Diffuse idiopathic skeletal hyperostosis (DISH)
- Simon M Helfgott, MD
Simon M Helfgott, MD
- Section Editor — General Rheumatology and Related Topics
- Associate Professor of Medicine
- Harvard Medical School
Diffuse idiopathic skeletal hyperostosis (DISH) has several synonyms, including ankylosing hyperostosis and Forestier's disease [1,2]. It is a noninflammatory disease, with the principal manifestation being calcification and ossification of spinal ligaments and the regions where tendons and ligaments attach to bone (entheses).
Radiographic changes characteristic of DISH may occur in the absence of any musculoskeletal symptoms.
The clinical manifestations, radiographic findings, and treatment of DISH are reviewed here. The clinical features and treatment of another noninflammatory arthritis, osteoarthritis, are presented separately. (See "Initial pharmacologic therapy of osteoarthritis" and "Overview of surgical therapy of knee and hip osteoarthritis" and "Clinical manifestations and diagnosis of osteoarthritis".)
ETIOLOGY AND PATHOGENESIS
While the cause of diffuse idiopathic skeletal hyperostosis (DISH) remains unknown, mechanical factors, dietary contributions, drugs, environmental exposures, and metabolic conditions have been hypothesized to be important. It is thought that the bone formation that is distinctive of DISH results from abnormal osteoblastic differentiation and activity at the enthesis. An appropriate genetic background, as yet unidentified, external factors, or local or systemic factors may stimulate the abnormal osteoblastic differentiation.
Mechanical factors — Bony bridging is usually more prominent on the right side of the thoracic spine in patients with DISH. By comparison, those with DISH and dextrocardia or situs inversus have more extensive bony bridging on the left side of the thoracic spine. Thus, mechanical factors associated with the change in location of the aorta may affect the development of bony outgrowths . In ossification of the posterior longitudinal ligament of the spine, a condition that can occur with DISH or as an independent entity, ligamentous stretching can increase prostaglandin I2 synthase resulting in stimulation of osteogenic differentiation .
- Utsinger PD. Diffuse idiopathic skeletal hyperostosis. Clin Rheum Dis 1985; 11:325.
- Resnick D, Shapiro RF, Wiesner KB, et al. Diffuse idiopathic skeletal hyperostosis (DISH) [ankylosing hyperostosis of Forestier and Rotes-Querol]. Semin Arthritis Rheum 1978; 7:153.
- Forestier J, Lagier R. Ankylosing hyperostosis of the spine. Clin Orthop Relat Res 1971; 74:65.
- Ohishi H, Furukawa K, Iwasaki K, et al. Role of prostaglandin I2 in the gene expression induced by mechanical stress in spinal ligament cells derived from patients with ossification of the posterior longitudinal ligament. J Pharmacol Exp Ther 2003; 305:818.
- Schlapbach P, Beyeler C, Gerber NJ, et al. Diffuse idiopathic skeletal hyperostosis (DISH) of the spine: a cause of back pain? A controlled study. Br J Rheumatol 1989; 28:299.
- Utsinger PD, Resnick D, Shapiro R. Diffuse skeletal abnormalities in Forestier disease. Arch Intern Med 1976; 136:763.
- Abiteboul M, Arlet J, Sarrabay MA, et al. [Metabolism of vitamin A in Forestier-Rotès-Quérol hyperostosis]. Rev Rhum Mal Osteoartic 1986; 53:143.
- Dougados M, Leporho MA, Esmilaire L, et al. [Plasma levels of vitamins A and E in hyperostosis, ankylosing spondylarthritis and rheumatoid polyarthritis]. Rev Rhum Mal Osteoartic 1988; 55:251.
- Troillet N, Gerster JC. [Forestier disease and metabolism disorders. A prospective controlled study of 25 cases]. Rev Rhum Ed Fr 1993; 60:274.
- DiGiovanna JJ, Helfgott RK, Gerber LH, Peck GL. Extraspinal tendon and ligament calcification associated with long-term therapy with etretinate. N Engl J Med 1986; 315:1177.
- Moskowitz RW, Boja B, Denko CW. The role of growth factors in degenerative joint disorders. J Rheumatol Suppl 1991; 27:147.
- DiGiovanna JJ. Isotretinoin effects on bone. J Am Acad Dermatol 2001; 45:S176.
