eMedicine Specialties > Radiology > Musculoskeletal
Diffuse Idiopathic Skeletal Hyperostosis: Imaging
Updated: Aug 17, 2009
Radiography
Radiograph of the lumbosacral spine (anteroposterior view) showing flowing osteophytes and soft-tissue ligamentous ossification consistent with diffuse idiopathic skeletal hyperostosis.
Radiograph of the lumbosacral spine (lateral view) showing flowing anterior osteophytes indicative of diffuse idiopathic skeletal hyperostosis.
Radiograph of the thoracic spine (anteroposterior view) showing osteophytes on the right side only, a feature typical of diffuse idiopathic skeletal hyperostosis.
Findings
Radiographs of the spine typically demonstrate thoracic spinal involvement; however, diffuse idiopathic skeletal hyperostosis (DISH) can also affect the lumbar and cervical spine. DISH is distinguished by the presence of flowing syndesmophytes along, but separated from, the anterior aspect of the vertebral bodies, involving at least 4 levels. The disease begins as fine ossification, 1- to 2-mm thick, but ossification may thicken to as much as 20 mm as the disease progresses.
Radiographic findings in DISH include the following extra-axial features:
- Skull - Ossification of the nuchal ligaments
- Pelvis
- Enthesopathy at the ischial tuberosities
- Ossification of the sacrotuberous ligament
- Ossification of the symphysis pubis
- Lower extremities
- Ossification of the quadriceps and infrapatellar tendons
- Ossification of the Achilles tendon and the plantar aponeurosis
- Upper extremities - Ossification of the triceps tendon
- Skin - Subcutaneous calcification
Degree of Confidence
The hallmark of DISH is ossification occurring along the anterior aspect of the vertebral bodies but remaining separate from the vertebrae. Osteophytes of degenerative spinal disease usually occur along the anterolateral aspect. The location of the ossification distinguishes DISH from OPLL.
False Positives/Negatives
Omnipresent degenerative osteophytes represent the most common finding that mimics DISH; however, DISH is defined by the strict criteria of anterior location and the bridging involvement of 4 contiguous vertebral bodies (3 intervertebral disk spaces).
Computed Tomography
Lateral reconstruction computed tomography (CT) scan showing anterior syndesmophytes.
Computed tomography (CT) scans showing large, flowing syndesmophytes.
Findings
CT scanning usually is not indicated unless there is a need to evaluate complications, such as fracture, spinal canal stenosis secondary to associated ossification of the posterior longitudinal ligament (OPLL), and pressure effects on the esophagus or inferior vena cava.
CT scans show ossification along the anterior aspect, and coronal reconstruction depicts the classic pattern.
Degree of Confidence
The same criteria used in radiographic evaluation (the location of the ossification and an involvement over at least 4 vertebral bodies) define DISH and distinguishes this entity from degenerative osteophytes.
Magnetic Resonance Imaging
Findings
MRI of the spine usually is not indicated, because diagnosis is made using plain radiographic findings. CT scanning, using coronal and sagittal reconstruction, is useful because it provides better anatomic definition.
When associated ossification of the posterior longitudinal ligament (OPLL) causes neurologic symptoms, MRI is valuable for determining the extent of the ossification, the mass effect on the thecal sac, and the presence of cord compression. Typically, diffuse idiopathic skeletal hyperostosis (DISH) manifests as a long segment of low T1 and T2 signals that is anterior to several contiguous vertebrae, while OPLL manifests as a signal that is posterior to the vertebral body and that extends for several segments. Cord edema manifests as a high T2 signal.
Nuclear Imaging
Bone scan showing heterogeneous, nonspecific increased uptake in the spine with 2 additional focal hotspots.
Findings
In nuclear medicine, bone scanning usually is requested for the evaluation of back pain, revealing the nonspecific pattern of the diffusely increased and heterogeneous uptake of radiopharmaceutical in the spine. Diagnosis relies primarily on the use of radiographs.
Degree of Confidence
The appearance of DISH on a bone scan is nonspecific, and without radiographic correlation, diagnosis is difficult.
More on Diffuse Idiopathic Skeletal Hyperostosis |
| Overview: Diffuse Idiopathic Skeletal Hyperostosis |
 Imaging: Diffuse Idiopathic Skeletal Hyperostosis |
| Multimedia: Diffuse Idiopathic Skeletal Hyperostosis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, et al. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. Apr 2009;22(2):77-85. [Medline].
Mader R, Lavi I. Diabetes mellitus and hypertension as risk factors for early diffuse idiopathic skeletal hyperostosis (DISH). Osteoarthritis Cartilage. Jun 2009;17(6):825-8. [Medline].
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].
