Article

Apr 2016
SPINE

Study design: Cross sectional study. Objectives: To investigate the prevalence, concomitance, and distribution of various types of ossification of the spinal ligaments in healthy subjects using computed tomography (CT). Summary of background data: CT has better diagnostic accuracy for ossification of the spinal ligaments compared to plain radiography. Currently there is no study that examines the prevalence of ossification of the spinal ligaments using whole spine CT scans. Methods: One thousand and five hundred Japanese patients (888 men and 612 women) who underwent positron emission tomography and computed tomography (PETCT) in a private health check center between 2006 and 2013 were included. This PETCT was performed on self-paying participants as a prevenative cancer screen. Existence of ossification of the posterior longitudinal ligament (OPLL), ligamentum flavum (OLF), anterior longitudinal ligament (OALL), diffuse idiopathic skeletal hyperostosis (DISH), and nuchal ligament (ONL) was examined. Results: The prevalence of spinal ligament ossifications was found to be 6.3% in cervical OPLL (8.3% in men and 3.4% in women), 23% in ONL (33% in men and 8.8% in women), 1.6% in thoracic OPLL (1.4% in men and 2.0% in women), 12 % in thoracic OLF (15% in men and 7.7% in women), 37% in thoracolumbar OALL (45% in men and 26% in women), and 12% in DISH (16% in men and 6.2% in women). 13% of patients with cervical OPLL had thoracic OPLL, 34% of cervical OPLL had thoracic OLF, 45% of cervical OPLL had ONL, and 36% of cervical OPLL had DISH. The most common level was C5 for cervical OPLL, T1/2 for thoracic OPLL, T11 for thoracic OLF, and T8/9 for OALL. Conclusions: Accurate prevalence of various types of ossification of the spinal ligaments evaluated by CT was revealed. High concomitance was observed in each classification of spinal ligament ossification. Level of evidence: 3.

Calcification and ossification of vertebral ligaments (spondylitis ossificans ligamentosa): Roentgen study of pathogenesis and clinical significance

Article

Feb 1942

A. Oppenheimer

Distinctions Between Diagnostic and Classification Criteria?

Article

Mar 2015

Rheumatologists face unique challenges in discriminating between rheumatologic and non-rheumatologic disorders with similar manifestations, and in discriminating among rheumatologic disorders with shared features. The majority of rheumatic diseases are multisystem disorders with poorly understood etiology; they tend to be heterogeneous in their presentation, course, and outcome, and do not have a single clinical, laboratory, pathological, or radiological feature that could serve as a “gold standard” in support of diagnosis and/or classification. Thus, the development of criteria for use in routine clinical care and in clinical research has been an important focus in rheumatology. Improved understanding of disease pathogenesis and new diagnostic tools have led to reexamination of existing classification and diagnostic criteria with updated classification criteria for some diseases being endorsed recently (1, 2). The American College of Rheumatology (ACR) Subcommittee on Classification and Response Criteria is responsible for guiding the development and validation of new classification and response criteria that are eventually considered for ACR endorsement. This includes review of proposals for the development of new criteria sets and providing the ACR leadership with recommendations for development and approval of new classification and response criteria sets (1, 3–5). The Subcommittee has previously published a guidance paper for the development of classification and response criteria (6). This prior work has provided details about the rationale for the ACR’s position on classification criteria, but clarification around the issue of diagnostic criteria was lacking. Indeed, the ACR endorsed preliminary diagnostic criteria for fibromyalgia (7) in 2010, which prompted discussions about whether the Subcommittee should also support the development and ACR endorsement of diagnostic criteria, in addition to that of classification and response criteria. The primary objectives of this current article, by former and current members of the Subcommittee on Classification and Response Criteria, are to compare diagnostic and classification criteria, using specific examples from the published literature, and to clarify the ACR’s position on both types of criteria.

