eMedicine Specialties > Orthopedic Surgery > Pediatrics

Diffuse Idiopathic Skeletal Hyperostosis: Differential Diagnoses & Workup

Author: Bruce M Rothschild, MD, Professor of Medicine, The Northeastern Ohio Universities College of Medicine; Director, Arthritis Center of Northeast Ohio; Adjunct Professor, Department of Biomedical Engineering, University of Akron
Contributor Information and Disclosures

Updated: Jan 8, 2009

Differential Diagnoses

Ankylosing Spondylitis
Rheumatoid Spondylitis

Other Problems to Be Considered

Spondylosis deformans
Fluorosis
Osteomalacia
Acromegaly
Hypervitaminosis A
Retinoids
Pachydermoperiostosis
Hypophosphatemia
Hypoparathyroidism
Ossified posterior longitudinal ligament (OPLL)

Workup

Laboratory Studies

  • No laboratory tests are indicated. An apparent association with elevated glucose levels has not been substantiated as a relationship with diabetes.21,22

Imaging Studies

  • Thoracic vertebrae are involved in 100% of affected individuals, lumbar vertebrae in 68-90% of these persons, and cervical vertebrae in 65-78% of affected individuals. Ligamentous ossification affects both sides of the lumbar vertebral column but tends to be unilateral in the human spine. Prominence of diffuse idiopathic skeletal hyperostosis (DISH) on the right lateral aspect of the thoracic spine is apparently related to aortic pulsations. Left-sided overgrowth is much reduced, also probably because of the influence of aortic pulsations, an idea supported by the notation of left-sided prominence in individuals with situs inversus (left-sided thoracic aorta).
  • The earliest sign of DISH appears to be new bone formation adjacent to the midportion of the vertebral body, a phenomenon often below the limits of radiologic detection. Recognition of DISH is facilitated by its separation from the body of the vertebrae. This gives rise radiologically to the appearance of a radiodense line paralleling the longitudinal axis of the spine but separated by a clearly definable space.
  • The general term DISH emphasizes that the ligamentous ossification phenomenon is not limited to the spine. Exuberant ossification at sites of tendon, ligamentous, or joint capsule insertion (enthesitis) is strongly suggestive of the diagnosis. A tendency toward such ossification at any site of ligament and perhaps tendon insertion appears to exist. Enthesial reaction at the iliac crest and ischial tuberosities often is referred to as pelvic whiskering and typically is quite exuberant. Such whiskering was noted in two thirds of iliac crests studied and in 53% of ischial tuberosities. Enthesial reaction was noted in 42% of lesser and 36% of greater trochanters of the femur. Enthesial spurs at the site of insertion of the quadriceps mechanism into the patella were present in 29% of patients studied. Osseous bridging of fibula and tibia was noted in 10% of patients. Distal metacarpal and phalangeal capsular hyperostosis were present in 13% of patients with DISH.14

Histologic Findings

Ossified tissues in diffuse idiopathic skeletal hyperostosis (DISH) are composed of normal-appearing haversian bone as opposed to the wormian or disorganized structure of bone seen in patients with hypervitaminosis A.23

More on Diffuse Idiopathic Skeletal Hyperostosis

Overview: Diffuse Idiopathic Skeletal Hyperostosis
Differential Diagnoses & Workup: Diffuse Idiopathic Skeletal Hyperostosis
Treatment & Medication: Diffuse Idiopathic Skeletal Hyperostosis
Follow-up: Diffuse Idiopathic Skeletal Hyperostosis
References
[ CLOSE WINDOW ]

References

  1. Miyazawa N, Akiyama I. Ossification of the ligamentum flavum of the cervical spine. J Neurosurg Sci. Sep 2007;51(3):139-44. [Medline].

  2. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. Sep 13 2008;[Medline].

  3. Rothschild BM, Woods R. Old World spondylarthropathy: the gorilla connection. Arthritis Rheum. Jul 1988;31(7):934-5. [Medline].

  4. Ferigolo J. Estudos multidisciplinares. In: Goncalves de Araujo AJ, Ferreira LF, eds. Non-human Vertebrate Paleopathology. Brazil: Panorama. 1988:213-34.

  5. Bjorkengren AG, Sartoris DJ, Shermis S, et al. Patterns of paravertebral ossification in the prehistoric saber-toothed cat. AJR Am J Roentgenol. Apr 1987;148(4):779-82. [Medline].

  6. McDonald JN, Bartlett CS Jr. An associated musk ox skeleton from Saltville, Virginia. J Vert Paleontol. 1983;2:453-470.

  7. Moodie RL. Studies in Paleopathology: XX. Vertebral lesions in the sabre-tooth, Pleistocene of California, resembling the so-called Myositis Ossificans Progressiva, compared with certain ossifications in the dinosaurs. Ann Med Hist. 1927;9:91-102.