Vezyroglou G, Mitropoulos A, Antoniadis C. A metabolic syndrome in diffuse idiopathic skeletal hyperostosis. A controlled study. J Rheumatol. Apr 1996;23(4):672-6. [Medline].
Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. May 1998;27 Suppl 1:S7-11. [Medline].
Dar G, Peleg S, Masharawi Y, et al. The association of sacroiliac joint bridging with other enthesopathies in the human body. Spine. May 1 2007;32(10):E303-8. [Medline].
Resnick D, Guerra J Jr, 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]. [Full Text].
Akhtar S, O'Flynn PE, Kelly A, et al. The management of dysphasia in skeletal hyperostosis. J Laryngol Otol. Feb 2000;114(2):154-7. [Medline].
Leon JA, Calamia KT, Leventhal JP. Chronic obstructive pneumonia caused by a vertebral body osteophyte. Mayo Clin Proc. Feb 2000;75(2):185-8. [Medline].
Yoshida M, Kibe A, Aizawa H, et al. [Diffuse idiopathic skeletal hyperostosis with fibrobullous change in upper lung lobes and dyspnea due to limitation of thoracic cage]. Nihon Kokyuki Gakkai Zasshi. Oct 1999;37(10):823-8. [Medline].
Le Hir PX, Sautet A, Le Gars L, et al. Hyperextension vertebral body fractures in diffuse idiopathic skeletal hyperostosis: a cause of intravertebral fluidlike collections on MR imaging. AJR Am J Roentgenol. Dec 1999;173(6):1679-83. [Medline]. [Full Text].
Verdone F. Anterior atlantoaxial subluxation in a patient with DISH. J Rheumatol. Jul 1999;26(7):1639-40. [Medline].
Papakostas K, Thakar A, Nandapalan V, et al. An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease). J Laryngol Otol. Jan 1999;113(1):65-7. [Medline].
Verstraete WL, De Cauwer HG, Verhulst D, et al. Vocal cord immobilisation in diffuse idiopathic skeletal hyperostosis (DISH). Acta Otorhinolaryngol Belg. 1998;52(1):79-84. [Medline].
Scapinelli R. Compression of the inferior vena cava due to diffuse idiopathic skeletal hyperostosis. Rev Rhum Engl Ed. Mar 1997;64(3):198-201. [Medline].
Fahrer H, Koch P, Ballmer P, et al. Ectopic ossification following total hip arthroplasty: is diffuse idiopathic skeletal hyperostosis a risk factor?. Br J Rheumatol. Jun 1988;27(3):187-90. [Medline].
Nishimura Y, Mochizuki T, Negoro K, et al. [A case of diffuse idiopathic skeletal hyperostosis (DISH) with various neurological complications]. Nippon Ronen Igakkai Zasshi. Mar 1996;33(3):186-90. [Medline].
Weisz GM. Ossifying surgical scar in Forestier's disease. Int Surg. Jul-Sep 1985;70(3):273. [Medline].
Ciocci A, Buratti L, Maurelli G. [Vertebral hyperostosis and hyperostosis frontalis interna]. Rev Rhum Mal Osteoartic. Apr 1985;52(4):227-30. [Medline].
Cassim B, Mody GM, Rubin DL. The prevalence of diffuse idiopathic skeletal hyperostosis in African blacks. Br J Rheumatol. Apr 1990;29(2):131-2. [Medline].
Kiss C, Szilagyi M, Mituszova M, et al. [Prevalence and risk factors in diffuse idiopathic skeletal hyperostosis in a population sample in Hungary]. Orv Hetil. Jun 22 1997;138(25):1619-23. [Medline].
Al-Herz A, Snip JP, Clark B, et al. Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clin Rheumatol. Sep 21 2007;[Medline].
Battaglia M, Zompatori M, Nassetti C, et al. [An unusual cause of nocturnal orthopnea: Forestier's cervical hyperostosis spondylopathy]. Radiol Med (Torino). Jul-Aug 1996;92(1-2):135-7. [Medline].
Miyazawa N, Akiyama I. Diffuse idiopathic skeletal hyperostosis associated with risk factors for stroke: a case-control study. Spine. Apr 15 2006;31(8):E225-9; discussion E230. [Medline].
Further Reading
Related eMedicine topics
Diffuse Idiopathic Skeletal Hyperostosis [Orthopedic Surgery]
Ankylosing Spondylitis [Radiology]
Ankylosing Spondylitis [Neurology]
Ankylosing Spondylitis [Ophthalmology]
Ankylosing Spondylitis [Orthopedic Surgery]
Keywords
diffuse idiopathic skeletal hyperostosis, Forestier disease, Forestier's disease, DISH, ossification of the posterior longitudinal ligament, OPLL, anterior longitudinal ligament, posterior longitudinal ligament, ankylosing spondylitis, senile ankylosing spondylitis, enthesopathy
