eMedicine from WebMD
 

eMedicine Specialties > Orthopedic Surgery > Pediatrics

Diffuse Idiopathic Skeletal Hyperostosis

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

Updated: Jan 8, 2009

Introduction

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 whales3,4,5,6,7,8,9 ; DISH was also present in dinosaurs.10,11,12 An age-dependent phenomenon, it occurs in 15-25% of older mammals.

Related eMedicine topics:
Diffuse Idiopathic Skeletal Hyperostosis - Radiology

Spinal Stenosis and Neurogenic Claudication - Physical Medicine and Rehabilitation

Muscle Biopsy and the Pathology of Skeletal Muscle - Neurology

Disk Herniation - Radiology

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.

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

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 Finland19 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%

Clinical

History

Diffuse idiopathic skeletal hyperostosis (DISH) is an asymptomatic phenomenon. The condition is discovered inadvertently. Rarely, dysphagia may result, either from neuropathy or from physical impingement by bony overgrowth.

Physical

If vertebral fusion is quite extensive, reduction in range of spinal motion occurs.20 Because uniform vertebral involvement is extremely rare, no relatable findings exist.

Causes

Causes are unknown. Diffuse idiopathic skeletal hyperostosis (DISH) is simply a tendency toward calcification of entheses.

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

Treatment

Medical Care

No medical care is indicated (see Introduction, Mortality/Morbidity).

Follow-up

Complications

  • Overgrowth of ligamentous calcification could impinge on other structures (eg, the esophagus). Reports of this are rare and often represent inadvertently discovered, neurologically mediated swallowing deficits.24,25
  • Posterior longitudinal ligament ossifications may impinge on the spinal cord on rare occasions.
  • Reduced vertebral column flexibility predisposes to vertebral fracture.

Prognosis

  • The prognosis is excellent, as diffuse idiopathic skeletal hyperostosis (DISH) is not a source of morbidity or mortality.

Miscellaneous

Medicolegal Pitfalls

  • The major pitfall is mistakenly attributing back complaints to diffuse idiopathic skeletal hyperostosis (DISH) rather than investigating for the true cause.
  • Failing to observe resorption of preexisting DISH due to pulsating abrasion by an aortic aneurysm is another potential pitfall.

Special Concerns

  • Resorption of preexisting diffuse idiopathic skeletal hyperostosis (DISH) suggests the presence of an aortic aneurysm.

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.

Keywords

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

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.

Further Reading

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)