Diffuse idiopathic skeletal hyperostosis


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a case report of DISH, differential diagnosis with Paget's disease, Skeletal Fluorosis, and Ankylosing spondylitis.

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Diffuse idiopathic skeletal hyperostosis

  1. 1. Diffuse idiopathic skeletal hyperostosis Vinod Naneria Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research Centre, Indore, India
  2. 2. DISH • Diffuse idiopathic skeletal hyperostosis or Forestier disease is a common condition characterized by bone proliferation at sites of tendinous and ligamentous insertion. • Epidemiology • It most commonly affects the elderly (especially 6th to 7th decades). • Its estimated frequency in the elderly is at ~ 5- 15%
  3. 3. Pathology • Pathologic features of spinal DISH include: • Focal and diffuse calcification and ossification of the anterior longitudinal ligament, • Paraspinal connective tissue and annulus fibrosis, • Degeneration in the peripheral annulus fibrosis fibers, • Anterolateral extensions of fibrous tissue, • Hypervascularity, • Chronic inflammatory cellular infiltration, • Periosteal new bone formation on the anterior surface of the vertebral bodies.
  4. 4. Associations • Ossification of the posterior longitudinal ligament (OPLL) • Hyperglycaemia. • Approximately one-third of patients test positive for human leukocyte antigen (HLA)B27.
  5. 5. Spinal features: • Florid, flowing ossification along the anterior or right anterolateral aspects of at least four contiguous vertebrae. • Disc spaces are usually well preserved. • Ankylosis is more commonly seen in the thoracic than in the cervical or lumbar spine. Frequently incomplete can have interdigitating areas of protruding disk material in the flowing ossifications.
  6. 6. Extra spinal features • Enthesopathy of: • iliac crest, • ischial tuberosities, • greater trochanters, • spur formation in the appendicular skeleton (olecranon, calcaneum).
  7. 7. Dr Noyan ZengerDr Andrew Ho & Dr Radswiki .
  8. 8. Dr Andrew Ho
  9. 9. DISH
  10. 10. DISH
  11. 11. DISH
  12. 12. DISH
  13. 13. Ankylosing Spondylitis – Radiological features • early spondylitis is characterized by small erosions at the corners of vertebral bodies with reactive sclerosis • squaring of the vertebral body • diffuse syndesmophyitic ankylosis can give a "bamboo spine" appearance • interspinous ligament calcification can give a "dagger spine" appearance • ossification of spinal ligaments, joints and discs. • Psuedoarthroses may form at fracture sites. • enthesophyte formation from enthesopathy. • Romanus lesions of the spine - shiny corner sign.
  14. 14. Ankylosing spondylitis
  15. 15. Ankylosing spondylitis
  16. 16. Fluorosis - radiological features: • The earliest radiological findings appear within six mouths of continuous exposure to high intakes of fluoride and include periosteal and endosteal reactions, coarse axial trabcculations and osteopenia in the metaphyseal regions, sclerosis, and modelling abnormalities of the epiphyses, carpal and other bones of the hand, more particularly observed in growing children. • The incidence of spinal osteoporosis is significantly low and of osteomalacia and secondary hyperparathyroid bone disease significantly higher in women residing in endemic fluorosis villages.
  17. 17. Fluorosis
  18. 18. Fluorosis
  19. 19. Paget’s disease – Spine Radiology • Spine: cortical thickening encasing the vertebral margins, which gives rise to the picture frame sign on radiographs in mixed phase disease. • On lateral radiographs flattening or squaring of the normal concavity of the anterior margin of the vertebral body also adds to the rectangular appearance. • The osteoblastic activity is seen along all four margins of the vertebral body cortices. • The vertical trabecular thickening pattern in Paget disease is coarser than the more delicate pattern seen in hemangiomas with which it can be confused.
  20. 20. Paget’s disease – Radiology Pelvis • Paget disease of the pelvis usually manifests with cortical thickening and sclerosis of the iliopectineal and ischiopubic lines. These findings are often asymmetric and for some reason, may be more commonly seen on the right side. Enlargement of the pubic rami and ischium are also often seen.
  21. 21. Paget
  22. 22. Paget
  23. 23. Paget
  24. 24. Paget
  25. 25. Osteopetrosis • X-ray findingsDiffuse osteosclerosis • Cortical thickening with medullary encroachment • Erlenmeyer flask deformity = clublike long bones due to lack of tubulization + flaring of ends • Bone-within-bone appearance • "Sandwich" vertebrae=alternating sclerotic + radiolucent transverse metaphyseal lines (phalanges, iliac bones) indicate fluctuating course of disease • Longitudinal metaphyseal striations • Mandible least involved
  26. 26. Osteopatrosis
  27. 27. DISCLAIMER Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India. Some of the representative x-rays and relevant text is taken from Radiopaedia.org It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact naneria@yahoo.com