This document discusses diffuse idiopathic skeletal hyperostosis (DISH), a condition characterized by excessive bone formation along the sides of the spine. It provides diagnostic criteria for DISH, including flowing bone formation along at least four contiguous vertebrae while maintaining disk height. Risk factors include age, metabolic syndrome, and high BMI. Symptoms may include back pain, stiffness, dysphagia, and neurological stenosis. Imaging shows characteristic bone formation patterns, and differential diagnoses include ankylosing spondylitis and other arthritic conditions. Treatment involves NSAIDs, bisphosphonates, and other medications to reduce inflammation.

1. DISH
Upper Chesapeake Medical Center
Spine Conference
October 10, 2014

2. R
QUINTESSENTIAL RIGHT ANTEROLATERAL THORACIC SYNDESMOPHYTES T7-T11; bone forming

3. DISH: diffuse idiopathic skeletal hyperostosis
• Foresteir and Rotes-Querol
• Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann
• Rheum Dis 1950;9:321-30.
• Senile ankylosing hyperostosis
• Generalized juxta-articular ossification of
vertebral ligaments
• Spondylosis hyperostotica
• DISH D. Resnick Radiology 1975; 115:513-524

4. Diagnosis
• Diagnostic Criteria for DISH
• 1. Flowing ossification along the
anterolateral aspect of at least four
contiguous vertebrae
• 2. Preservation of disk height in the
involved vertebral segment; the relative
absence of significant degenerative
changes, such as marginal sclerosis in
vertebral bodies or vacuum
phenomenon
• 3. Absence of facet-joint ankylosis;
absence of SI joint fusion

6. prevalence
• >30 years old
7% men 4%
women
• >50 most
prevalent
• 28% autopsy
specimens
avg age 65
years

7. RISK FACTORS
• Metabolic syndrome
• Diabetes
• Age
• High BMI
• Uric acid

9. Symptoms
• Pain
• Stiffness
• Dysphagia
• Rhinophonia
• Neurologic stenosis

10. Imaging Characteristics of Diffuse Idiopathic Skeletal Hyper
• Mihra S. Taljanovic et al
• AJR 2009; 193 S10-S19
• The University of Arizona Helath Sciences Center in Tucson, Arizona

11. Diffuse Idiopathic Skeletal Hyperostosis: Musculoskeletal Manifestations
Belanger, Theodore and Rowe, Dale JAAOS 2011; 9:258-267
Michigan State University, Kalamazoo, Michigan

13. • Extra-articular ankylosis

14. AS Radiographic features
• Squaring vertebra
• Bridging syndesmophytes
• Bamboo spine

17. • Bone scan
can
mimick
metastatic
disease

18. Dysphagia
• 28% have large
cervical
syndesmophytes
• Hoarseness
• Sleep apnea
• Difficult intubation

19. Rib expansion < 2.5cm

20. DDX
• Ankylosing
spondylitis
• Reactive arthritis
(Reiter’s)
• Spondylosis
deformans
• Psoriatric arthritis
• Rheumatoid arthritis
• Acromegaly
• Hypervitaminosis A

21. Chronic LBP with Clinical Features make Dx
of AS Likely:
1. Sx<45 years of age
2. Dactylitis, enthesitis
3. Nongranulomatous Acute anterior uveitis
4. FH 15-20%
5. HLA B27
6. Sacroiliitis/spondylitis
7. Proximal aortic disease, MV, conduction, aortitis
8. Inflammatory Bowel Disease
9. Pulmonary Fibrosis

22. What
direction
are the
syndesmophytes?

24. • Are the joints fused?

30. Fear of the unknown

31. Delay in diagnosis

33. Chronic
spondylodiscitis

35. Calcification of the sacrotuberous and iliolumbar ligaments
Periarticular osteophytes of the hip, SI joint, symphysis pubis
Bone proliferation “whiskering” at site of ligament and tendon
attachment

36. Type: JPG

37. 64 year old man with
R shoulder pain to
the acromium

45. Does the aortic pulsation affect
the location of bone formation
is DISH?

48. • Bilateral and symmetrical
• Arrowhead tufts

49. Medical treatment
• NSAID: short/long acting, Cox2
selective
• Bisphophonates for osteoporosis
• DMARDs such
as ciclosporin, methotrexate, sulf
asalazine, and corticosteroids,
used to reduce the immune
system response through
immunosuppression
• TNFα blockers (antagonists) such
as etanercept, infliximab and ad
alimumab

51. 66 year old man with four month history of mid thoracic back pain not
Improving despite NSAID and PT

61. Thanks!!

67. THANKS!!

68. THANKS!