Diffuse idiopathic skeletal hyperostosis

Symptoms may include pain, stiffness, and restricted movements of the affected areas. The majority of people with DISH are not symptomatic,{{Cite journal|last1=Mader|first1=Reuven|last2=Verlaan|first2=Jorrit-Jan|last3=Buskila|first3=Dan|date=Nov 2013|title=Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms|journal=Nature Reviews Rheumatology|language=En|volume=9|issue=12|pages=741–750|doi=10.1038/nrrheum.2013.165|pmid=24189840|s2cid=19347729|issn=1759-4804}} and the findings are an incidental imaging abnormality.

In some, the x-ray findings may correspond to symptoms of back stiffness with flexion/extension or with mild back pain. Back pain or stiffness may be worse in the morning.{{Cite journal|last1=Resnick|first1=Donald|last2=Shapiro|first2=Robert F.|last3=Wiesner|first3=Kenneth B.|last4=Niwayama|first4=Gen|last5=Utsinger|first5=Peter D.|last6=Shaul|first6=Stephen R.|title=Diffuse idiopathic skeletal hyperostosis (DISH) [ankylosing hyperostosis of forestier and Rotes-Querol]|journal=Seminars in Arthritis and Rheumatism|volume=7|issue=3|pages=153–187|doi=10.1016/0049-0172(78)90036-7|pmid=341323|year=1978}} Rarely, large anterior cervical spine osteophytes may affect the esophagus or the larynx and cause pain, difficulty swallowing{{cite journal | vauthors = Utsinger PD | title = Diffuse idiopathic skeletal hyperostosis | journal = Clinics in Rheumatic Diseases | volume = 11 | issue = 2 | pages = 325–51 | date = August 1985 | doi = 10.1016/S0307-742X(21)00544-0 | pmid = 3899489}}{{cite journal | vauthors = Mata S, Fortin PR, Fitzcharles MA, Starr MR, Joseph L, Watts CS, Gore B, Rosenberg E, Chhem RK, Esdaile JM | title = A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status | journal = Medicine | volume = 76 | issue = 2 | pages = 104–17 | date = March 1997 | pmid = 9100738 | doi = 10.1097/00005792-199703000-00003 | s2cid = 5950196 | doi-access = free }} or even dyspnea.{{Cite journal|last1=Psychogios|first1=Georgios|last2=Jering|first2=Monika|last3=Zenk|first3=Johannes|date=2018|title=Cervical Hyperostosis Leading to Dyspnea, Aspiration and Dysphagia: Strategies to Improve Patient Management|journal=Frontiers in Surgery|language=en|volume=5|pages=33|doi=10.3389/fsurg.2018.00033|pmid=29740589|issn=2296-875X|pmc=5928235|doi-access=free}} Similar calcification and ossification may be seen at peripheral entheseal sites, including the shoulder, iliac crest, ischial tuberosity, trochanters of the hip, tibial tuberosities, patellae, and bones of the hands and/or feet.

DISH can be a complicating factor when suffering from trauma involving the spine. It increases the risk of unstable fractures involving the intervertebral disc and the calcified/ossified ligaments which influences the need for surgical treatment.{{Cite journal |last1=Okada |first1=Eijiro |last2=Shimizu |first2=Kentaro |last3=Kato |first3=Masanori |last4=Fukuda |first4=Kentaro |last5=Kaneko |first5=Shinjiro |last6=Ogawa |first6=Jun |last7=Yagi |first7=Mitsuru |last8=Fujita |first8=Nobuyuki |last9=Tsuji |first9=Osahiko |last10=Suzuki |first10=Satoshi |last11=Nagoshi |first11=Narihito |last12=Tsuji |first12=Takashi |last13=Nakamura |first13=Masaya |last14=Matsumoto |first14=Morio |last15=Watanabe |first15=Kota |date=May 2019 |title=Spinal fractures in patients with diffuse idiopathic skeletal hyperostosis: Clinical characteristics by fracture level |url=https://pubmed.ncbi.nlm.nih.gov/30415821 |journal=Journal of Orthopaedic Science|volume=24 |issue=3 |pages=393–399 |doi=10.1016/j.jos.2018.10.017 |issn=1436-2023 |pmid=30415821|s2cid=53278226 }}

DISH most commonly affects the elderly, especially 6th to 7th decades. The estimated frequency in the elderly is ~10% – 20%, with a slight male predominance.

The exact cause is unknown. Mechanical, dietary factors and use of some medications (e.g. isotretinoin, etretinate, acitretin and other vitamin A derivatives){{cite journal |journal=Surg Neurol Int |date=2014 |volume=5 |issue=Suppl 3 |pages=S122–S125 |author=Nascimento |display-authors=etal |title=Diffuse idiopathic skeletal hyperostosis: A review |pmc=4023007|pmid=24843807 |doi=10.4103/2152-7806.130675 |doi-access=free }} may be of significance. There is a correlation between these factors but not a cause or effect. The distinctive radiological feature of DISH is the continuous linear calcification along the antero-medial aspect of the thoracic spine. DISH is usually found in people in their 60s and above, and is extremely rare in people in their 30s and 40s. The disease can spread to any joint of the body, affecting the neck, shoulders, ribs, hips, pelvis, knees, ankles, and hands. The disease is not fatal; however, some associated complications can lead to death. Complications may include paralysis, dysphagia (difficulty swallowing), and lung infections.

