Diffuse Idiopathic Skeletal Hyperostosis :Causes-Symptoms-Diagnosis-Treatment

What is Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

Diffuse idiopathic skeletal hyperostosis (DISH)could be a skeletal disorder that causes ligaments and tendons within the body to calcify (harden). These calcified areas also can kind bone spurs (abnormal new bone growth) that may cause pain, stiffness, and remittent mobility.

whereas DISH sometimes affects the spine, it can also occur in different areas throughout the body. DISH is a sort of arthritis. It's also referred to as Forestier’s disease.

What is Diffuse Idiopathic Skeletal Hyperostosis (DISH)?
Diffuse Idiopathic Skeletal Hyperostosis (

DISH is a systemic condition that typically affects the spine and can cause back pain and stiffness. Resnick et al. originally coined the term DISH to describe this condition. The term "disorder of the spine" was first used in 1975 and is now the most commonly used term to describe this condition in the medical literature. The ossifications are typically described as flowing ossifications along the anterolateral aspect in at least three places. The DISH disease most commonly affects the right side of the thoracic spinal segment. This activity reviews the causes of the DISH disease, which often affect levels or vertebrae in a sequence from the base of the spine to the top. The evaluation and management of diffuse idiopathic skeletal hyperostosis is a complex process that requires the involvement of a team of professionals.

  1. Musculoskeletal system

  1. Human skeleton

  2. Joints

  3. Ligaments

  4. Muscular system

  5. Tendons

Medical terms

  • Diffuse idiopathic skeletal hyperostosis (DISH) is a bony hardening of ligaments in areas wherever they attach to your spine. conjointly called Forestier' disease, this condition may not cause symptoms or need treatment. If it will cause symptoms, the foremost common are gentle to moderate pain and stiffness in your higher back. DISH may have an effect on your neck and lower back, and a few individuals have DISH in different areas, corresponding to shoulders, elbows, knees and heels. DISH may be progressive. because it worsens, it can cause serious complications. 
  • Diffuse idiopathic skeletal hyperostosis (DISH) is a diagnostic category that refers to the finding of widespread dense calcification of ligamentum flavum in patients without any other findings of rheumatoid arthritis The prevalence has been estimated at 40-60% in the population over age 65 years with a higher prevalence among men than women.
  • Diffuse idiopathic skeletal hyperostosis (DISH) is a form of pathological bone overgrowth in which the patient suffers from pain due to excess growth of bone tissue in the joints and spine; it does not cause any systemic problems Although it is commonly referred to as DISH there are other similar conditions that are more accurately termed diffuse idiopathic skeletal hyperostosis.
  • There is not a lot of information about DISH in the medical field. DISH is rarely seen in patients younger than 50 years old. The incidence of DISH in the general population is 6 to 12%. In older people, DISH occurs in about 25% of males. The disease is more common in women than in men, and it affects more people over the age of 80. The rates of prevalence are 28% for women and 26% for men. Currently, postulations are that the disease begins between the third and fifth decade of life, but it can present clinically later on.
  • In autopsy studies, DISH was found in approximately one-fourth of the specimens with a mean age of 65 years (50 years is the minimum age). Population-based studies have also shown an overall prevalence rate that ranges from 2.5% to 28%. There is an incremental increase in age and a gender preference that favors DISH diagnosis in males compared to females. Additionally, DISH may be more common in the white population than black Asian or Native-American populations.
  • There is a discrepancy between the DISH prevalence rates that are diagnosed via computed tomography scans (a type of imaging that uses X-rays) compared to radiographs alone. In the general population in Japan, the DISH prevalence rate was 17.6% and 27.2%.
  • Dish is most commonly found on the right side of the thoracic region. The literature supports the original theory that predicts a protective effect and a mechanical barrier preventing dish formation on the opposite side of the thoracic spine, due to the pulsatile descending blood flow. The aorta (heart artery) is different in people with DISH presentations in different parts of the spine. Recent studies have shown this definitively.
  • For example, a study from 2017 found that new bone formation in the cervical spine occurred mostly anterior to the vertebrae, in contrast to the pattern seen in DISH (disharmony of the spine), which is most common in the thoracic spine. A plausible explanation for this difference is still unknown. The ossification patterns discussed concern the regional arterial anatomy. Supporting the theory that a pulsatile mechanical barrier protects the body is highlighted by studies noting that patients with situs inversus (a disorder in which the baby's spine is reversed) have DISH (discovered images on x-rays) on the left side of their thoracic spine. Finally, both the cervical and lumbar spines are mentioned. Researchers studying DISH have found symmetrical patterns of non-marginal syndesmophyte ossification.

