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Diffuse Idiopathic Skeletal Hyperostosis (DISH) Workup

  • Author: Bruce M Rothschild, MD; Chief Editor: Jeffrey D Thomson, MD  more...
Updated: Jul 11, 2016

Laboratory Studies

No laboratory tests are indicated. An apparent association with elevated glucose levels has not been substantiated as a relationship with diabetes.[23, 24]


Imaging Studies

Diffuse idiopathic skeletal hyperostosis (DISH) involves the thoracic vertebrae in 100% of cases, the lumbar vertebrae in 68-90%, and the cervical vertebrae in 65-78%. Ligamentous ossification affects both sides of the lumbar vertebral column but tends to be unilateral in the human spine.

Prominence of 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. Radiologically, this appears as a radiodense line paralleling the longitudinal axis of the spine but separated by a clearly definable space.

The most commonly used diagnostic criteria for DISH are those set by Resnick and Niwayama, which are as follows[2, 25] :

  • Calcification and ossification along the ventrolateral aspects of at least four contiguous vertebral bodies, with or without localized pointed excrescences at intervening vertebral body–disk junctions
  • Relative preservation of intervertebral disc height in the involved areas, with absence of extensive radiographic changes of degenerative disc disease (intervertebral osteochondrosis), including vacuum phenomena and vertebral body marginal sclerosis
  • Absence of apophyseal joint bony ankylosis and sacroiliac joint erosion, sclerosis, or intra-articular bony fusion

Criteria suggested by Julkunen and colleagues are substantially the same as those from Resnick and Niwayama, but also include the presence of bridges connecting two vertebral bodies in at least two sites on the thoracic spine.[26] Utsinger criteria are as follows:

  • Definite DISH: Bridging of four contiguous vertebral bodies, primarily in the thoracolumbar spine, minimal intervertebral disk disease, and no facet joint ankylosis
  • Probable DISH: Bridging of two contiguous vertebral bodies plus bilateral patellar tufting, heel spurring, and olecranon tufting.
  • Possible DISH: Two vertebrae joined in the absence of extraspinal enthesophytes, or symmetrical extraspinal enthesophytes in the absence of spinal involvement

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. One study found pelvic enthesopathy on CT to be significantly more prevalent in patients with DISH compared with matched control patients.[27]

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.[15]

For complete discussion, see Imaging in Diffuse Idiopathic Skeletal Hyperostosis (DISH).


Histologic Findings

Histologic examination of vertebral specimens from patients with diffuse idiopathic skeletal hyperostosis (DISH) show partial or complete bone bridges consisting of cortical woven bone, accompanied by morphological changes in the adjoining part of the intervertebral disc.[28] Ossified tissues DISH are composed of normal-appearing haversian bone as opposed to the wormian or disorganized structure of bone seen in patients with hypervitaminosis A.[29]

Contributor Information and Disclosures

Bruce M Rothschild, MD Professor of Medicine, Northeast Ohio Medical University; Adjunct Professor, Department of Biomedical Engineering, University of Akron; Research Associate, University of Kansas Museum of Natural History; Research Associate, Carnegie Museum

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, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George H Thompson, MD Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Jeffrey D Thomson, MD Associate Professor, Department of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Department of Pediatric Orthopedic Surgery, Associate Director of Clinical Affairs for the Department of Surgical Subspecialties, Connecticut Children’s Medical Center; President, Connecticut Children's Specialty Group

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

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 College of Sports Medicine, Pediatric Orthopaedic Society of North America, American Association for the History of Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society

Disclosure: Received consulting fee from Smith & Nephew Endoscopy for consulting; Received consulting fee from EBI Biomet for consulting; Received consulting fee from OrthoPediatrics for consulting; Received stock from Pivot Medical for consulting; Received consulting fee from pediped for consulting; Received royalty from WB Saunders for none; Received stock from Fixes-4-Kids for consulting.

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Radiograph of the thoracic spine (anteroposterior view) showing osteophytes on the right side only, a feature typical of diffuse idiopathic skeletal hyperostosis.
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