The natural course of bridging osteophyte formation in diffuse idiopathic skeletal hyperostosis: Retrospective analysis of consecutive CT examinations over 10 years

Article

Oct 2013

Objective: The aim of this study was to evaluate the natural progression of bridging osteophyte formation in diffuse idiopathic skeletal hyperostosis (DISH) on CT by a newly proposed scoring system. Methods: CT examinations of the thoracic/lumbar spine of DISH patients (Resnick criteria) obtained at two or more time points within a minimum of 3 years were evaluated. Twenty-six patients (mean age at first CT 57 years, 21 males) fulfilled the entry criteria. A semi-quantitative scoring system for osteophyte progression was evaluated for intra- and interreader reliability on 68 vertebral units (VUs) in five patients. CT sagittal reformates of all 26 study patients were scored by two readers in consensus. Results: Scoring intra- and interobserver intraclass correlation coefficient values were high (0.971 and 0.893, respectively). The average time points per patient was 3.6 in 398 VUs analysed for 93 time points. The average time between the first and last scans was 5.6 years (range 3-10). The scores of six patients were unchanged. The scores of 20 patients increased by 3 units in 48 VUs over 5.6 (s.d. 3.1) years. The time for a DISH score to increase by 1 scoring unit was 1.6 (s.d. 0.4) years. Two bridging patterns were observed: osteophyte fusion associated with a calcified anterior longitudinal ligament (ALL, 66%) and osteophyte fusion without apparent ALL calcification (33%). Both patterns were observed concomitantly in 15 patients. Conclusion: The new scoring system may enable earlier diagnosis and help predict disease progression into its final confluent osteophyte form. The two described patterns may indicate an underlying inflammatory rather than a degenerative pathogenesis.

Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients

Article

Aug 2013

The clinical outcome of patients with ankylosing spinal disorders (ASDs) sustaining a spinal fracture has been described to be worse compared with the general trauma population. To investigate clinical outcome (neurologic deficits, complications, and mortality) after spinal injury in patients with ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) compared with control patients. Retrospective cohort study. All patients older than 50 years and admitted with a traumatic spinal fracture to the Emergency Department of the University Medical Center Utrecht, the Netherlands, a regional level-1 trauma center and tertiary referral spine center. Data on comorbidity (Charlson comorbidity score), mechanism of trauma, fracture characteristics, neurologic deficit, complications, and in-hospital mortality were collected from medical records. With logistic regression analysis, the association between the presence of an ASD and mortality was investigated in relation to other known risk factors for mortality. A total of 165 patients met the inclusion criteria; 14 patients were diagnosed with AS (8.5%), 40 patients had DISH (24.2%), and 111 patients were control patients (67.3%). Ankylosing spinal disorder patients were approximately five years older than control patients and predominantly of male gender. The Charlson comorbidity score did not significantly differ among the groups, but Type 2 diabetes mellitus and obesity were more prevalent among DISH patients. In many AS and DISH cases, fractures resulted from low-energy trauma and showed a hyperextension configuration. Patients with AS and DISH were frequently admitted with a neurologic deficit (57.1% and 30.0%, respectively) compared with controls (12.6%; p=.002), which did not improve in the majority of cases. In AS and DISH patients, complication and mortality rates were significantly higher than in controls. Logistic regression analysis showed the parameters age and presence of DISH to be independently, statistically significantly related to mortality. Many patients with AS and DISH showed unstable (hyperextension) fracture configurations and neurologic deficits. Complication and mortality rates were higher in patients with ASD compared with control patients. Increasing age and presence of DISH are predictors of mortality after a spinal fracture.

La maladie hyperostosique

Article

Dec 1985
REV MED INTERNE

Comprehensive radiographic evaluation of diffuse idiopathicskeletal hyperostosis: Development and interrater reliability of a scoring system

Article

Oct 1998
SEMIN ARTHRITIS RHEU

To develop a scoring system for radiographic findings in diffuse idiopathic skeletal hyperostosis (DISH) and to test interrater reliability. Fifty-five DISH patients and 35 spondylosis patients underwent two views (anteroposterior and lateral) of the cervical, thoracic, and lumbar spine, lateral views of both ankles, knees, and elbows, and anteroposterior views of the pelvis and shoulders. Two raters reviewed and scored the x-rays. Interrater reliability was assessed with the alpha statistic (alpha) for categorical variables and with the intraclass correlation coefficient (ICC) for continuous variables. The agreement was similar for the three spinal segments (alpha = 0.44 to 0.71). The lower extremity agreement ranged from 0.28 to 0.76, with higher agreement at the knee (alpha > or = 0.46) and the ankle (alpha > or = 0.56) than at the pelvis (ICC < or = 0.58). The agreement at the shoulders and elbows ranged from 0.50 to 0.75. The agreement between the readers was higher with summary measurements than with single (site-by-site) measurements: for each spinal segment, the ICC was 0.83 or greater; for the lower extremity, the ICC = 0.79; and for the upper extremity, the ICC = 0.68. We have described a comprehensive scoring system to assess the spinal and peripheral involvement of DISH.