DISH can lead to pain in the nerve or bones. This can cause acute monoarticular synovitis, a limited range of motion in the spine, dysphagia (a problem with swallowing), polyarticular pain, spinal or extremity pain, and an increased risk of unstable spine fractures.

Some people with DISH (disseminated intravascular coagulation) may be asymptomatic, meaning the disease is not noticed until later. When neuropathy or bony overgrowth occurs, it can cause pain.

The diagnostic criteria for DISH (Dyslexia Identification and Severity of Handwriting) have previously included three major elements:

  • At least four vertebrae must be present that are surrounded by flowing ossifications (cartilage).

  • The discs in the spine did not decline significantly, and the height of the discs remained unchanged.

    • This passage explains how DISH (differentiated spondylosis) is different from degenerative spondylosis.

  • The absence of ankylosis at the joint interface and the lack of erosion or fusion of the sacroiliac joint are good signs.

    • This passage distinguishes DISH from ankylosing spondylitis (AS).

The current widespread definition of DISH (disfigurement, signs and symptoms) by Resnick and Niwayama is being challenged as these criteria may be best applied to the more advanced stages of the condition. Moreover, dating back to 1985 Utsinger had challenged the contemporary definition and advocated for a lower threshold for diagnosing DISH. Spinal involvement is considered when two contiguous vertebrae are involved, as well as the presence of peripheral enthesopathies (nodes or lesions on the outside of the spine).

Some people have questioned the validity and consensus agreement of the current level of support for these specific criteria. A 2013 Delphi exercise found that there may only be consensus agreement for the following elements:

  • The areas mentioned have been seen to exhibit vigorous new bone growth.

  • If you see enlarged bony bridges on either the C-spine T-spine or L-spine, this could be a sign of a spinal injury.

Differentiating DISH from AS

Healthcare providers are often confused about the differences between DISH and AS. In general, the main distinguishing features between DISH and AS can be summarized as follows: DISH is a disorder that affects the spine, while AS affects only one side of the body. DISH is more common, and it typically occurs in people over the age of 40. AS usually affects younger people. DISH causes pain on one side of the body, while AS does not always cause pain.

  • The older the presentation, the more likely it is that DISH will be the most appropriate type of surgery.

  • If there are no erosions on the sacroiliac joint favoring the dish over as, this means that the child is likely to have a good outcome.

    • It is important to recognize the overlap between conditions that can be associated with the SI joint, such as osteophytes in DISH patients.

  • The absence of apophyseal joint obliteration is favorable for DISH over AS.

  • Anterior longitudinal ligament (ALL) is often ossified.

  • There are no enthesopathies (abnormalities in the plant's vascular system) with erosions (dissolution of tissue) favoring DISH (dish disease) over AS (apple scab).

  • There is no association between HLA-B27, which favors DISH over AS, and the outcome of the transplant.

  • Dish compared to AS is a relatively mild or painless disease.

    • The clinical symptoms are mild in comparison to the more extensive radiographic or advanced imaging methods.

    • Dish is often discovered incidentally in asymptomatic patients.

The classic clinical presentation of an older patient with increasing back pain and stiffness is still the same--a person with this condition may have difficulty breathing, experience sleep apnea, and have soft tissue involvement in the neck or upper back. It is important to evaluate a patient with acute back pain for complications such as difficult intubation. If the problem is not resolved with a simple evaluation, or if the patient has symptoms of both an acute and chronic condition, further evaluation may be necessary with a swallow study or consultation to an ear, nose, and throat specialist (ENT). Especially in elderly patients, increased clinical suspicion is warranted when presenting with back pain. All patients who have undergone vertebral fusion require a thorough comprehensive neurovascular exam. This includes checking for any fractures that may have occurred. The x-ray should image the entire spine to lessen the risk of overlooking fractures in adjacent spinal regions.