  8. Rothschild BM. Scientifically rigorous reptile and amphibian osseous pathology: Lessons for forensic herpetology from comparative and paleo-pathology. Applied Herpetology. 2008;10:39-116.

  9. Rothschild BM. Skeletal paleopathology of rheumatic diseases: the subprimate connection. In: McCarty DJ, ed. Arthritis and Allied Conditions. 11th ed. Philadelphia, Pa: Lea and Febiger;1989:3-7.

  10. Rothschild BM. Diffuse idiopathic skeletal hyperostosis as reflected in the paleontologic record: dinosaurs and early mammals. Semin Arthritis Rheum. Nov 1987;17(2):119-25. [Medline].

  11. Rothschild BM, Berman D. Fusion of caudal vertebrae in late Jurassic sauropods. J Vert Paleontol. 1991;11(1):29-36.

  12. Rothschild BM, Martin LD. Paleopathology: Disease in the Fossil Record. Boca Raton, Fla: CRC Press;. 1993.

  13. Fornasier VL, Littlejohn G, Urowitz MB, et al. Spinal entheseal new bone formation: the early changes of spinal diffuse idiopathic skeletal hyperostosis. J Rheumatol. Dec 1983;10(6):939-47. [Medline].

  14. Rothschild BM. Diffuse idiopathic skeletal hyperostosis (DISH): misconceptions and reality. Clin Rheumatol. 1985;4:207-12.

  15. Ono M, Russell WJ, Kudo S, et al. Ossification of the thoracic posterior longitudinal ligament in a fixed population. Radiological and neurological manifestations. Radiology. May 1982;143(2):469-74. [Medline].

  16. Tsuyama N. Ossification of the posterior longitudinal ligament of the spine. Clin Orthop Relat Res. Apr 1984;71-84. [Medline].

  17. Westerveld LA, van Ufford HM, Verlaan JJ, Oner FC. The prevalence of diffuse idiopathic skeletal hyperostosis in an outpatient population in the Netherlands. J Rheumatol. Aug 2008;35(8):1635-8. [Medline].

  18. Schlapbach P, Beyeler C, Gerber NJ, et al. Diffuse idiopathic skeletal hyperostosis (DISH) of the spine: a cause of back pain? A controlled study. Br J Rheumatol. Aug 1989;28(4):299-303. [Medline].

  19. Julkunen H, Knekt P, Aromaa A. Spondylosis deformans and diffuse idiopathic skeletal hyperostosis (DISH) in Finland. Scand J Rheumatol. 1981;10(3):193-203. [Medline].

  20. Olivieri I, D'Angelo S, Cutro MS, Padula A, Peruz G, Montaruli M, et al. Diffuse idiopathic skeletal hyperostosis may give the typical postural abnormalities of advanced ankylosing spondylitis. Rheumatology (Oxford). Nov 2007;46(11):1709-11. [Medline].

  21. Mader R, Novofestovski I, Adawi M, Lavi I. Metabolic Syndrome and Cardiovascular Risk in Patients with Diffuse Idiopathic Skeletal Hyperostosis. Semin Arthritis Rheum. Feb 25 2008;[Medline].

  22. Daragon A, Mejjad O, Czernichow P, et al. Vertebral hyperostosis and diabetes mellitus: a case-control study. Ann Rheum Dis. May 1995;54(5):375-8. [Medline].

  23. Seawright AA, English PB, Gartner RJ. Hypervitaminosis A and hyperostosis of the cat. Nature. Jun 12 1965;206(989):1171-2. [Medline].

  24. Seidler TO, Pèrez Àlvarez JC, Wonneberger K, Hacki T. Dysphagia caused by ventral osteophytes of the cervical spine: clinical and radiographic findings. Eur Arch Otorhinolaryngol. Jun 28 2008;[Medline].

  25. Burduk PK, Wierzchowska M, Grzelalak L, Dalke K, Mierzwinski J. Diffuse idiopathic skeletal hyperostosis inducted stridor and dysphagia. Otolaryngol Pol. 2008;62(2):138-40. [Medline].

  26. Burkus JK, Denis F. Hyperextension injuries of the thoracic spine in diffuse idiopathic skeletal hyperostosis. Report of four cases. J Bone Joint Surg Am. Feb 1994;76(2):237-43. [Medline].

  27. De Bandt M, Meyer O, Fuster JM, et al. Ossification of the posterior longitudinal ligament, diffuse, idiopathic skeletal hyperostosis, abnormal retinol and retinol binding protein: a familial observation. J Rheumatol. Jul 1995;22(7):1395-8. [Medline].

  28. Fish DE, Middleton K, Gluzman A. Atypical Presentation of Osteomyelitis, Discitis, Epidural, and Iliopsoas Abscess in DISH Syndrome. Am J Phys Med Rehabil. Aug 6 2008;[Medline].