Diffuse idiopathic skeletal hyperostosis and new bone formation in male gouty subjects

Article

Jun 1982

Ninety-nine males with gout were identified and their radiographs examined for features of vertebral hyperostosis and entheseal changes (diffuse idiopathic skeletal hyperostosis, DISH). Of patients over the age of 45 years 43% fulfilled criteria for diagnosis of DISH. New bone formation in other regions of the skeleton was also common. The overhanging margin sign, seen in well developed tophi, was noted only in patients with prominent new bone formation elsewhere in their skeleton. Some of the radiologic manifestations of gout may be modified by a co-existent tendency, in these patients, to form new bone. It is suggested that a common metabolic factor, possibly hyperinsulinaemia, underlies the association of gout and hyperostosis.

Spondylosis Deformans and Diffuse Idiopathic Skeletal Hyperostosis (Dish) in Finland: Incidence and Pathogenetic Factors

Article

Jan 1981

A population study with 6-year follow-up of 6167 persons aged over 30 was carried out in nine population groups in Southern Finland. Estimation of spondylosis and DISH (Diffuse Skeletal Hyperostosis) was made from lateral chest X-rays. Reliability coefficients (kappa) in the repeat reading of 1025 films ranged between 0.60 and 0.76. 214 cases of newly developed DISH and 1080 of spondylosis were observed. With the exception of 4 new cases, all cases of DISH had developed in persons who had had spondylosis at baseline or developed it during the follow-up. The sexual incidence of spondylosis was fairly similar, i.e. 4 cases per 100 person years in both. Prevalence and incidence of spondylosis were highest in rural areas, in persons with strenuous occupations and in the obese. Incidence of DISH was 0.7 cases per 100 person years in men and 0.4 in women. DISH was equally common in all types of population. It was not associated with arduousness of occupation. Obesity and–to a lesser degree–diabetes meilitus and glucose intolerance were associated with DISH. Neither condition was associated with elevated serum calcium, serum cholesterol or bacteriuria. The study supports the concept that DISH is epidemiologically and pathogenetically different from spondylosis deformans.

Diffuse idiopathic skeletal hyperostosis (Forestier-Rotes-Querol disease): What's new?

Article

Apr 2013

Bernard Mazieres

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier-Rotes-Querol disease, is characterized by the ossification of the entheses (i.e., enthesopathy). The diagnosis of DISH requires at least two (according to Forestier) or three (according to Resnick) contiguous intervertebral bridges, without severe disk alterations (in contrast to degenerative spinal disease) or ankylosis of the sacroiliac or facet joints (in contrast to spondylarthritis). Although prevalence estimates vary with the number of bridges used to define the disease, the prevalence of DISH is consistently high and increases with age and obesity. Peripheral involvement is common but difficult to ascribe to DISH in the absence of typical spinal changes. Cervical spine ossification is the most extensively studied manifestation, as dysphagia due to esophageal compression may require surgery. As with spondylarthritis, vertebral fractures on a hyperostotic fused spine may escape recognition, placing the patient at risk for complications in the event of subsequent displacement. These fractures are particularly severe, as they often involve the cervical spine and can therefore, cause major neurological impairments. DISH is associated with an increased risk of metabolic syndrome (odds ratio, 3.88). Research into the pathophysiology of DISH has established that serum levels of the natural osteogenesis inhibitor Dickkopf-1 (DKK-1) are low in patients with DISH or spondylarthritis. Although this abnormality might contribute to the entheseal ossification, it has not been found consistently.

DISH and the Monastic way of life

Article

Sep 2001
INT J OSTEOARCHAEOL

Diffuse idiopathic skeletal hyperostosis (DISH) is common condition and its prevalence increases markedly with age. This paper describes the pathology and aetiology of the condition; DISH seems to be related to obesity and type II diabetes and is probably a multisystem hormonal disorder. DISH occurs frequently in human skeletal remains, particularly in those recovered from monastic sites. Evidence is presented to confirm this association and the causes are discussed. We also present criteria for the diagnosis of DISH in human remains, which we suggest would permit valid inter-study comparisons. Copyright

Disseminated idiopathic skeletal hyperostosis (DISH) in a dog

Article

May 2005
VET RADIOL ULTRASOUN

Spinal and extraspinal manifestations similar to Forestier's disease, or disseminated idiopathic skeletal hyperostosis (DISH), are described in a 4-year-old female Great Dane dog. Radiographic features included linear new bone formation with a smooth wavy contour along the ventral and lateral aspects of vertebral bodies plus hyperostosis at ligamentous attachments in the spine (enthesiophytes) causing bony ankylosis. Periarticular new bone and enthesiopathy were present in extraspinal locations. Clinical signs possibly relate to limitations in motion because of the vertebral fusion and extraspinal arthrosis.

