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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

para>Diffuse idiopathic skeletal hyperostosis (DISH) is typically asymptomatic and may be "a protective mechanism" (increases spinal stability). Therefore, DISH should not be the presumed etiology of back pain in the elderly.

Incidence increases with age and is higher in men.

May have increased tendency for heterotopic ossifications following orthopedic surgery (1)

Inpatient care is usually required only when complications develop, such as unstable fractures, myelopathy, or if there is a need for surgery.

Admission Criteria/Initial Stabilization

Seek immediate medical attention if neurologic symptoms develop or if involved in significant trauma (e.g., fall, car accident).

Avoid falls and high-risk activities (skydiving).

Generally good. Depends on patient comorbidities

11 Mazi ¨res B. Diffuse idiopathic skeletal hyperostosis (Forestier-Rotes-Querol disease): what's new? Joint Bone Spine. 2013;80(5):466-470.22 Taljanovic MS, Hunter TB, Wisneski RJ, et al. Imaging characteristics of diffuse idiopathic skeletal hyperostosis with an emphasis on acute spinal fractures: review. AJR Am J Roentgenol. 2009;193(Suppl 3):S10-S19.33 Mader R, Novofastovski I, Iervolino S, et al. Ultrasonography of peripheral entheses in the diagnosis and understanding of diffuse idiopathic skeletal hyperostosis (DISH). Rheumatol Int. 2015;35(3):493-497.44 Carlson ML, Archibald DJ, Graner DE, et al. Surgical management of dysphagia and airway obstruction in patients with prominent ventral cervical osteophytes. Dysphagia. 2011;26(1):34-40.55 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. 2009;18(2):145-156.

721.6 Ankylosing vertebral hyperostosis

disseminated idiopathic skeletal hyperostosis (disorder)

DISH and osteoarthritis (OA) may coexist. Both affect the same population (elderly and obese).

Bone mineral density (BMD) measurements obtained by dual energy x-ray absorptiometry (DEXA), and quantitative CT may not be accurate (falsely high) due to lumbar ossification/calcification in DISH.

DISH should be considered in elderly patients with unexplained respiratory distress or dysphagia (1).

EPIDEMIOLOGY

  • Most common in elderly males
  • Prevalence varies geographically.
  • United States: 25% in men and 15% in women aged ≥50 years
  • Korea: 3%

ETIOLOGY AND PATHOPHYSIOLOGY

  • The etiology is unknown. Increased levels of insulin-like growth factor 1 and growth hormone are believed to stimulate osteoblasts and bone proliferation.
  • Low serum levels of Dickkopf-1 (DKK-1), an inhibitor of the Wnt signaling required for new bone formation, may also play a role in DISH and is associated with more severe spinal involvement (1).

RISK FACTORS

  • Age
  • Male gender
  • Increased BMI
  • Hypertension
  • Metabolic syndrome
  • Diabetes
  • Hyperuricemia
  • Dyslipidemia
  • Lumbar spondylosis and knee osteoarthritis

GENERAL PREVENTION

COMMONLY ASSOCIATED CONDITIONS

  • Obesity; large waist circumference
  • Diabetes; hyperinsulinemia/insulin resistance
  • Hypertension
  • Dyslipidemia
  • Hyperuricemia
  • Metabolic syndrome

DIAGNOSIS

HISTORY

  • Most commonly asymptomatic
  • Diagnosis often made incidentally on imaging studies.
  • Back and neck pain are the most common complaints.
  • Stiffness and reduced range of motion in the peripheral joints
  • Dysphagia and/or airway obstruction secondary to large anterior longitudinal ligament ossification encroaching the pharynx, esophagus, and/or trachea

PHYSICAL EXAM

  • Decreased spinal mobility
  • Tenderness to palpation of the spine

DIFFERENTIAL DIAGNOSIS

  • Spondylosis deformans
  • AS
  • Reactive arthritis
  • Psoriatic arthritis
  • Intervertebral osteochondrosis

