DIFFUSE IDIOPATHIC

SKELETAL HYPEROSTOSIS
03 NOVEMBER
• also known as Forestier disease, is a common condition characterised
by bony proliferation at sites of tendinous and ligamentous insertion
of the spine affecting elderly individuals.
• ypically characterised by the flowing ossification of the anterior
longitudinal ligament involving the thoracic spine and enthesopathy
(e.g. at the iliac crest, ischial tuberosities, and greater trochanters)
• no involvement of the sacroiliac synovial joints
• flowing bridging anterior osteophytes spanning at least four vertebral
levels, with normal disk spaces and sacroiliac joints
• affects the elderly, especially 6th to 7th decades.
• The estimated frequency in the elderly is ~10%, with a male
predominance.
• commonly identified as an incidental finding when imaging for other
reasons. However, spine stiffness and decreased mobility are referred
to as possible symptoms.
Associations

• Recognised associations include:

• ossification of the posterior longitudinal ligament, which may be a

cause of spinal stenosis
• hyperglycaemia
• approximately one-third of patients test positive for HLA-B27
• The cervical and thoracic (particularly T7-11) spines, in particular, are
affected.
• enthesopathy may be identified in the pelvis and extremities
Plain radiograph and CT
Spinal features
 flowing ossifications: florid, flowing ossification along the anterior or right 7
anterolateral aspects of at least four contiguous vertebrae
 disc spaces are usually well preserved
• ankylosis is more common in the thoracic than cervical or lumbar spine
• frequently incomplete
• can have interdigitating areas of protruding disc material in the flowing
ossifications
• no sacroiliitis or facet joint ankylosis although sacroiliac joint anterior
bridging, posterior bridging, entheseal bridging may be present 10
Extraspinal features
 enthesopathy of the iliac crest, ischial tuberosities, and greater
trochanters
• spur formation in the appendicular skeleton (olecranon, calcaneum,
patellar ligament) frequently present
• 'whiskering' enthesophytes
• AP radiograph of the pelvis
reveals extensive fluffy or
"whiskering" enthesopathy
of the iliac crests (red
arrows), ischial tuberosities
(yellow arrows), and the
trochanters (black arrows).
Note is also made of
ossification of the iliolumbar
ligament (blue arrow).
Importantly, both sacroiliac
joints appear normal. These
findings are in keeping with
diffuse idiopathic skeletal
hyperostosis (DISH).
Treatment and prognosis
• DISH is generally managed clinically with analgesics and non-steroidal
anti-inflammatory drugs when pain and stiffness are related
• Possible complications may require specific treatment:
acute spinal fractures
• chalk stick fracture
rarely dysphagia caused by mechanical compression due to anterior
cervical bone production 8
DIFFERENTIAL DIAGNOSIS
• ankylosing spondylitis
• syndesmophytes: thinner, form over the annulus, and are vertically orientated ("bamboo spine")
• sacroiliac joint involvement early on and is in the synovial portion (inferior two-thirds)
• osteoporosis is prominent
• degenerative spine disease
• usually has prominent facet and apophyseal joints degenerative changes as well
• disc degenerative changes
• usually, the anterior longitudinal ligament of the thoracic spine is not affected 9
• retinoid arthropathy
• patients using retinoid acid for skin diseases
• skeletal hyperostosis
• predominantly involves the cervical spine
• fluorosis
• fluorite intoxication due to long-term ingestion
• can cause paraspinal ligament calcification
• if seen in a child, consider juvenile idiopathic arthritis (JIA)
• THANK YOU