Diffuse Idiopathic Skeletal Hyperostosis

Authored by , Reviewed by Dr Helen Huins | Last edited | Meets Patient’s editorial guidelines

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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.

Further reading and references

  1. Nascimento FA, Gatto LA, Lages RO, et al; Diffuse idiopathic skeletal hyperostosis: A review. Surg Neurol Int. 2014 Apr 165(Suppl 3):S122-S125. eCollection 2014.

  2. Wheeless' Textbook of Orthopaedics; Diffuse Idiopathic Skeletal Hyperostosis.

  3. Burduk PK, Wierzchowska M, Grzelalak L, et al; Diffuse idiopathic skeletal hyperostosis inducted stridor and dysphagia. Otolaryngol Pol. 200862(2):138-40.

  4. Sarzi-Puttini P, Atzeni F; New developments in our understanding of DISH (diffuse idiopathic skeletal hyperostosis). Curr Opin Rheumatol. 2004 May16(3):287-92.

  5. Mader R, Sarzi-Puttini P, Atzeni F, et al; Extraspinal manifestations of diffuse idiopathic skeletal hyperostosis. Rheumatology (Oxford). 2009 Dec48(12):1478-81. doi: 10.1093/rheumatology/kep308. Epub 2009 Sep 25.