eMedicine Specialties > Radiology > Musculoskeletal

Diffuse Idiopathic Skeletal Hyperostosis

Khozaim Nakhoda, MD, MBBS, DRM, Director of Nuclear Medicine, Department of Radiology, Crozer Chester Medical Center
Gary S Greene, MD, FACNM, Attending Radiologist, Director of PET/CT Imaging Section, and Chief of Nuclear Medicine, Pennsylvania Hospital; Clinical Associate Professor of Radiology, University of Pennsylvania School of Medicine

Updated: Aug 17, 2009

Introduction

Background

Paraspinal ligaments undergo degeneration secondary to attrition, and they often ossify. This condition is broadly termed spinal enthesopathy. Physicians recognize the following syndromes as being associated with this phenomenon:

• Forestier disease - The most common of the 3 syndromes, Forestier disease involves the anterior longitudinal ligament.
  • Forestier disease's more diffuse variant (which exhibits additional extra-axial features) is termed diffuse idiopathic skeletal hyperostosis (DISH)
• Ossification of the posterior longitudinal ligament (OPLL)

Radiograph of the lumbosacral spine (anteroposterior view) showing flowing osteophytes and soft-tissue ligamentous ossification consistent with diffuse idiopathic skeletal hyperostosis.

Sagittal, T2-weighted magnetic resonance image of the cervical spine showing ossification of the posterior longitudinal ligament. Courtesy of A. Vincent Thamburaj, MD, Apollo Hospital, Chennai, India.

Pathophysiology

The etiology of diffuse idiopathic skeletal hyperostosis (DISH) is uncertain. Glucose metabolism imbalance (diabetes), dyslipidemia, and hyperuricemia have been implicated.⁴ DISH diagnostic criteria include the following⁵ :

• Flowing calcifications and ossifications along the anterolateral aspect of at least 4 contiguous vertebral bodies, with or without osteophytes
• Preservation of disk height in the involved areas and an absence of excessive disk disease
• Absence of bony ankylosis of facet joints and absence of sacroiliac erosion, sclerosis, or bony fusion, although narrowing and sclerosis of facet joints are acceptable⁶

Unlike ankylosing spondylitis, DISH does not involve the sacroiliac joint. DISH is also distinct from marginal osteophytes that form in response to degenerative disk disease. Patients with DISH infrequently demonstrate disk height reduction or vacuum changes.

Lower thoracic spine involvement is typical of DISH, but the lumbar and cervical spine also can be affected. The left side of the spine typically is spared or less involved, which probably is attributable to the pulsating aorta. Forestier disease includes many extra-axial features, such as ossification of other ligaments and tendons, as well as subcutaneous calcification.

Frequency

United States

The incidence of diffuse idiopathic skeletal hyperostosis (DISH) generally is believed to be 6-12% but is probably higher. In men older than 80 years, the incidence is 28%.

International

Although diffuse idiopathic skeletal hyperostosis (DISH) occurs more commonly in Europeans and North Americans, ossification of the posterior longitudinal ligament (OPLL) occurs more frequently in the Japanese population.⁷

Mortality/Morbidity

• Most patients present with a stiff back, although nonspecific back pain may be associated with diffuse idiopathic skeletal hyperostosis (DISH). Rarely, kyphosis is present. Dysphagia occasionally is attributed to prominent osteophytes in the cervical spine.⁸
• Chronic pneumonia has been reported secondary to the obstruction of a bronchus. Fibrobullous changes have been reported, but they are probably secondary to the mechanical deformity of the thorax rather than to an intrinsic relationship (as found in ankylosing spondylitis).^9,10
• Hyperextension vertebral fractures and atlantoaxial subluxation have been reported.^11,12
• Stridor, nocturnal dyspnea, and vocal cord paralysis have been noted.^13,14
• Compression of the inferior vena cava has been attributed to DISH.¹⁵
• Neurologic manifestations (secondary to spinal canal stenosis), heterotopic ossification, and metabolic causes (manifesting as paresthesia, gait disturbance, hyporeflexia) can be seen.^16,17
• Increased risk of heterotopic bone formation after hip surgery has been questioned.¹⁶
• Soft-tissue calcification, as in surgical scars, has been noted.¹⁸
• Association with hyperostosis frontalis interna and OPLL has been mentioned.¹⁹

Race

Diffuse idiopathic skeletal hyperostosis (DISH) occurs more commonly in whites than in black, Native American, and Asian populations. Although ankylosing spondylitis rarely occurs in the African black population, DISH is not uncommon, although its incidence is much lower than it is in the white population.²⁰

Sex

Diffuse idiopathic skeletal hyperostosis (DISH) occurs more commonly in males (65%) than in females (35%).⁵

Age

Diffuse idiopathic skeletal hyperostosis (DISH) occurs most often in persons aged 50-75 years.^5,21

Anatomy

The vertebra consists of the anterior body and the posterior arch. The arch is composed of the paired pedicles, the laminae, the superior and inferior articular facets, and, posteriorly, the midline spinous process. Several ligaments extend across the vertebral column, providing stability. The anterior and posterior longitudinal ligaments run on the anterior and posterior surfaces of the vertebral bodies. The ligamentum flavum connects the laminae. The interspinous ligament extends between the spinous processes, while the supraspinous ligament extends between the tips of the spinous processes.

Ossification of the anterior longitudinal ligament is the underlying pathology of Forestier disease and DISH.