Diffuse idiopathic skeletal hyperostosis: Diagnosis in a palaeopathological context

Article

May 2012

Clinically, the presence of diffuse idiopathic skeletal hyperostosis (DISH) has been linked to a disturbance of glucose and insulin metabolism, hypertension, dyslipidemia and obesity associated with a rich diet. The prevalence of DISH in archaeological skeletal samples may therefore be a valuable indicator of their socio-economic status when compared to other contemporary groups. However, various methods are currently being used to diagnose DISH. The purpose of this study was therefore to assess the comparability of results obtained using four different diagnostic methods to estimate the prevalence of DISH in a skeletal sample, and to discuss the implications of the results in relation to palaeopathological health assessments. Four different diagnostic criteria were applied to 127 male and 113 female skeletons to diagnose DISH. Skeletal remains were obtained from two 16th century samples from Delft and one modern sample from the anatomy dissection hall of the Leiden University Medical Centre. The estimated prevalences were statistically compared. Special attention was also given to the distribution of extra-spinal enthesophytes described in diagnostic criteria, in order to assess their diagnostic value. The prevalence of DISH observed in the skeletal samples varied significantly depending on the criteria used for diagnosis. Furthermore, extra-spinal enthesophytes, suggested as being indicative of DISH, proved to be variable and unreliable. It was concluded that it is of great importance to explicitly state and adhere to criteria employed for diagnosing DISH in both palaeopathological and clinical investigations in order to ensure reliable comparisons between studies. Also, DISH cannot be positively diagnosed solely based on the presence of extra-spinal enthesophytes.

Diffuse Idiopathic Skeletal Hyperostosis and Its Relation to Back Pain Among Older Men: The MrOS Study

Article

Mar 2011

To estimate the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in a cross-sectional study of elderly men age 65 to 100 years and to examine back and neck pain as possible correlates of DISH. DISH was defined using Resnick's criteria and scored according to Mata on lateral spine radiographs of 298 randomly selected participants from the MrOS Study. Standardized self-reported questionnaires were used to assess the frequency and severity of back and neck pain, and the relation of these to DISH status was estimated with χ(2) tests, as well as prevalence ratios and 95% confidence intervals using log-binomial regression models. DISH was observed in 126 older men (42%), increased with age (30%, 39%, 48%, and 56% for ages 65-69, 70-74, 75-79, and ≥80 respectively), and was positively associated with body mass index (BMI) (P = 0.04) and blood pressure (P = 0.02). Significantly less back pain in the past 12 months was reported among men with DISH as compared to men without (59% vs 71%, P = 0.03), which remained after adjustment for age, BMI, and blood pressure (prevalence ratios = 0.73, 95% confidence interval = 0.57-0.95). Back pain severity (P = 0.07) and frequency (P = 0.06) were also less frequent among men with DISH compared to men without, whereas reported neck pain was similar between groups (P = 0.39). Among community-dwelling elderly men, DISH prevalence is high, increases with age, and is positively associated with BMI and blood pressure. Frequency of self-reported back pain over the past 12 months was lower in older men with DISH as compared to those without DISH.

Radiographic and Pathologic Features of Spinal Involvement in Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Article

Jul 1976

The vertebral involvement of DISH is described from an evaluation of 215 cadaveric spines and 100 patients with the disease. Radiographic features include linear new bone formation along the anterolateral aspect of the thoracic spine, a bumpy contour, subjacent radiolucency, and irregular and pointed bony excrescences at the superior and inferior vertebral margins in the cervical and lumbar regions. Pathologic features include focal and diffuse calcification and ossification in the anterior longitudinal ligament, paraspinal connective tissue, and annulus fibrosis, degeneration in the peripheral annulus fibrosis fibers, L-T-, and Y-shaped anterolateral extensions of fibrous tissue, hypervascularity, chronic inflammatory cellular infiltration, and periosteal new bone formation on the anterior surface of the vertebral bodies.

