Diffuse Idiopathic Skeletal Hyperostosis 

  • Author: Bruce M Rothschild, MD; Chief Editor: Dennis P Grogan, MD   more...
 
Updated: Mar 31, 2011
 

Background

Diffuse idiopathic skeletal hyperostosis (DISH) describes a phenomenon characterized by a tendency toward ossification of ligaments. It most characteristically affects the spine.[1] Ossification of the longitudinal ligaments (especially the anterior ligaments) of the spine produces a tortuous paravertebral mass anterior to and distinct (at least radiologically) from the vertebral bodies.[2] Grossly, the appearance is that of candle wax dripping down the spine. While the thoracic anterior longitudinal ligament is ossified, the areas of ossification often meet without fusion. Motion actually is possible, in contrast to lumbar vertebral bridging, which is associated with loss of lumbar motion. The zygapophyseal and sacroiliac joints are not involved in DISH, and the intervening intervertebral disk space is preserved.

DISH is well represented in the zoologic and paleontologic record. It is found in 1-3% of baboons and monkeys, as well as in gorillas, bears, camels, horses, bison, musk oxen, canids, felids, and whales[3, 4, 5, 6, 7, 8, 9] ; DISH was also present in dinosaurs.[10, 11, 12] An age-dependent phenomenon, it occurs in 15-25% of older mammals.

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Pathophysiology

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by a tendency toward ossification of ligament, tendon, and joint capsule (enthesial) insertions.[13] DISH is a completely asymptomatic phenomenon; no alterations are detectable based on history or through physical examination.

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Epidemiology

Frequency

United States

Diffuse idiopathic skeletal hyperostosis (DISH) is present in approximately 19% of men and 4% of women older than 50 years. Frequency information in the US was derived from the study of nonselected skeletal/cemetery populations.[14]

International

The posterior longitudinal ligament of the cervical spine is ossified in 2% of Japanese individuals but in only 0.16% of white persons.[15] The anterior longitudinal ligament is calcified in 24% of patients with posterior longitudinal ligament ossification.[16] Diffuse idiopathic skeletal hyperostosis (DISH) was reported in 17% of individuals in the Netherlands, paradoxically with male predominance.[17]

Mortality/Morbidity

Diffuse idiopathic skeletal hyperostosis (DISH) appears to be a phenomenon rather than a disease. Double-blind controlled evaluation (in which controls and patients were drawn from the same population) revealed no associated pathology. Arthritis, bursitis, and tendinitis appeared no more frequently in patients with DISH than in controls. Any back pain present was no different in character or duration than that noted in control subjects. A history of back injury was actually found to be twice as frequent in control subjects as it was in patients with DISH. Back flexibility was no more limited in patients with DISH than it was in controls. In fact, patients with DISH who had decreased lumbar spinal motion had a lower frequency of back pain, implying that DISH may be protective.[14, 18] One study has showed that DISH may be protective against back pain.[19]

Race

The posterior longitudinal ligament of the cervical spine is ossified in 2% of Japanese individuals but in only 0.16% of whites.

Sex

Diffuse idiopathic skeletal hyperostosis (DISH) is present in approximately 19% of men older than 50 years but is found in only 4% of women in this age group.

Age

Diffuse idiopathic skeletal hyperostosis (DISH) is uncommon in patients younger than 50 years and is extremely rare in patients younger than 40 years.

  • A study from Finland[20] revealed the age frequency in Finnish men to be as follows:
    • 40-49 years - 0.3%
    • 50-59 years - 2.7%
    • 60-69 years - 8.4%
    • 70 years or older - 11.2%
  • The same study revealed the age frequency in Finnish women to be as follows:
    • 40-49 years - 0.2%
    • 50-59 years - 1.7%
    • 60-69 years - 4.3%
    • 70 years or older - 6.9%
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Contributor Information and Disclosures
Author

Bruce M Rothschild, MD  Professor of Medicine, Northeastern Ohio Universities College of Medicine; Adjunct Professor, Department of Biomedical Engineering, University of Akron; Adjunct Professor, Department of Anthropology, University of Kansas; Director, Arthritis Center

Bruce M Rothschild, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Rheumatology, International Skeletal Society, New York Academy of Sciences, Sigma Xi, and Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

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 College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society, and Pediatric Orthopaedic Society of North America

Disclosure: Smith & Nephew Endoscopy Consulting fee Consulting; EBI Biomet Consulting fee Consulting; OrthoPediatrics Consulting fee Consulting; Pivot Medical Stock Consulting; pediped Consulting fee Consulting; WB Saunders Royalty None; Fixes-4-Kids Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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: OrthoPediatrics None Consulting; Journal of Pediatric Orthopaedics Salary Management position

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

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.

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