Diffuse Idiopathic Skeletal Hyperostosis
Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Top Contributors - Jessica Ernstes, Cassy Hasara, Elaine Lonnemann, Kim Jackson, WikiSysop, 127.0.0.1 and Erica Hunter
Definition/Description[edit | edit source]
Diffuse Idiopathic Skeletal Hyperostosis (DISH) refers to a non-inflammatory disease that is characterized by ossification/calcification of soft tissues, entheses, and spinal ligaments. DISH primarily affects the Anterior Longitudinal Ligament (ALL) at the attachment sites to bone in the vertebral column. [1-7] DISH is a complex disorder that not only affects the musculoskeletal system, but also can cause additional gastrointestinal, respiratory, cardiovascular, and neurological impairments due to bone compression of adjacent structures. [1,4,6,7]
Prevalence
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The reported prevalence of diffuse idiopathic skeletal hyperostosis is widely varied throughout the course of available research.[5] One of the main reasons for this variability is the different locations of structural manifestations in the vertebral column. The recent evidence of DISH reports prevalence of the disease is increased in with increasing age more prominently found in the 60s and 70s.[1,2,3,7] DISH is found to affect the axial skeleton with the thoracic spine (T7-T11), being the most common levels affected.[1,2,4,7] Other structures commonly affected include: pelvis, patella, calcaneus, and the olecranon. [1,4,5] It has also been discussed throughout the research that a genetic component has a possible place in the role of development and diagnosis of the disease. [1,5,7]
Characteristics/Clinical Presentation[edit | edit source]
DISH has been found to be present asymptomatically in most clinical cases. However, due to the varying manifestations and differing locations of the characteristics of the disease, a number of characteristics can be seen in clinical presentations. These characteristics are typically attributed to altered biomechanics of the axial skeleton that lead to pain and decreased mobility. Other symptoms can include, but are not limited to the following characteristics [1-7]:
- Decreased ROM - Primarily in the Axial Skeleton or Peripheral Joints
- Stiffness
- Pain
- Dysphagia
- Respiratory Distress
- Odynophagia
- Cough
- Hoarseness
- Pharyngeal Perforation
- Weight Loss
- Reflux
- Dysphonia
- Horner’s Syndrome
- Aphonia
Associated Co-morbidities[edit | edit source]
DISH has been shown to have a multiple associations with a number of conditions and dysfunctions. One of the most prevalent associations according to recent research is to metabolic syndromes. [1,6] The following conditions are shown to be commonly associated with the diagnosis of DISH across the spectrum of individuals affected.
- Diabetes Mellitus [1-7]
- Obesity [1-7]
- Dyslipidemia [1,3,5,6,7]
- Hyperuricemia [1,3,5,6,7]
- Hyperinsulinemia [1,3,5,7]
- Osteoarthritis [1,3,4,6]
- Cardiovascular conditions including, but not limited to hypertension, atrial fibrillation, left ventricular hypertrophy, peripheral arterial disease, and cardiovascular disease. [1,3]
- Increased Risk of Fracture [1,2,3,6]
- Neurological impairments, while typically uncommon with the presentation of this disease, can manifest in the form of spinal cord compression, muscle weakness, numbness and tingling, and sesory loss. [1,4,7]
Medications[edit | edit source]
Current research does not outline a specific and definitive schedule of medications used to treat DISH. The following medications have been used as a method of control and/or manage the symptoms of the disease process. [1,4,5,6]
- Analgesics
- Anti-Inflammatories
- Muscle Relaxants
- Corticosteroids
- Sedation
- Reflux Medications
- Gastro-Protectants
Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]
The most commonly used classification criteria to diagnose DISH was designed by Resnick and Niwayama in 1976 and includes the following: [1,2,3,5,6,7]
1. Anterolateral ossifications of at least 4 contiguous thoracic segments.
2. Preservation of intervertebral disc spaces.
3. Absence of apophyseal joint degeneration or SI inflammatory changes.
A formal diagnosis of DISH does not require or mandate the presence of constitutional and metabolic abnormalities; however, it is known through numerous studies that systemic conditions are associated with DISH in varying degrees. [2,3,5,6,7]
Specific features shown either through a radiograph, MRI, or CT scan in patients who are diagnosed with DISH could include a few of the following and not all are required to be seen to have the diagnosis of DISH [1,2,3,5,7]
1. Spinal Features [2]
- Flowing ossification along the anterior or right anterolateral aspects of at least 4 consecutive vertebrae
- Well preserved disc space
- No inflammation at sacroiliac joint or facet joint ankylosis
2. Extraspinal Features [2]
- Enthesopathies, which is a disorder involving attachment of tendon or ligament to bone at the entheses, are commonly seen in the iliac crest, ischial tuberosity, and greater trochanters.
- Spur formation in appendicular skeleton seen at the olecranon process, patellar ligament, and calcaneus.
Etiology/Causes[edit | edit source]
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Systemic Involvement[edit | edit source]
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Medical Management (current best evidence)[edit | edit source]
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Differential Diagnosis[edit | edit source]
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