Diffuse Idiopathic Skeletal Hyperostosis (DISH): Forestier's Disease with Extraspinal Manifestations 1

Article

Jul 1975

The extraspinal manifestations of Forestier's disease are described in 21 consecutive cases; diffuse idiopathic skeletal hyperostosis (DISH) is suggested as a more appropriate description of this ossifying diathesis. Characteristic roentgen abnormalities of the spine were present in all individuals and associated with significant axial clinical complaints. In extraspinal locations, hyperostosis at ligament attachments usually occurs in the pelvis, calcaneus, tarsal bones, ulnar olecranon and patella, and is occasionally associated with clinical signs and symptoms requiring surgery. The radiographic appearance in the peripheral skeleton is frequently distinctive and allows the radiologist to suggest the correct diagnosis, even in the absence of axial radiographs.

Evaluation of the involvement of axial entheses and sacroiliac joints in relation to diagnosis: Comparison among diffuse idiopathic skeletal hyperostostis (DISH), osteoarthrosis and ankylosing spondylitis

Article

Jan 1993

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.

Diffuse idiopathic skeletal hyperostosis (DISH) of the shoulder: A cause of shoulder pain?

Article

Nov 1990

Shoulder pain is a common complaint and shoulder hyperostosis a frequent radiological condition. However, little is known about the association between the clinical and radiological findings. To evaluate the clinical relevance of shoulder hyperostosis we performed a controlled, blind study of 99 hospitalized probands with and without thoracospinal hyperostosis on lateral chest X-rays. The study included grading of the shoulder hyperostosis on the basis of three bilateral standard radiographs, assessing shoulder pain in a standardized way by an interviewer and recording extraskeletal causes of shoulder pain. The prevalence of shoulder hyperostosis was doubled in probands with thoracospinal hyperostosis compared to controls (X2= 5.90, F>0.025, n = 99). Shoulder hyperostosis, irrespective of thoracospinal hyperostosis, predisposed to shoulder pain (40% versus 18%, x2 = 4.06, F>0.05, n = 74). Shoulder hyperostosis in combination with thoracospinal hyperostosis (shoulder DISH) predisposed to shoulder pain to an even greater extent (46% versus 12%, x2 = 6.64, P>0.01, n = 47). We conclude that shoulder hyperostosis is a radiological finding of potential clinical relevance

Diffuse idiopathic skeletal hyperostosis: Diagnostic significance of radiographic abnormalities of the pelvis

Article

Oct 1989

Retrospective evaluation of the osseous pelvis in 93 patients with severe diffuse idiopathic skeletal hyperostosis (DISH) revealed 14 locations of radiographic abnormalities. Two osteoradiologists independently studied these sites for abnormalities in a prospective, blinded fashion in 103 patients over the age of 45 years. Lateral radiographs of the thoracolumbar spine were quantitatively and qualitatively evaluated to determine whether DISH, spondylosis deformans, or a normal spine was present. Statistical analysis was performed for evaluation of interobserver reliability, the relationship between pelvic and spinal abnormalities, and the significance and predictive values of pelvic abnormalities for DISH versus non-DISH and DISH versus spondylosis deformans. Although significantly higher frequencies and greater extents of radiographic abnormalities at 10 of 14 pelvic locations were noted for DISH compared with non-DISH, this number decreased to four of 14 locations when compared with spondylosis deformans. The alterations in three of these four pelvic sites consisted of ossification of ligaments. These changes appear to be good indicators of the presence of spinal DISH and support the concept that DISH is an entity separate from spondylosis deformans.

Diffuse Idiopathic Skeletal Hyperostosis

Article

Sep 1985
Clin Rheum Dis

P D Utsinger

Diffuse idiopathic skeletal hyperostosis (DISH, ankylosing hyperostosis) is a common skeletal disease of unknown aetiology seen in middle-aged and elderly patients. The principal manifestation of DISH is ligamentous calcification and ossification of the anterolateral aspect of the spinal column, sometimes leading to bony ankylosis. DISH also frequently involves the peripheral skeletal system, where entheseal ossification and bony spurs are seen. DISH has been described in various forms for at least 50 years. It is curious that only recently rheumatologists have become widely interested in the condition. This interest has led to the establishment of diagnostic criteria, a description of the primary clinical features and the delineation of the extensive histopathological and roentgenographic abnormalities. In addition, hypotheses concerning the aetiology and pathogenesis can now be offered.

Ankylosing hyperostosis. I. Clinical and radiological features

Article

Jun 1974

The clinical and radiological features of 34 patients with ankylosing hyperostosis are presented. Pain in some region of the back was found in 29 cases. The condition may sometimes be suspected clinically by the presence of moderate to severe limitation of back movements (without rigidity) in an obese elderly patient, but the diagnosis can usually only be made radiologically. The peripheral joints and the pelvis may be affected by fluffy periostitis. No abnormality in growth hormone levels was found and the hypothesis that this condition is a form of acromegaly was not substantiated.