Some features of peripheral joint involvement in DISH are specific:

  • The use of osteoarthritis-fighting supplements might involve joints that are typically unaffected by primary OA.

    • Foot and ankle involvement is common among patients.

      • Clinical and radiographic findings are often consistent with heel spurs, Achilles tendonitis, and plantar fasciitis.

  • This passage indicates that there have been increased changes in the tissue of someone with primary osteoarthritis compared to someone who does not have the disease.

  • There are enthesopathies (inflammatory lesions) near joints nearby.

  • Entheses (the connective tissues that hold bones together) can calcify and harden in other places besides the joints.

Some peripheral findings may include increased bone density and tendonitis. Hyperostosis and tendon formations have been reported in the pelvis, hip, knee, shoulder, elbow, and wrist.

Laboratory values (such as erythrocyte sedimentation rate and C-reactive protein) are often normal in DISH patients. Radiographic evaluations (such as AP and lateral spine imaging) of DISH patients demonstrate "flowing candle wax," which describes the lack of evidence of inflammation on these scans. The syndesmophytes that project horizontally from the vertebrae are distinctive from the vertical "bamboo spine" that forms intra-articular disc space ossification in AS.

The increased radiodensity preservation of facet joints and disc spaces on spine imaging helps to distinguish DISH from AS, which may present with osteopenia and degenerative changes. The association between DISH and low bone density remains controversial in the literature, but it is still a valid diagnosis. There is a theoretical clinical association between low energy mechanisms and increased risk for vertebral fractures. In the setting of osteoporosis, patients may present with compression fractures while merely lying in bed in a nursing home. Some vertebral fractures have been reported in patients who have DISH (dyslexia), following elective unrelated surgeries. One report from 2012 highlighted a patient who became paralyzed after having a routine total hip replacement.

In cases where the clinician has a low threshold for obtaining chest or thoracic spine radiographs, even in patients with primary neck or low back pain, it is important to establish a diagnosis of DISH. If an imaging test (like a bone scan) suggests that there may be a problem, it may help to prevent additional testing and surgery. However, this finding may be confusing in non-traumatic cases and so is not always helpful. It is important to evaluate a person's involvement radiologically at the lumbar spine and pelvis in order to determine if they have sacroiliac pathology. This will direct the diagnostic workup toward other possible conditions, such as seronegative spondyloarthropathies.

In patients with DISH, minor injuries may result in fractures and instability. These can commonly lead to missed injuries that cause neurological problems and delayed treatment. Fractures in these patients must be evaluated using advanced imaging (such as a CT MRI or CT myelogram). Plain radiographs may be used to evaluate extraspinal complaints in patients with DISH.

Is DISH a form of arthritis?

DISH is not a form of arthritis It's a term that describes severe joint pain and swelling in joints usually affecting one or two joints at a time The symptoms tend to be worse in the morning and can last for years The cause of DISH is unknown; it's possible that people who get it have unusually sensitive immune systems that respond to an infection by attacking healthy tissue within the joint.

Symptoms Diffuse idiopathic skeletal hyperostosis (DISH)

Patients with DISH who sustain spine fractures are at increased risk of instability because of ligamentous calcification and increased deforming forces due to vertebral ankylosis. Often, longer instruments are needed to accommodate the lever arms acting on the fracture site. Surgical treatment for cervical fractures in elderly patients with DISH results in a 15% rate of mortality, compared to 67% after conservative treatment. This demonstrates the importance of prompt diagnosis and treatment after trauma in patients with DISH.

Heterotopic ossification (HO) is a common complication following total hip replacement surgery in patients with DISH (30 to 56%).[42][43] In contrast, patients without DISH in the cited study had a 10 to 22% rate of HO.[42][43] Fahrer et al. reported low rates of pain and functional impairment following THA in these patients. There are some limitations to the use of prophylaxis against HO in patients with DISH after undergoing THA.