- Sarzi-Puttini P, Atzeni F. New developments in our understanding of DISH (diffuse idiopathic skeletal hyperostosis). Curr Opin Rheumatol 2004; 16:287.
- Denko CW, Boja B, Malemud CJ. Intra-erythrocyte deposition of growth hormone in rheumatic diseases. Rheumatol Int 2003; 23:11.
- Mata S, Fortin PR, Fitzcharles MA, et al. A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status. Medicine (Baltimore) 1997; 76:104.
- Sencan D, Elden H, Nacitarhan V, et al. The prevalence of diffuse idiopathic skeletal hyperostosis in patients with diabetes mellitus. Rheumatol Int 2005; 25:518.
- Spagnola AM, Bennett PH, Terasaki PI. Vertebral ankylosing hyperostosis (Forestier's disease) and HLA antigens in Pima Indians. Arthritis Rheum 1978; 21:467.
- Julkunen H, Heinonen OP, Pyörälä K. Hyperostosis of the spine in an adult population. Its relation to hyperglycaemia and obesity. Ann Rheum Dis 1971; 30:605.
- Littlejohn GO, Smythe HA. Marked hyperinsulinemia after glucose challenge in patients with diffuse idiopathic skeletal hyperostosis. J Rheumatol 1981; 8:965.
- Scarpa R, De Brasi D, Pivonello R, et al. Acromegalic axial arthropathy: a clinical case-control study. J Clin Endocrinol Metab 2004; 89:598.
- Denko CW, Malemud CJ. Body mass index and blood glucose: correlations with serum insulin, growth hormone, and insulin-like growth factor-1 levels in patients with diffuse idiopathic skeletal hyperostosis (DISH). Rheumatol Int 2006; 26:292.
- el Miedany YM, Wassif G, el Baddini M. Diffuse idiopathic skeletal hyperostosis (DISH): is it of vascular aetiology? Clin Exp Rheumatol 2000; 18:193.
- Kosaka T, Imakiire A, Mizuno F, Yamamoto K. Activation of nuclear factor kappaB at the onset of ossification of the spinal ligaments. J Orthop Sci 2000; 5:572.
- Julkunen H, Knekt P, Aromaa A. Spondylosis deformans and diffuse idiopathic skeletal hyperostosis (DISH) in Finland. Scand J Rheumatol 1981; 10:193.
- Julkunen H, Heinonen OP, Knekt P, Maatela J. The epidemiology of hyperostosis of the spine together with its symptoms and related mortality in a general population. Scand J Rheumatol 1975; 4:23.
- Kiss C, O'Neill TW, Mituszova M, et al. The prevalence of diffuse idiopathic skeletal hyperostosis in a population-based study in Hungary. Scand J Rheumatol 2002; 31:226.
- Cassim B, Mody GM, Rubin DL. The prevalence of diffuse idiopathic skeletal hyperostosis in African blacks. Br J Rheumatol 1990; 29:131.
- Bloom RA. The prevalence of ankylosing hyperostosis in a Jerusalem population--with description of a method of grading the extent of the disease. Scand J Rheumatol 1984; 13:181.
- Castellano DM, Sinacori JT, Karakla DW. Stridor and dysphagia in diffuse idiopathic skeletal hyperostosis (DISH). Laryngoscope 2006; 116:341.
- Beyeler C, Schlapbach P, Gerber NJ, et al. Diffuse idiopathic skeletal hyperostosis (DISH) of the shoulder: a cause of shoulder pain? Br J Rheumatol 1990; 29:349.
- Beyeler C, Schlapbach P, Gerber NJ, et al. Diffuse idiopathic skeletal hyperostosis (DISH) of the elbow: a cause of elbow pain? A controlled study. Br J Rheumatol 1992; 31:319.
- Mader R. Clinical manifestations of diffuse idiopathic skeletal hyperostosis of the cervical spine. Semin Arthritis Rheum 2002; 32:130.
- Trojan DA, Pouchot J, Pokrupa R, et al. Diagnosis and treatment of ossification of the posterior longitudinal ligament of the spine: report of eight cases and literature review. Am J Med 1992; 92:296.