Pathology of the dorsal spine in ankylosing hyperostosis

Article

Aug 1974

Hyperostosis of the spine in an adult population. Its relation to hyperglycaemia and obesity

Article

Dec 1971

The Prevalence of Ankylosing Hyperostosis in a Jerusalem Population—with Description of a Method of Grading the Extent of the Disease

Article

Feb 1984

Ronald A. Bloom

The prevalence of ankylosing hyperostosis in a Jewish hospital population is presented. In inndividuals over the age of 40 years the overall prevalence was 22.4% in males and 13.4% in females. The prevalence increased with age to a maximum of 46% in males and 30% in females over the age of 80 years. A method of grading the disease according to extent is described. The most extensive grade III is seen almost exclusively in males. © 1984 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.

Pagetic Vertebral Ankylosis and Diffuse Idiopathic Skeletal Hyperostosis

Article

Mar 1995

A retrospective radiologic analysis of Paget's disease of the spine. The prevalence, anatomic distribution, mechanisms of formation of Pagetic vertebral ankylosis (PVA) and the possibility of a relationship to diffuse idiopathic skeletal hyperostosis (DISH) were assessed in a large population of persons with Paget's disease. Acquired vertebral ankylosis is not a common feature of the Paget's disease of the spine and its mechanisms of formation remain unknown. In some reports, PVA was associated with radiographic signs of DISH. Of 337 Pagetic patients monitored in the Division of Rheumatology from 1961 to 1990, all 245 who had entire spine radiographs were selected for study. Radiographs were studied for signs of Pagetic vertebral lesions and for spinal lesions of DISH. The study group contained 156 men with a mean age of 68 years (range 37-92) and 89 women with a mean age of 71 years (range 50-89). Fourteen PVA were observed on the radiographs of 11 men (mean age 68 years; range 60-76). One PVA was cervical, eight were thoracic, one thoracolumbar, three lumbar, and one lumbosacral. Eighty of the two hundred forty-five patients (32.6%) had characteristic features of DISH. Eight out of the eleven patients with PVA also had evidence of spinal lesions of DISH and radiographic features of DISH were observed contiguous to ten of the fourteen PVA. The scarcity of PVA reported in the literature and in our study (4.4% of 245 patients) suggests that constant progression of the disease from one vertebra to another by invasion of intervertebral disc space is rare. However, the higher incidence of PVA in men, their preferential location at the thoracic spine and their association with lesions of DISH suggest that progression of Pagetic lesions by invasion of bridging osteophytes may be an important mechanism for the intervertebral spread of Paget's disease.

Senile Ankylosing Hyperostosis of the Spine

Article

Jan 1951

Clinical and Radiological Analysis of Ossification of the Anterior Longitudinal Ligament Causing Dysphagia and Hoarseness

Article

Jun 2006
NEUROSURGERY

We retrospectively analyzed the clinical and radiological characteristics of ossification of the anterior longitudinal ligament (OALL). Seventeen patients with OALL who underwent surgery between 1995 and 2003 were reviewed. Symptomatic OALL was found in four patients. In 13 asymptomatic OALL patients who experienced mild to severe myelopathy, no swallowing difficulty was noted. The OALL was classified into three types by sagittal computed tomographic (CT) scans as segmental, continuous, and mixed and three types on axial CT scans as flat, nodular, and globular type. The thickness, numbers of involved vertebral bodies, and type and shape for symptomatic OALL were analyzed and compared with those for asymptomatic OALL. The mean thickness of 13.5 mm for symptomatic OALL was significantly higher than that of 6.5 mm for asymptomatic OALL (P = 0.0009). A globular shape on axial CT was common for symptomatic OALL. There were no differences in the numbers of involved vertebral bodies and types of OALL on sagittal CT scans. Surgical excision of OALL was performed for all cases of symptomatic OALL. In 7 of 13 asymptomatic cases, OALL was simultaneously removed during anterior decompressive surgery for the associated pathology. The thickness on axial CT scans was an important contributing factor to dysphagia and hoarseness as was the shape of the OALL. The type of OALL on sagittal CT scans was similar to that of ossification of the posterior longitudinal ligament but did not influence the development of dysphagia. Good relief from symptoms was achieved for symptomatic OALL after removal of OALL.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Jan 2009
b2535

Classification criteria for diffuse idiopathic skeletal hyperostosis: A lack of consensus

Abstract

No full-text available

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