Although DISH manifests in a similar manner to ankylosing spondylitis, they are separate diseases. Ankylosing spondylitis is a genetic disease with identifiable marks, tends to start showing signs in adolescence or young adulthood, is more likely to affect the lumbar spine, and affects organs. DISH has no indication of a genetic link, is primarily thoracic and does not affect organs other than the lungs, and only indirectly due to the fusion of the rib cage.

Long-term treatment of acne with vitamin derived retinoids, such as etretinate{{cite journal | vauthors = DiGiovanna JJ, Helfgott RK, Gerber LH, Peck GL | title = Extraspinal tendon and ligament calcification associated with long-term therapy with etretinate | journal = The New England Journal of Medicine | volume = 315 | issue = 19 | pages = 1177–82 | date = November 1986 | pmid = 3463863 | doi = 10.1056/NEJM198611063151901}} and acitretin,{{cite journal | vauthors = DiGiovanna JJ | title = Isotretinoin effects on bone | journal = Journal of the American Academy of Dermatology | volume = 45 | issue = 5 | pages = S176–82 | date = November 2001 | pmid = 11606950 | doi = 10.1067/mjd.2001.113721}} have been associated with extraspinal hyperostosis.

DISH is diagnosed by findings on x-ray studies. Radiographs of the spine will show abnormal bone formation (ossification) along the anterior spinal ligament. The disc spaces, facet and sacroiliac joints remain unaffected. Diagnosis requires confluent ossification of at least four contiguous vertebral bodies. Classically, advanced disease may have "melted candle wax" appearance along the spine on radiographic studies.Waldron, T. "Paleopathology". Cambridge University Press, 2009, p. 73. In some cases, DISH may be manifested as ossification, or enthesis, in other parts of the skeleton.

The calcification and ossification is most common on the right side of the spine. In people with dextrocardia and situs inversus this calcification occurs on the left side.{{cite journal | vauthors = Forestier J, Lagier R | title = Ankylosing hyperostosis of the spine | journal = Clinical Orthopaedics and Related Research | volume = 74 | pages = 65–83 | date = January 1971 | pmid = 4993095 | doi=10.1097/00003086-197101000-00009}}

File:Thoracic spine Lat.png|Confluent ossification of multiple contiguous vertebral bodies in diffuse idiopathic skeletal hyperostosis (DISH)

File:Thoracic spine AP.png|alt=DISH spine|"Melted candle wax" appearance of calcification and ossification in diffuse idiopathic skeletal hyperostosis (DISH). Note the preponderance on the patient's left side (right side of image).

File:Calcification in Achilles tendon insertion and calcaneal spur.png|Ectopic calcification and new bone formation in diffuse idiopathic skeletal hyperostosis (DISH)

File:Ossifikation Ligamentum longitudinale posterius HWS bei DISH - CT axial und sagittal - 001.jpg|Ossification of the posterior longitudinal ligament in DISH

File:3DPOSTERIORRIBS (top) Nov 2018.jpg

There is limited scientific evidence for the treatment for symptomatic DISH.

Symptoms of pain and stiffness may be treated with conservative measures, analgesic medications (such as non-steroidal anti-inflammatory drugs), and physical therapy.{{cite journal | vauthors = Al-Herz A, Snip JP, Clark B, Esdaile JM | title = Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis | journal = Clinical Rheumatology | volume = 27 | issue = 2 | pages = 207–10 | date = February 2008 | pmid = 17885726 | doi = 10.1007/s10067-007-0693-z | s2cid = 13481354 }}

In extraordinary cases where calcification or osteophyte formation is causing severe and focal symptoms, such as difficulty swallowing or nerve impingement, surgical intervention may be pursued.{{cite journal | vauthors = Castellano DM, Sinacori JT, Karakla DW | title = Stridor and dysphagia in diffuse idiopathic skeletal hyperostosis (DISH) | journal = The Laryngoscope | volume = 116 | issue = 2 | pages = 341–4 | date = February 2006 | pmid = 16467731 | doi = 10.1097/01.mlg.0000197936.48414.fa | s2cid = 30733962 |issn=0023-852X}}

• Ankylosing spondylitis
• Enthesitis
• Osteoarthritis
• Retinoids

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{{Medical resources

| DiseasesDB = 4932

| ICD10 = {{ICD10|M|48|1|m|48}}

| ICD9 = {{ICD9|721.6}}

| ICDO =

| OMIM = 106400

| MedlinePlus =

| eMedicineSubj = article

| eMedicineTopic = 1258514

| eMedicine_mult = {{eMedicine2|article|388973}}

| MeshID =

| GeneReviewsName =

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{{commons category|Diffuse idiopathic skeletal hyperostosis}}

{{DEFAULTSORT:Diffuse Idiopathic Skeletal Hyperostosis}}

Category:Musculoskeletal disorders

Category:Idiopathic diseases