You would possibly not have any signs or symptoms with DISH. For people who have signs and symptoms, the higher portion of the rear is most typically affected. Signs and symptoms might include:

  • Stiffness. Stiffness may be most noticeable in the morning.

  • Pain. You might feel pain in your back or in other affected areas, such as your shoulder, elbow, knee or heel.

  • Loss of range of motion. You might notice this most when stretching side to side.

  • Difficulty swallowing or a hoarse voice. You might have these if you have DISH in your neck.

When to see a doctor

Make a rendezvous together with your doctor if you've got persistent pain or stiffness in any joint or in your back.

Causes Diffuse idiopathic skeletal hyperostosis (DISH)

Scientists have found an association between DISH (dishwashing) and metabolic disorders, such as diabetes, obesity, dyslipidemia, and hyperuricemia. While this connection has been suggested in the literature, the cause and effects of this link are still being studied. The proposed mechanism that contributes to these characteristic ossification patterns remains disputed. Some authors have attempted to describe underlying causes related to mechanical stress and strain patterns, exposure to various toxic factors, and genetic contributions. A common investigative pathway that, in theory, provides a plausible link between DISH and various clinical manifestations. For example, carotid atherosclerosis and DISH are more commonly linked in patients with metabolic syndrome. Furthermore, higher rates of DISH correlate with metabolic syndrome. Aortic valve sclerosis is an independent risk factor that predicts cardiovascular events in patients with DISH.

DISH is caused by the buildup of calcium salts in the ligaments and tendons and a hardening and overgrowth of bone. But what causes these to occur is unknown.

Risk factors Diffuse idiopathic skeletal hyperostosis (DISH)

Doctors have some idea of what can increase your risk of the condition. Risk factors include:

  • Sex. Men are more likely to develop DISH.

  • Older age. DISH is most common in older adults, especially in people older than 50.

  • Diabetes and other conditions. People with two polygenic disorders can be additional probably to develop DISH than are those that don't have diabetes. alternative conditions which will raise hypoglycemic agent levels in your body may additionally increase your risk, as well as hyperinsulinemia, prediabetes and obesity. 

  • Certain medications. Long-term use of medicines referred to as retinoids, akin to isotretinoin (Amnesteem, Claravis, others), that are accustomed to treat skin conditions such as acne, will increase your risk. 

Complications Diffuse Idiopathic Skeletal Hyperostosis

People with DISH are at risk of certain complications, such as:

  • Disability. Loss of vary of motion within the affected joint will build it tough to use that joint. For instance, DISH in your shoulder can make it difficult to use your arm. 

  • Difficulty swallowing. Bone spurs within the neck can place pressure on your esophagus. The pressure from bone spurs may also cause a cacophonous  voice or sleep apnea, a disorder during which you stop breathing repeatedly throughout sleep. Rarely, this could become serious and may need surgery to get rid of the bone spurs. 

  • Spinal fracture. DISH will increase your risk of breaking bones in your spine, particularly if you've got moderate to severe disease. Even minor injuries can cause fractures. Breaks would possibly need surgery to repair. 

Diagnosis Diffuse idiopathic skeletal hyperostosis (DISH)

To determine whether or not you have got DISH, your doctor would possibly begin with a physical examination of your spine and joints. He or she's going to press gently on your spine and joints to condole with abnormalities and check your vary of motion. Your doctor will order imaging tests, corresponding to X-rays, CT scans or MRIs, to see for changes in your spine. 

There are many possible causes of back pain, including stiffness and spondylosis, but it is not limited to these conditions.

  • Ankylosing spondylitis (AS)

  • Spondylosis deformans (SD)

    • A differentiation between DISH and SD is that DISH does not have an association with thoracic ALL ossification.

  • Seronegative spondyloarthropathies

  • Charcot spine

  • Acromegaly

  • Psoriasis

  • Reactive arthritis

  • Pseudogout

  • Hypoparathyroidism

Treatment Diffuse idiopathic skeletal hyperostosis (DISH)

For most patients with isolated back discomfort, the mainstays of treatment include activity modification, physical therapy, and NSAIDs or bisphosphonates.

Surgical decompression and stabilization may be necessary for specific sequelae of the condition, including fracture of the cervical spine, lumbar stenosis, neurologic deficits, or infection.

While there's no cure for diffuse upset skeletal hyperostosis, you'll take steps to scale back pain and stiffness. Treatment is additionally geared toward keeping the condition from worsening and at preventing complications. due to the connection between DISH and conditions equivalent to obesity, endocrine resistance and sort two diabetes, treating those conditions may slow or halt the progression of DISH.


Your doctor would possibly suggest over-the-counter pain relievers, resembling Panadol (Tylenol, others) or nonsteroidal anti-inflammatory (Advil, Motrin IB, others). More-severe pain is treated with steroid hormone injections.


Physical therapy can cut back the stiffness related to DISH. Exercises may additionally increase the variety of motion in your joints. raise your doctor regarding specific exercises you'll do. He or she would possibly refer you to a healer for more guidance.


Surgery may well be required in rare cases once diffuse disorder skeletal hyperostosis causes severe complications. folks that have problem swallowing thanks to giant bone spurs within the neck would possibly want surgery to get rid of the bone spurs. Surgery may additionally  relieve pressure on the funiculus caused by DISH.

Lifestyle and home remedies

To help you manage pain and stiffness and to halt progression of the disease, attempt these self-care measures:

  • Exercise regularly. Regular aerobic exercise, adore walking or swimming, will increase your endurance, keep your body a lot nimble and assist you agitate DISH. speak together with your doctor before beginning an exercise program. 

  • Achieve and maintain a desirable weight. Since blubber is related to DISH, losing weight may facilitate keeping the unwellness from progressing and lower your risk of complications. 

  • Apply heat. Use a heating pad on affected areas of your body to reduce pain. Set the heating pad to low to reduce the risk of burns.

Preparing for your appointment

You're seemingly starting out by seeing your general practitioner or a general practitioner. When Associate in Nursing initial evaluation, your doctor may refer you to a specialist, an appreciative rheumatologist, physiatrist, orthopedic sawbones or neurologist. Here's some data to assist you make preparations for your appointment.

What you can do

Make a list of:

  • Your symptoms and when they began

  • Key medical information, including other conditions you have as well as the names and doses of all medications, vitamins or supplements you take

  • Possible causes of injury to the affected area

  • Questions to ask your doctor

For DISH, some basic questions to ask include:

  • What's the most likely cause of my symptoms?

  • What are other possible causes?

  • What tests do I need?

  • Which treatment do you recommend?

  • What self-care steps can help me manage this condition?

  • Do I need to restrict my activities?

  • How often will you see me for follow-up visits?

  • I have other health conditions. How can I best manage them together?

  • Are there brochures or other materials I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, including:

  • Have your symptoms gotten worse over time?

  • Are your symptoms worse in the morning?

  • Do you have difficulty moving the affected joint?

  • Are you having difficulty swallowing?

  • What, if anything, seems to improve your symptoms?

  • Have you previously taken long-term, prescribed medications, such as for acne or other skin conditions?

General summary

  1. Diffuse idiopathic skeletal hyperostosis (DISH) is a rare disorder that affects the spine DISH was first described in the medical literature in 1943 and is characterized by abnormal bone growth on the back of the vertebrae also known as bony overgrowth The bony overgrowth can result in degenerative changes of the spinal column.
  2. DISH is an uncommon disorder that creates areas of abnormal bone growth in the spine (vertebrae) Most commonly seen in middle-aged and older women DISH is thought to be caused by the breakdown of estrogen In a healthy spine smaller vertebrae fit together tightly like a stack of coins With DISH vertebrae fuse into a single mass and become enlarged The resulting pressure on the spinal cord can cause symptoms such as numbness or weakness in your arms and legs Your doctor may order tests to help confirm a diagnosis of DISH including MRI scans or X-rays with specialized contrast dyes.

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