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Diffuse Idiopathic Skeletal Hyperostosis (DISH)


KEY FACTS

Terminology

  • Diffuse idiopathic skeletal hyperostosis (DISH)

  • Forestier disease, senile ankylosing hyperostosis, asymmetrical skeletal hyperostosis

Imaging

  • Flowing anterior vertebral ossification with minimal degenerative disc disease, facet arthropathy, absent facet ankylosis

  • Thoracic spine (100%) > cervical (65-80%), lumbar spine (68-90%); R > L

  • Lateral radiography inexpensive, reliable

  • Reserve MR to evaluate for coexistent OPLL or spondylosis-related cord compression

Top Differential Diagnoses

  • Spondylosis

  • Ankylosing spondylitis

  • Psoriatic or reactive (Reiter) arthritis

Pathology

  • Exact cause for exaggerated new bone formation stimuli unknown

    • Exuberant entheseal reaction at tendon, ligament, and joint capsule insertions

    • Associated with OPLL

    • Dysphagia related to DISH multifactorial

  • Primary diagnostic criteria for DISH

    • Flowing anterior ossification extending over at least 4 contiguous vertebral bodies

    • No apophyseal or SI joint ankylosis

    • Mild degenerative disc changes, no facet ankylosis

Clinical Issues

  • Majority of cases incidental

  • Osteophyte resection if severe symptoms

  • Increased risk of extension-type fractures with high morbidity

Sagittal graphic shows bulky flowing ossification of the anterior longitudinal ligament extending over > 4 contiguous vertebra. Disc spaces are relatively preserved.

Lateral radiograph shows a large anterior ossified mass
that is discontinuous at several disc spaces, a variation implying some degree of continued cervical spine mobility.

Sagittal T1WI MR shows bulky anterior flowing ossification
consistent with DISH. Fatty marrow is responsible for high T1 signal intensity within the anterior ossification.

Sagittal T1WI MR right parasagittal slice shows bulky flowing ALL ossification
spanning more than 4 vertebral levels but minimal disc abnormality that is typical of DISH.

TERMINOLOGY

Abbreviations

  • Diffuse idiopathic skeletal hyperostosis (DISH)

Synonyms

  • Forestier disease, senile ankylosing hyperostosis, asymmetrical skeletal hyperostosis

  • Spondylosis hyperostotica, spondylitis ossificans ligamentosa

Definitions

  • Flowing coarse osteophytes bridging 4 vertebral adjacent bodies

IMAGING

General Features

  • Best diagnostic clue

    • Flowing anterior vertebral ossification with minimal degenerative disc disease, facet arthropathy, and absent facet ankylosis

  • Location

    • Thoracic spine (100%) > cervical (65-80%), lumbar spine (68-90%); R > L

  • Size

    • Range from small, focal to large, and extensive

  • Morphology

    • Bulky flowing multilevel ossification anterior to vertebral bodies

    • Predominantly right side of thoracic spine

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