Diffuse Idiopathic Skeletal Hyperostosis

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Synonym: Forestier's disease

Diffuse idiopathic skeletal hyperostosis (DISH) is a tendency for ossification of ligaments, tendons and joint capsule insertions, most often affecting the spine.[1]Calcification of the longitudinal ligaments (particularly anterior) can often produce the radiological appearance of 'wax dripping from a candle', distinct from the vertebral bodies. The thoracic spine is mainly affected but it can also affect the lumbar and cervical spine, and other areas of the skeleton. The tendon/osseous junctions are occasionally affected around the elbow, patella, calcaneus, hip and knee joints. The cause is unknown.

  • The prevalence may be as high as 28%. Elderly men are most commonly affected.[2]
  • it is uncommon in patients younger than 50 years and rare in patients younger than 40 years.
  • Most often, it affects the thoracic spine, especially on the right side.[2]
  • Clinical features vary from monoarticular synovitis to dysphagia and even airway obstruction.[1]
  • Is often asymptomatic and discovered by chance on X-rays or CT/MRI scans.
  • Symptoms may include pain, stiffness and restricted movements of the affected areas.
  • Osteophytes may rarely cause symptoms by mechanical compression or by causing an inflammatory reaction. When an upper segment of the cervical spine is involved, particular at the C3-C4 level, the larynx may be affected. This could be result of hoarseness, stridor, laryngeal stenosis and obstruction.[3]
  • Sometimes vocal fold paralysis may result from injury to the recurrent laryngeal nerve.[3]
  • X-rays:
    • Characteristic appearance of 'wax dripping from a candle', distinct from the vertebral bodies.
    • Thoracic vertebrae are involved in 100%, lumbar in 68-90%, and cervical in 65-78% of affected individuals.
  • CT and MRI scans are better at detecting associated findings (eg, ossification of the posterior longitudinal ligament of the cervical spine) and complications (eg, spinal cord compressive myelomalacia).
  • Non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed for symptomatic relief.
  • Physiotherapy has been used to good effect.
  • Ossification around hip and knee joints may require arthroplastic surgery.
  • Upper respiratory problems may required initial stabilisation of the airway with tracheostomy, followed by osteophysectomy, which is usually effective.[3]
  • Compression of nerve roots may cause myelopathy.
  • Overgrowth of ligamentous calcification may rarely impinge on other structures - eg, the oesophagus. Dysphagia should be treated conservatively, surgical management being reserved for severe and recalcitrant cases.
  • Occasionally, osteophytic formation in the cervical vertebrae causes cervical compression symptoms.
  • Thoracic spine osteophytes have on rare occasions been found to compress a bronchus, the larynx and trachea, and the inferior vena cava.
  • Reduced vertebral column flexibility predisposes to vertebral fracture.

Life expectancy is usually not affected in any adverse way, unless there are complications and associated joint or soft tissue problems.

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Original Author:
Dr Colin Tidy
Current Version:
Dr Colin Tidy
Peer Reviewer:
Dr Helen Huins
Document ID:
2165 (v22)
Last Checked:
16 June 2014
Next Review:
15 June 2019

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