Presentation

Clinical symptoms include back stiffness with restricted motion. Complaints are intermittent; stiffness is worse in the morning and is relieved with mild activity. Symptoms are worsened when the patient sits for a length of time or when the weather is wet and cold. The lower thoracic area most commonly is involved. In the later stages, signs of spinal stenosis may be noted.

Although advanced disease is the most common clinical feature in patients, various symptoms have been attributed to florid ossification, including dysphagia, stridor, chronic pneumonia, and vascular compression.

Preferred Examination

Radiography of the thoracic and lumbar spine usually is sufficient for diagnosing diffuse idiopathic skeletal hyperostosis (DISH). Occasionally, computed tomography (CT) scanning may be performed to evaluate complications, such as fracture, or symptoms caused by pressure effects on the trachea, esophagus, and veins. Bone scanning and magnetic resonance imaging (MRI) do not play a significant role in the diagnosis of DISH.

Limitations of Techniques

Radiography of the spine is the single most useful imaging modality in the diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). However, patient body habitus or an inability of the patient to lie on his or her side for a lateral view may compromise the quality of radiographs. In addition, radiographs are inadequate for evaluating the extent of the compression caused by the large syndesmophytes on the trachea, bronchi, or esophagus. In this case, CT scanning of the spine is helpful and especially is aided by coronal and sagittal reconstructions.

Conversely, CT scanning usually is not cost-effective for imaging the entire spine and provides limited information about spinal cord involvement. In this situation, MRI is of benefit and thus is reserved primarily for evaluating possible cord compression. This is especially true if DISH is associated with ossification of the posterior longitudinal ligament (OPLL), as it is in a minority of patients.⁵

Differential Diagnoses

Ankylosing Spondylitis
Neuropathic Arthropathy (Charcot Joint)
Osteoarthritis, Primary
Psoriatic Arthritis

Other Problems to Be Considered

Reiter syndrome, musculoskeletal

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.

Multimedia

Media file 1: Radiograph of the lumbosacral spine (anteroposterior view) showing flowing osteophytes and soft-tissue ligamentous ossification consistent with diffuse idiopathic skeletal hyperostosis.

Media file 2: Radiograph of the lumbosacral spine (lateral view) showing flowing anterior osteophytes indicative of diffuse idiopathic skeletal hyperostosis.

Media file 3: Radiograph of the thoracic spine (anteroposterior view) showing osteophytes on the right side only, a feature typical of diffuse idiopathic skeletal hyperostosis.

Media file 4: Lateral reconstruction computed tomography (CT) scan showing anterior syndesmophytes.

Media file 5: Bone scan showing heterogeneous, nonspecific increased uptake in the spine with 2 additional focal hotspots.

Media file 6: Sagittal, T2-weighted magnetic resonance image of the cervical spine showing ossification of the posterior longitudinal ligament. Courtesy of A. Vincent Thamburaj, MD, Apollo Hospital, Chennai, India.

Media file 7: Computed tomography (CT) scans showing large, flowing syndesmophytes.

References

1. 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].

2. 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].

3. 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].

4. 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].

5. Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. May 1998;27 Suppl 1:S7-11. [Medline].

6. 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].

7. 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].

8. 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].

9. 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].

10. 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].

11. 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].

12. Verdone F. Anterior atlantoaxial subluxation in a patient with DISH. J Rheumatol. Jul 1999;26(7):1639-40. [Medline].

13. 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].

14. 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].

15. 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].

16. 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].

17. 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].

18. Weisz GM. Ossifying surgical scar in Forestier's disease. Int Surg. Jul-Sep 1985;70(3):273. [Medline].

19. Ciocci A, Buratti L, Maurelli G. [Vertebral hyperostosis and hyperostosis frontalis interna]. Rev Rhum Mal Osteoartic. Apr 1985;52(4):227-30. [Medline].

20. 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].

21. 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].

22. Al-Herz A, Snip JP, Clark B, et al. Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clin Rheumatol. Sep 21 2007;[Medline].

23. 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].

24. 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].

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

Contributor Information and Disclosures

Author

Khozaim Nakhoda, MD, MBBS, DRM, Director of Nuclear Medicine, Department of Radiology, Crozer Chester Medical Center
Khozaim Nakhoda, MD, MBBS, DRM is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gary S Greene, MD, FACNM, Attending Radiologist, Director of PET/CT Imaging Section, and Chief of Nuclear Medicine, Pennsylvania Hospital; Clinical Associate Professor of Radiology, University of Pennsylvania School of Medicine
Gary S Greene, MD, FACNM is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, American Medical Association, Pennsylvania Radiological Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Leon Lenchik, MD, Director, Densitometry Minifellowship, Assistant Professor, Department of Radiology, Wake Forest University Medical Center
Leon Lenchik, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

William R Reinus, MD, MBA, FACR, Professor of Radiology, Temple University; Chief of Musculoskeletal and Trauma Radiology, Vice Chair, Department of Radiology, Temple University Hospital
William R Reinus, MD, MBA, FACR is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

Related eMedicine topics

Diffuse Idiopathic Skeletal Hyperostosis [Orthopedic Surgery]

Ankylosing Spondylitis [Radiology]

Ankylosing Spondylitis [Neurology]

Ankylosing Spondylitis [Ophthalmology]

Ankylosing Spondylitis [Orthopedic Surgery]

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