Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the ossification and calcification of ligaments and entheses. DISH is observed on all continents and in all races, but most commonly in men over 50 years of age. Although DISH is asymptomatic in most individuals, the condition is often an indicator of underlying metabolic disease, and the presence of spinal or extraspinal ossifications can sometimes lead to symptoms including pain, stiffness, a reduced range of articular motion, and dysphagia, as well as increasing the risk of unstable spinal fractures. The aetiology of DISH is poorly understood, and the roles of the many factors that might be involved in the development of excess bone are not well delineated. The study of pathophysiological aspects of DISH is made difficult by the formal diagnosis requiring the presence of multiple contiguous fully formed bridging ossifications, which probably represent advanced stages of DISH. In this Review, the reader is provided with an up-to-date discussion of the epidemiological, aetiological and clinical aspects of DISH. Existing classification criteria (which, in the absence of diagnostic criteria, are used to establish a diagnosis of DISH) are also considered, together with the need for modified criteria that enable timely identification of early phases in the development of DISH.

Pelvic enthesopathy on CT is significantly more prevalent in patients with diffuse idiopathic skeletal hyperostosis (DISH) compared with matched control patients

“…Mader et al further suggested a revised DISH definition that will include extraspinal, constitutional, and metabolic manifestations [10,14]. Our results support the notion that pelvic enthesopathy may be included in the classification DISH criteria, based on symmetrical and peripheral characteristic enthesopathies, even in the absence of spinal involvement [13].…”

“…1 CT slices of the pelvis in the axial and coronal orientation demonstrating prominent enthesophytes at a the hamstring attachment on the ischial tuberosity, b the gluteus medius insertion on the greater trochanter, and c on the iliac crest, and d the adductors attachment on the symphysis pubis DISH was considered a radiographic rather than a clinical entity; however, it is now recognized that patients with DISH may be symptomatic and complain of a broad range of symptoms starting from nonspecific back pain to severe debilitating limitation of spinal motion. Extra axial symptoms such as dysphagia are also recognized in DISH patients [12,13], as well as underlying metabolic diseases with an increased risk for cardiac disease [14]. Though enthesophytes in DISH patients tend to be asymptomatic [8,15], their presence on pelvic CT scan may be used as a surrogate marker for early diagnosis of DISH thus facilitating prompt management of DISH-associated metabolic diseases as well as potentially slowing the progression of spinal DISH manifestations by enhancing range of motion geared exercise.…”

Imaging Findings Suggestive of Axial Spondyloarthritis in Diffuse Idiopathic Skeletal Hyperostosis

“…Diffuse idiopathic skeletal hyperostosis (DISH) is, like axial SpA, a disease characterized by the ossification of ligaments and enthesis of the axial skeleton, with prevalence that increases with age (10). The typical radiographic feature of DISH is the presence of flowing ossification along vertebral bodies, mostly found in, but not limited to, the thoracic spine (11).…”

Anterior longitudinal ligament in diffuse idiopathic skeletal hyperostosis: Ossified or displaced?

“…Additional research to explore and validate the proposed two types of changes was, however, not performed. In recent literature it has become customary to describe DISH as an ossification or calcification of spinal longitudinal ligaments, especially the ALL (17/44 DISH articles published in 2016) 5, 8, 9. However, none of these 17 articles cited a study testing the validity of this assumption.…”