DISH

Definition

 

Diffuse Idiopathic Skeletal Hyperostosis

- non-inflammatory disease

- ossifying enthesopathy / bone forming diasthesis

- most commonly involves spine / anterior longitudinal ligament

 

AKA  Forestier's disease

 

DDx

 

Ankylosing Spondylosis

 

DISH

- non inflammatory

- no facet or SIJ involvement

- no squaring of anterior vertebral body

- non marginal syndesmophytes

 

Diagnostic Criteria for DISH

 

1.  Flowing ossification along the anterolateral aspect of at least 4 contiguous vertebrae

2.  Preservation of disc height / relative absence of significant degenerative changes

3.  Absence of facet joint ankylosis or sacroiliac erosion

 

DISH Thoracic VertebraeDISH Thoracic Vertebra LateralLumbar DISH Lateral

 

Epidemiology

 

Common 

- 1/3 over age 65

 

Middle-aged or elderly 

 

Associations

 

Diabetes

Hypertension

Gout

Obesity

 

Normal incidence of HLA B27

 

Clinical Presentation

 

Principal symptom is LBP

 

Occasional dysphagia

- anterior osteophytes in cervical spine impinging on oesophagus

 

Occasional spinal stenosis 

- due to ossification of PLL

 

Achilles tendonitis

 

X-ray

 

Thoracic vertebra

 

DISH Right sided

 

Most common right sided and unilateral

- anterior & lateral spine

 

Non marginal syndesmophytes 

- flowing / candle wax  

- marginal osteophytes of ankylosing spondylitis very vertical

 

Integrity of disc spaces & facet joints maintained 

- not an arthritis

 

Cervical spine

- less frequent

 

Cervical DISHDISH Cervical Spine Lateral

 

Lumbar spine

- least common

 

DISH LumbarDISH Lumbar VertebraLumbar DISH

 

Other

 

Pelvis

- osseous whiskering at sites of ligament attachment

- iliac crests / ischial tuberosity / trochanters

 

DISH Pelvis Osseous Whiskering

 

Pelvic Whispering DISH

 

Heel 

- calcaneal spurs / achilles tendonitis

 

Hip

- periarticular bone formation with intact joint space

- increased risk of HO in THR

 

Shoulder

- hyperostosis deltoid insertion, LT, GT

 

Elbow

- olecranon spurs

 

Management

 

Symptomatic

 

Analgesia

NSAID

Physiotherapy to maintain motion

 

Issues

 

Surgery rarely required to remove osteophytes

- sometimes in cervical spine to relieve symptoms

 

Trauma

- high risk of fracture

- need to be carefully assessed

- high risk of neurology and instability