  29. Forestier J, Lagier R. Ankylosing hyperostosis of the spine. Clin Orthop Relat Res. Jan 1971;74:65-83. [Medline].

  30. Hendrix RW, Melany M, Miller F, et al. Fracture of the spine in patients with ankylosis due to diffuse skeletal hyperostosis: clinical and imaging findings. AJR Am J Roentgenol. Apr 1994;162(4):899-904. [Medline].

  31. Hukuda S, Mochizuki T, Ogata M, et al. The pattern of spinal and extraspinal hyperostosis in patients with ossification of the posterior longitudinal ligament and the ligamentum flavum causing myelopathy. Skeletal Radiol. 1983;10(2):79-85. [Medline].

  32. Littlejohn GO, Urowitz MB, Smythe HA, et al. Radiographic features of the hand in diffuse idiopathic skeletal hyperostosis (DISH): comparison with normal subjects and acromegalic patients. Radiology. Sep 1981;140(3):623-9. [Medline].

  33. Mata S, Fortin PR, Fitzcharles MA, et al. A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status. Medicine (Baltimore). Mar 1997;76(2):104-17. [Medline].

  34. Moodie RL. The histological nature of ossified tendons found in dinosaurs. Amer Mus Novit. 1928;311:1-15.

  35. Oppenheimer A. Calcification and ossification of vertebral ligaments (spondylitis ossificans ligamentosa): roentgen signs of pathogenesis and clinical significance. Radiology. 1942;38:160-73.

  36. Ozkalkanli MY, Katircioglu K, Ozkalkanli DT, et al. Airway management of a patient with Forestier's disease. J Anesth. 2006;20(4):304-6. [Medline].

  37. Pennes DR, Martel W, Ellis CN. Retinoid-induced ossification of the posterior longitudinal ligament. Skeletal Radiol. 1985;14(3):191-3. [Medline].

  38. Resnick D, Guerra J, Robinson CA, et al. Association of diffuse idiopathic skeletal hyperostosis (DISH) and calcification and ossification of the posterior longitudinal ligament. AJR Am J Roentgenol. Dec 1978;131(6):1049-53. [Medline].

  39. Resnick D, Shapiro RF, Wiesner KB, et al. Diffuse idiopathic skeletal hyperostosis (DISH) [ankylosing hyperostosis of Forestier and Rotes-Querol]. Semin Arthritis Rheum. Feb 1978;7(3):153-87. [Medline].

  40. Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations. Radiology. Jun 1975;115(3):513-24. [Medline].

  41. Rothschild BM. Diffuse idiopathic skeletal hyperostosis. Compr Ther. Feb 1988;14(2):65-9. [Medline].

  42. Smith CF, Pugh DG, Polley HF. Physiologic vertebral ligamentous calcification: an aging process. Am J Roentgenol Radium Ther Nucl Med. Dec 1955;74(6):1049-58. [Medline].

  43. Utsinger PD, Resnick D, Shapiro R. Diffuse skeletal abnormalities in Forestier disease. Arch Intern Med. Jul 1976;136(7):763-8. [Medline].

  44. Vernon-Roberts B, Pirie CJ, Trenwith V. Pathology of the dorsal spine in ankylosing hyperostosis. Ann Rheum Dis. Jul 1974;33(4):281-8. [Medline].

  45. Westerveld LA, van Ufford HM, Verlaan JJ, Oner FC. The prevalence of diffuse idiopathic skeletal hyperostosis in an outpatient population in the Netherlands. Journal of Rheumatology. 2008/08;35:1635-1638.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

DISH, Forestier disease, Forestier's disease, asymmetrical skeletal hyperostosis, Rotes-Querol disease, senile ankylosing hyperostosis, ankylosing hyperostosis, hyperostosis of the spine

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Bruce M Rothschild, MD, Professor of Medicine, The Northeastern Ohio Universities College of Medicine; Director, Arthritis Center of Northeast Ohio; Adjunct Professor, Department of Biomedical Engineering, University of Akron
Bruce M Rothschild, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Rheumatology, American Federation for Clinical Research, American Heart Association, American Society for Clinical Pharmacology and Therapeutics, International Skeletal Society, New York Academy of Sciences, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Mininder S Kocher, MD, MPH, Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston
Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the History of Medicine, American Medical Association, American Orthopaedic Society for Sports Medicine, and Massachusetts Medical Society
Disclosure: Smith & Nephew Endoscopy Consulting fee Consulting; ConMed Linvatec Consulting fee Consulting; Covidian Consulting fee Consulting; EBI Biomet Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

George H Thompson, MD, Director, Pediatric Orthopedics, Rainbow Babies and Children's Hospital
George H Thompson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dennis P Grogan, MD, Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa
Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.