DIAGNOSTIC TESTS & INTERPRETATION

  • Plain radiograph3 Resnick criteria:Flowing calcification/ossification along the anterolateral aspect of at least four contiguous vertebral bodiesRelative preservation of intervertebral disc height in the involved vertebral segment in the absence of extensive radiographic changes of degenerative disc diseaseAbsence of apophyseal joint ankylosis and sacroiliac (SI) joint erosions, sclerosis, and fusionA thin radiolucent line can be seen between the ossified anterior longitudinal ligament and anterior vertebral body on lateral film (2).Thoracic spine: most common; ossification predominantly of the right lateral aspect (2)Cervical spine: ossification of posterior longitudinal ligament (2)Lumbar spine: equal bilateral ossification (2)Pelvic radiograph: ossification of the joint capsule on the anterior surface of the SI joint, resembling the obliteration of the SI joints seen in ASCT scan can differentiate (2).Bony proliferation and enthesopathies on radiograph of pelvis, elbow, knee, and foot (2)
  • CT scanIntact SI joint space and presence of anterior capsular bridging caused by capsular ossification
  • MRIHelps assess complications, such as myelopathy, radiculopathy, if suspected
  • UltrasoundEvaluate extraspinal enthesophytes (3).
  • No specific lab tests; may consider testing for associated metabolic diseases
  • 3 Resnick criteria:Flowing calcification/ossification along the anterolateral aspect of at least four contiguous vertebral bodiesRelative preservation of intervertebral disc height in the involved vertebral segment in the absence of extensive radiographic changes of degenerative disc diseaseAbsence of apophyseal joint ankylosis and sacroiliac (SI) joint erosions, sclerosis, and fusion
  • A thin radiolucent line can be seen between the ossified anterior longitudinal ligament and anterior vertebral body on lateral film (2).
  • Thoracic spine: most common; ossification predominantly of the right lateral aspect (2)
  • Cervical spine: ossification of posterior longitudinal ligament (2)
  • Lumbar spine: equal bilateral ossification (2)
  • Pelvic radiograph: ossification of the joint capsule on the anterior surface of the SI joint, resembling the obliteration of the SI joints seen in ASCT scan can differentiate (2).
  • Bony proliferation and enthesopathies on radiograph of pelvis, elbow, knee, and foot (2)
  • Flowing calcification/ossification along the anterolateral aspect of at least four contiguous vertebral bodies
  • Relative preservation of intervertebral disc height in the involved vertebral segment in the absence of extensive radiographic changes of degenerative disc disease
  • Absence of apophyseal joint ankylosis and sacroiliac (SI) joint erosions, sclerosis, and fusion
  • CT scan can differentiate (2).
  • Intact SI joint space and presence of anterior capsular bridging caused by capsular ossification
  • Helps assess complications, such as myelopathy, radiculopathy, if suspected
  • Evaluate extraspinal enthesophytes (3).

TREATMENT

GENERAL MEASURES

  • Typically asymptomatic: no need for specific therapy
  • Symptomatic reliefPain control with analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Physical therapy to improve/maintain spinal mobility
  • Pain control with analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs)

MEDICATION

  • Analgesics, such as acetaminophen, tramadol
  • NSAIDs

ISSUES FOR REFERRAL

  • Need to differentiate from AS, as the treatment differs significantly (especially with the availability of tumor necrosis factor [TNF] inhibitor therapy). If uncertain, consider rheumatology referral.
  • Orthopedic referral if symptoms are severe and surgical treatment is considered

ADDITIONAL THERAPIES

SURGERY/OTHER PROCEDURES

  • Surgical treatment is indicated only in selected cases with large osteophytes and severe symptoms (4,5)[B].
  • Surgical treatment may have more favorable outcomes in case of spinal fracture.

INPATIENT CONSIDERATIONS

  • Myelopathy
  • Acute unstable fracture

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

DIET

PATIENT EDUCATION

PROGNOSIS

COMPLICATIONS

  • Acute spinal fracture
  • Severe limitation of spinal mobility and postural abnormalities resembling long-standing advanced AS
  • Spinal stenosis, particularly at the cervical spine
  • Myelopathy
  • Aspiration
  • Sleep apnea
  • Atlantoaxial complication
  • Dysphagia

Notify anesthesiology about DISH diagnosis prior to surgery or procedure requiring sedation due to increased risk for difficulty with airway access or respiratory compromise.

REFERENCES

ADDITIONAL READING

  • Holton KF, Denard PJ, Yoo JU, et al. Diffuse idiopathic skeletal hyperostosis and its relation to back pain among older men: the MrOS Study. Semin Arthritis Rheum. 2011;41(2):131-138.
  • Kagotani R, Yoshida M, Muraki S, et al. Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) of the whole spine and its association with lumbar spondylosis and knee osteoarthritis: the ROAD study. J Bone Miner Metab. 2015;33(2):221-229.
  • Olivieri I, D'Angelo S, Palazzi C, et al. Diffuse idiopathic skeletal hyperostosis: differentiation from ankylosing spondylitis. Curr Rheumatol Rep. 2009;11(5):321-328.
  • Verlaan JJ, Boswijk PF, de Ru JA, et al. Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction. Spine J. 2011;11(11):1058-1067. doi: 10.1016/j.spinee.2011.09.014.

CODES

ICD10

  • M48.10 Ankylosing hyperostosis [Forestier], site unspecified
  • M48.14 Ankylosing hyperostosis [Forestier], thoracic region
  • M48.15 Ankylosing hyperostosis [Forestier], thoracolumbar region
  • M48.12 Ankylosing hyperostosis [Forestier], cervical region
  • M48.19 Ankylosing hyperostosis [Forestier], multiple sites in spine
  • M48.18 Ankylosing hyperostosis, sacral and sacrococcygeal region
  • M48.13 Ankylosing hyperostosis [Forestier], cervicothoracic region
  • M48.11 Ankylosing hyperostosis, occipito-atlanto-axial region
  • M48.16 Ankylosing hyperostosis [Forestier], lumbar region

ICD9

SNOMED

CLINICAL PEARLS

  • DISH is typically asymptomatic. The diagnosis is often discovered incidentally on radiographic studies.
  • Clinical characteristics and radiographic findings may be confused with those of AS.
  • Patients with DISH are at increased risk of vertebral fractures.