- Schlapbach P, Beyeler C, Gerber NJ, et al. The prevalence of palpable finger joint nodules in diffuse idiopathic skeletal hyperostosis (DISH). A controlled study. Br J Rheumatol 1992; 31:531.
- Resnick D, Niwayama G. Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 1976; 119:559.
- Harris J, Carter AR, Glick EN, Storey GO. Ankylosing hyperostosis. I. Clinical and radiological features. Ann Rheum Dis 1974; 33:210.
- Fornasier VL, Littlejohn G, Urowitz MB, et al. Spinal entheseal new bone formation: the early changes of spinal diffuse idiopathic skeletal hyperostosis. J Rheumatol 1983; 10:939.
- Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations. Radiology 1975; 115:513.
- Bundrick TJ, Cook DE, Resnik CS. Heterotopic bone formation in patients with DISH following total hip replacement. Radiology 1985; 155:595.
- Littlejohn GO, Urowitz MB, Smythe HA, Keystone EC. Radiographic features of the hand in diffuse idiopathic skeletal hyperostosis (DISH): comparison with normal subjects and acromegalic patients. Radiology 1981; 140:623.
- Sahin G, Polat G, Bagis S, et al. Study of axial bone mineral density in postmenopausal women with diffuse idiopathic skeletal hyperostosis related to type 2 diabetes mellitus. J Womens Health (Larchmt) 2002; 11:801.
- Resnick D, Curd J, Shapiro RF, Wiesner KB. Radiographic abnormalities of rheumatoid arthritis in patients with diffuse idiopathic skeletal hyperostosis. Arthritis Rheum 1978; 21:1.
- Littlejohn GO, Hall S. Diffuse idiopathic skeletal hyperostosis and new bone formation in male gouty subjects. A radiologic study. Rheumatol Int 1982; 2:83.
- Mazières B, Jung-Rozenfarb M, Arlet J. [Paget's disease, ankylosing vertebral hyperostosis and hyperostosis frontalis interna]. Sem Hop 1978; 54:521.
- Bruges-Armas J, Couto AR, Timms A, et al. Ectopic calcification among families in the Azores: clinical and radiologic manifestations in families with diffuse idiopathic skeletal hyperostosis and chondrocalcinosis. Arthritis Rheum 2006; 54:1340.
- Mata S, Wolfe F, Joseph L, Esdaile JM. Absence of an association of rheumatoid arthritis and diffuse idiopathic skeletal hyperostosis: a case-control study. J Rheumatol 1995; 22:2062.
- Mader R, Novofestovski I, Adawi M, Lavi I. Metabolic syndrome and cardiovascular risk in patients with diffuse idiopathic skeletal hyperostosis. Semin Arthritis Rheum 2009; 38:361.
- Resnick D, Guerra J Jr, Robinson CA, Vint VC. Association of diffuse idiopathic skeletal hyperostosis (DISH) and calcification and ossification of the posterior longitudinal ligament. AJR Am J Roentgenol 1978; 131:1049.
- Saetia K, Cho D, Lee S, et al. Ossification of the posterior longitudinal ligament: a review. Neurosurg Focus 2011; 30:E1.
- Wang MY, Thambuswamy M. Ossification of the posterior longitudinal ligament in non-Asians: demographic, clinical, and radiographic findings in 43 patients. Neurosurg Focus 2011; 30:E4.
- Pham MH, Attenello FJ, Lucas J, et al. Conservative management of ossification of the posterior longitudinal ligament. A review. Neurosurg Focus 2011; 30:E2.
- Fulton JD. Analgesic use of etidronate in Forrestier's disease. Lancet 1992; 340:1287.
- Jun BY, Yoon KJ, Crockard A. Retro-odontoid pseudotumor in diffuse idiopathic skeletal hyperostosis. Spine (Phila Pa 1976) 2002; 27:E266.
- ETIOLOGY AND PATHOGENESIS
- Mechanical factors
- Environmental factors and diet
- Metabolic conditions
- CLINICAL FEATURES
- Physical findings
- Radiographic findings
- - Spinal involvement
- - Extraspinal involvement
- Laboratory findings
- Associated conditions
- DIAGNOSTIC CRITERIA
- DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
- Differential diagnosis
- - Spondylosis deformans
- - Ankylosing spondylitis
- - Ossification of the posterior longitudinal ligament
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS