Radiological Assessment of DISH in the Lumbar and Lumbosacral Vertebrae of Dogs

Figure: A lateral radiograph of the thoracic spine, left, shows bulky bridging osteophytes (arrowheads) along the anterior thoracic spine involving greater than 4 contiguous vertebral bodies compatible with DISH. A fracture along the inferior endplate of the T8 vertebral body is barely perceptible (arrow). A sagittal CT scan, center, of the thoracic spine shows an acute, minimally displaced fracture of the middle to inferior half of the T8 vertebral body which extends into and widens the disc space (arrow). Note the extent of DISH at levels above and below the fracture. A sagittal CT scan of the thoracic spine, right, further shows the extent of the fracture and intact bulky osteophytes above and below the fracture site (arrow).FigureFigureFigureA 66-year-old man was brought to the emergency department after being in a motor vehicle crash in which he was rear-ended with very low impact. He complained of point tenderness in the lower thoracic spine, and a trauma workup was performed according to routine protocol. Thoracic radiographs showed evidence of bulky bridging osteophytes consistent with DISH (diffuse idiopathic skeletal hyperostosis) but no evidence of a fracture at the site of pain. Further evaluation with CT showed a displaced fracture of the T8 vertebral body, which extended through the disc space. The patient was placed in a brace and managed for non-life-threatening injuries, and was then discharged home. DISH most commonly occurs in the thoracic spine, typically involving T7-T11 levels. Most patients with DISH are discovered incidentally on imaging because they are often asymptomatic. Occasionally, patients can present with pain, postural instability, neurological symptoms, or dysphagia. A DISH diagnosis is typically made on radiography, followed by cross-sectional imaging, namely CT or MRI. It is characterized by the presence of ‘‘flowing’’ bulky ossifications along the anterolateral margin of at least four contiguous vertebral bodies, preservation of the intervertebral disk height without any degenerative-related findings and absence of apophyseal joint ankyloses, or fusion at the costovertebral or sacroiliac joints. Imaging features are characteristic, but the differential diagnosis for DISH include seronegative spondyloarthropathies such as ankylosing spondylitis, reactive arthritis and psoriatic arthritis. Unlike ankylosing spondylitis, fusion of the sacroiliac, facet, and uncovertebral joints do not occur in DISH. Similarly, reactive arthritis has asymmetric sacroiliac joint involvement and psoriatic arthritis has a predilection for the cervical and lower lumbar spine, while DISH occurs most commonly in the thoracic spine. The fused spine in DISH or any preexisting fusion-type condition is more prone to fracture than a normal spine, and these fractures can involve multiple vertebral columns and can occur after even minor trauma. Patients with moderate to severe disease are more prone to fractures. The thoracic and cervical spine are most commonly involved. Hyperextension is the most common mechanism of injury resulting in DISH-related spinal fractures. Acute spinal fractures are not common, but can lead to neurological injury, nonunion, deformity, or death. DISH produces broad bridging osteophytes that encompass the anterior longitudinal ligament, annulus fibrosis, and paraspinal connective tissues. The bridging osteophytes are most robust at the intervertebral disk space, extending to the adjacent vertebral body. The proximal and distal thirds of a vertebral body, therefore, are typically covered by ossifications, leaving the mid-vertebral body above and below the site of attachment of the ossifications most vulnerable to fractures. Alternatively, fractures may occur at the end of a fused segment, involving the vertebral body at the junction of fused and unfused spine. Radiographs of the spine may be initially obtained if fractures are suspected following minor trauma. Fractures may not be easily detected with radiographs in the patients with DISH or any other spinal fusion because of overlapping bone and soft tissues and the presence of productive bone formation. It is therefore reasonable to conclude from this case that a low threshold must be used to order a CT scan of the spine if patients with spinal fusion sustain minor trauma. This will not only assist in making an early and accurate diagnosis but ensure appropriate and timely treatment for patients. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

This study was conducted to compare clinical characteristics and surgical outcomes based on the laterality of diffuse idiopathic skeletal hyperostosis (DISH) with vertebral fracture (VF). We extracted 444 thoracolumbar VF patients in a single center, and 217 patients who underwent balloon kyphoplasty and 159 patients with conservative treatment were excluded. This retrospective study enrolled 68 adult patients who were diagnosed with thoracolumbar VFs that required posterior fusion surgery due to instability. We examined the distribution of DISH on the preoperative whole spine CT images. In particular, we researched the radiographic and clinical characteristics according to the laterality of DISH. We developed a simple grading system (grade 0, no DISH; grade 1, unilateral DISH; grade 2, bilateral DISH≧involving 4 vertebral bodies on both sides). There were 23 DISH patients with VFs, consisting of seven bilateral DISH patients (grade 2) and 16 unilateral DISH patients (grade 1). The ratio of male and lumbar Young Adult Mean index were significantly higher in grade 2 (p < 0.05). The number of contiguous vertebrae was larger in grade 2 than in grade 1 (8.1 ± 3.1 vs. 16.3 ± 2.9, p < 0.001). Among all bilateral DISH patients, DISH extended to the lumbar and was accompanied by other ligamentous unions. The locations of fractured vertebrae in grade 2 were mainly between Th11-L1 (85.7%), and all of them were fractured within the contiguous vertebrae, accompanied by DISH. The present study demonstrated that bilateral DISH was significantly more extensive than unilateral DISH, and the fractured levels of bilateral type were within the contiguous vertebral bodies, accompanied by DISH. On the other hand, there were no differences in surgical outcomes. Our grading system may reflect the radiographic features of DISH with unstable VFs. Further studies with a large number of patients are warranted to provide a better understanding of its validity and reliability. Level of Evidence 2b.

Background Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of unknown cause characterized by ossifications of entheses with spinal and extraspinal manifestations(1). The prevalence ranges from 4% to 35%, depending on the diagnostic criteria (2). An increased risk of vertebral fracture in DISH has been suggested, due to the loss of flexibility of the fused spine, reminiscent of what is observed in ankylosing spondylitis(3–6). Objectives The aim of this study was to prospectively analyze the risk of vertebral fracture in men with DISH, compared with men without DISH. Methods Men older than 50 (n = 782) had coronal and lateral spine radiographs along with DXA and were monitored prospectively. We analyzed the risk of incident vertebral fractures (over 7.5 years) in men with DISH defined by flowing ossification alongside the anterolateral aspect of at least four contiguous vertebral bodies, relative intervertebral disc preservation and the absence of apophyseal ankylosis and inflammatory changes of the SI joints, according to Resnick’criteria (7). Incident vertebral fracture was defined by a decrease of at least 20% or 4 mm in any vertebral height (anterior, central or posterior) between the follow-up and the baseline radiographs. Results DISH was present in 21,7% (170/782) of men (mean age= ). Among the 782 examined at baseline, 761 had at least one spine X-ray after baseline and 164/170 men with DISH had enough available data to be analyzed. Vertebral fracture incidence was higher in men with DISH compared with those without DISH (mean 10/164 (6.1%) vs. 16/597 (2.7%); p Conclusion DISH is associated with higher risk of vertebral fracture, independently of BMD. The risk of vertebral fracture of men with DISH but normal BMD may be underestimated.

DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS: AN INCIDENTAL FINDING ON CBCT RADIOGRAPHIC ASSESSMENT

Diffuse Idiopathic Skeletal Hyperostosis

This was a retrospective multicenter study. To clarify the progression of diffuse idiopathic skeletal hyperostosis (DISH) using whole-spine computed tomography in patients with cervical ossification of the posterior longitudinal ligament (OPLL). DISH and cervical OPLL frequently coexist, and can cause ankylosing spinal fractures due to biomechanical changes and fragility of the affected vertebrae. The epidemiology and pathophysiology of DISH occurring with cervical OPLL are unclear. We used whole-spine computed tomography to determine the prevalence of DISH in 234 patients with a diagnosis of cervical OPLL based on plain cervical radiographs. We established a novel system for grading the progression of DISH based on a cluster analysis of the DISH distribution along the spine. We calculated the correlation coefficient between this grading system and patient age. The prevalence of DISH in patients with cervical OPLL was 48.7%. Patients with DISH were significantly older than those who did not have DISH (67.3 vs. 63.4 y; P=0.005). Cluster analysis classified the DISH distribution into 6 regions, based on the levels affected: C2-C5, C3-T1, C6-T5, T3-10, T8-L2, and T12-S1. DISH was observed most frequently at T3-T10. We defined a system for grading DISH progression based on the number of regions involved, from grade 0 to 6. DISH was distributed at T3-T10 in >60% of the grade 1 patients, whereas most patients with DISH at the cervical or lumbar spine were grade 4 or 5. There was a weak but significant correlation between the DISH grade and patient age. DISH was present in nearly half of the patients with cervical OPLL. DISH was more common in older patients. DISH developed at the thoracic level and progressed into the cervical and/or lumbar spine with age. Level III.

Diffuse idiopathic skeletal hyperostosis (DISH) is a disease characterized by massive, non-inflammatory ossification with intensive formation of osteophytes affecting ligaments, tendons, and fascia of the anterior part of the spinal column, mostly in the middle and lower thoracic regions. However, isolated and predominant cervical spinal involvement may occur. It has predilection for men (65%) over 50 years of age and a prevalence of approximately 15-20% in elderly patients.1 A CT scan is one of the diagnostic tools. The radiographic diagnostic criteria in the spine include: 1) osseous bridging along the anterolateral aspect of at least four vertebral bodies; 2) relative sparing of intervertebral disc heights, with minimal or absent disc degeneration; and 3) absence of apophyseal joint ankylosis and sacroiliac sclerosis.2 We present a rare case of dysphagia over 2 years duration due to DISH.&#x0D; Case Report&#x0D; A 55-year-old Malay man presented with intermittent dysphagia for 2 years duration. He denied foreign body ingestion, globus sensation or any laryngeal trauma, shortness of breath, hoarseness or any neurological deficits. A solitary smooth mass on the right posterolateral pharyngeal wall that was hard in consistency was appreciated on oropharyngeal examination. (Figure 1) There was no significant cervical lymphadenopathy and the neurological examination was unremarkable. Cervical Radiographs and CT scan showed marked ossification at the right anterolateral aspect of cervical vertebral bodies C2 to C7 most probably representing a Diffuse Idiopathic Skeletal Hyperostosis. (Figures 2, 3) He was treated conservatively with 6-monthly follow up.&#x0D; Discussion&#x0D; Diffuse Idiopathic Skeletal Hyperostosis (DISH) is an ossifying diasthesis characterized by the thickening and calcification of soft tissue (ligaments, tendons and joint capsule) resulting in secondary formation of osteophytes. Most commonly it affects the paraspinal ligaments, predominantly the anterior longitudinal ligament and occasionally the posterior longitudinal ligament.2 It was first described as senile ankylosing hyperostosis of the spine by Forestier and Rodes Querol in 1950.3 In 1970 Resnick et al. coined the term DISH for this systemic entity. Radiologically, they established 3-diagnostic criteria which include 1) Presence of flowing ossification of anterior longitudinal ligament of at least four contiguous vertebral bodies, 2) Preservation of intervertebral disc height, and 3) Absence of apophyseal joint ankylosis or sacroiliac joint erosion, sclerosis or fusion.4&#x0D; Cervical anterior osteophytes accompanying DISH are mostly asymptomatic. They may present with cervical pain and stiffness. Large osteophytes however do cause dysphagia and it is the most common presenting complaint, affecting 17 – 28% of patients.5 Many different mechanisms have been suggested as the cause of the dysphagia including mass effect on the esophagus by the osteophytes and neuropathy due to recurrent laryngeal nerve impingement.5,6 According to LIn et al., in addition to distortion of laryngoesophageal anatomy and functions, osteophytes of cervical vertebrae can alter the mechanics of pharyngeal swallowing leading to secondary inflammation and edema of mucosa and soft tissue.6 Although airway symptoms in patients with DISH appear to be rare, clinicians should be aware of this condition and its potential for acute respiratory complications.&#x0D; The etiology of DISH is still unclear, however according to Calisanellerr et al. it may be associated with excessive mechanical stress, hyperlipidaemia, increased levels of insulin with or without diabetes mellitus, increased levels of insulin-like growth factor-1 and hyperuricaemia.7 A positive HLA–B8 has also been reported, and hypervascularity may also play a role in the etiopathogenesis of DISH.7,8,9&#x0D; Differential diagnosis of DISH includes ankylosing spondylitis, spondylosis deformans, osteoarthritis and esophageal malignancies where it should be considered when the dysphagia cannot be explained by small anterior osteophytes.5&#x0D; Treatment can be divided into conservative treatment with dietary modification, swallowing therapy sessions and analgesia for early stages of mild dysphagia. Chiropractic treatment and acupuncture are popular alternatives among patients. The benefit of chiropractic therapy may lie in its role in increasing range of movement of the spine and providing pain relief.10 When conservative treatment fails, surgical interventions such as osteophytectomy, tracheotomy and feeding tube insertion are indicted. Surgical excision via perioral transpharyngeal route for C1 and C2 vertebrae or anterior cervical approach for C3 to C7 vertebrae is preferred.6,11 The aim of the surgery is to provide satisfactory decompression of the esophagus.6 Recent studies have shown that patients treated surgically with osteophytectomy had marked improvement, if not complete resolution, of their upper aerodigestive disturbances.11 It should be remembered that surgical interventions harbor the risk of recurrent laryngeal nerve injury, Horner’s syndrome, cervical instability, persistent symptoms, and recurrence.11&#x0D; Dysphagia caused by diffuse idiopathic skeletal hyperostosis is an uncommon entity. Radiological evaluation specifically CT scans are diagnostic and can rule out other possible causes of oropharygeal mass. Surgical decompression may relieve the dysphagia when conservative treatments fail.&#x0D;

Increased Bone Mineral Density in Cervical or Thoracic Diffuse Idiopathic Skeletal Hyperostosis (DISH): A Case-Control Study

To determine outcome and prognostic factors in small breed dogs in which hemangiosarcoma was diagnosed and whether outcomes differed between small and large breed dogs with splenic hemangiosarcoma. Bi-institutional retrospective study. Forty-three small breed (<20 kg) and 94 large breed client-owned dogs. Medical records were reviewed to identify dogs treated with splenectomy for splenic hemangiosarcoma. Data acquired included signalment, preoperative staging, bloodwork results, surgical findings, histopathologic findings, administration of chemotherapy, presence/absence of metastatic disease, and survival time (ST). Cox proportional hazards regression analysis was performed to assess prognostic factors associated with survival. The overall median ST was 116 days and 97 days for small and large breed dogs, respectively. The ST for dogs treated with surgery and chemotherapy was 207 and 139 days for small and large breed dogs, respectively. The disease-free interval (DFI) was 446 and 80 days for small and large breed dogs, respectively. Dog size was associated with DFI (P = .02) but not with ST (P = .09). The presence of metastasis at diagnosis was associated with decreased ST in small (P = .03) and large (P = .0009) breed dogs. Administration of chemotherapy (P = .02) was associated with increased ST (P = .02) in small breed dogs. The ST was not different in small and large breed dogs with splenic hemangiosarcoma treated with splenectomy and chemotherapy. Prognosis remains poor despite aggressive therapies in small and large breed dogs.

Study Design:Retrospective case-control studyObjectives:To determine whether diffuse idiopathic skeletal hyperostosis (DISH) can be diagnosed based on anterior longitudinal ligamental ossification in the lumbar spine using plain lumbar spine X-ray images.Methods:This study included 100 patients (59 men and 41 women; mean age, 64.8 ± 13.8 years; range, 27-89 years) who underwent computed tomography (CT) of the chest to the pelvis in our hospital and plain lumbar spine radiography within 6 months before and after CT scanning. DISH was diagnosed based on the thoracolumbar spine CT findings using Resnick’s diagnostic criteria. The patients were grouped according to DISH diagnosis into the DISH (+) and DISH (−) groups. On the frontal and lateral lumbar spine X-ray images, each spinal level from Th11/12 to L5/S was scored based on the Mata scoring system. The distribution of the Mata scores was compared between the 2 groups.Results:Forty (40%) patients were diagnosed with DISH based on the CT findings. A cutoff value ≥8 provided a sensitivity of 75% and specificity of 100% for diagnosing DISH, thus, indicating the validity of the cutoff value. In the DISH (−) group, no patient had ≥3 consecutive spinal levels with a Mata score ≥2, suggesting that DISH can be diagnosed on the basis of at least 3 consecutive spinal levels with a Mata score ≥2.Conclusion:On lumbar spine X-ray images of the T11/12 to L5/S levels, a Mata score ≥2 for at least 3 consecutive levels or a total score ≥8 strongly indicates the presence of DISH.

BackgroundDifferentiating between degenerative disc disease (DDD), diffuse idiopathic skeletal hyperostosis (DISH), and axial spondyloarthritis (axSpA) represents a diagnostic challenge in patients with low back pain (LBP). We aimed to evaluate the distribution of inflammatory and degenerative imaging features in a real-life cohort of LBP patients referred to a tertiary university rheumatology center.MethodsIn a retrospective cross-sectional analysis of patients referred for LBP, demographics, symptom information, and available imaging were collected. SpA-like changes were considered in the spine in the presence of one of the following lesions typically related to SpA: erosions, sclerosis, squaring, and syndesmophytes on conventional radiographs (CR) and bone marrow oedema (BMO), erosions, sclerosis, and fat lesions (FL) on MRI. SIJ CR were graded per New York criteria; on MRIs, SIJs were evaluated by quadrant for BMO, erosions, FL, sclerosis and ankylosis, similar to the approach used by the Berlin SIJ MRI scoring system. The final diagnosis made by the rheumatologist was the gold standard. Data were presented descriptively, by patient and by quadrant, and compared among the three diagnosis groups.ResultsAmong 136 referred patients, 71 had DDD, 38 DISH, and 27 axSpA; median age 62 years [IQR55-73], 63% males. On CR, SpA-like changes were significantly higher in axSpA in the lumbar (50%, vs. DDD 23%, DISH 22%), in DISH in the thoracic (28%, vs. DDD 8%, axSpA 12%), and in DDD in the cervical spine (67% vs. DISH 0%, axSpA 33%). On MRI, BMO was significantly higher in DISH in the thoracic (37%, vs. DDD 22%, axSpA 5%) and equally distributed in the lumbar spine (35-42%). FL were significantly more frequently identified in DISH and axSpA in the thoracic (56% and 52%) and DDD and axSpA in the lumbar spine (65% and 74%, respectively). Degenerative changes were frequent in the three groups. Sacroiliitis (NY criteria) was identified in 49% (axSpA 76%, DDD 48%, DISH 29%).ConclusionA significant overlap was found among DDD, DISH, and axSpA for inflammatory and degenerative imaging features. Particularly, SpA-like spine CR features were found in one-fourth of patients with DISH, and MRI BMO was found in one-third of those patients.

BackgroundDegenerative changes of the spine (DC), diffuse idiopathic skeletal hyperostosis (DISH) and radiographic axial Spondyloarthritis (r-axSpA) may present with overlapping inflammatory and degenerative findings on imaging, which, next to the...

Diffuse Idiopathic Skeletal Hyperostosis (DISH) [1] also known as Forestier disease, is a noninflammatory, systemic skeletal disease of unknown aetiology. DISH is a common but underdiagnosed disease that is usually observed in elderly people and has been reported to affect up to 10% of patients over 65 years of age [2]. The diagnosis is primarily radiological characterised by the ossification of the anterior longitudinal ligament, with osteophytes formation along the spinal column of at least four contiguous vertebral bodies, a minimal degree of degenerative disc disease and absence of apophyseal joint ankylosis and sacroiliac joint fusion, erosions, or sclerosis [3]. DISH is usually asymptomatic but may compress the posterior wall of the aero digestive tract and lead to dysphagia, globus, hoarseness, stridor, dyspnea and neurological problems. Although dysphagia is not uncommon among the presenting symptoms of DISH, dysphonia and stridor are rarely reported. Cervical hyperostosis in patients with DISH is responsible for 17%-28% incidence of dysphagia, and about 8% of patients failed to respond to conservative treatment and surgical excision through an anterior cervical approach was required [3]. Many studies have been conducted on the surgical approach [4] and anaesthetic evaluation of patients with DISH [5]. Less known are the difficulties in weaning from the tracheostomy tube in these patients, especially when the diagnosis of DISH is unknown.

PurposeThis study compared Hounsfield unit (HU) values on computed tomography (CT) scans at fractured sites and each vertebral level of the whole spine among three groups: individuals with diffuse idiopathic skeletal hyperostosis (DISH), young individuals without DISH, and older individuals without DISH.MethodsA total of 71 patients with thoracolumbar fracture treated at our hospital from 2011 to 2022 were enrolled. Patients were divided into three groups: those with DISH (22 cases), young without DISH (Y non-DISH; age < 50 years, 24 cases), and older without DISH (O-non-DISH; age ≥ 50 years, 25 cases). The total spine HU values from C2 to S1 were measured from CT axial images, as follows: C2-C6, cervical spine; C7-T4, upper thoracic spine; T5-T9, lower thoracic spine; T10-L2, thoracolumbar spine; and L3-S1, lumbar spine. We compared (1) the HU values between fractured and non-fractured sites in each group (2) the HU values by site within each group, and (3) the HU values at each vertebral level of the whole spine between the three groups.ResultsIn all groups, the mean HU values were significantly higher in the cervical spine than in the other regions (p < .05) and HU values increase at the fracture site (p < .05). The mean HU values for the lower thoracic, thoracolumbar, and lumbar spine were not significantly different in each group. The mean HU values below T6 were significantly lower in the DISH and O-non-DISH groups than in the Y-non-DISH group (p < .05). The mean HU values, except at T3, did not differ significantly between the DISH and O-non-DISH groups.ConclusionAmong patients with thoracolumbar injuries, spinal HU values were lower in older patients with and without DISH than in younger patients.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12891-025-09382-5.

The prevalence and characteristics of diffuse idiopathic skeletal hyperostosis in the community-living middle-aged and elderly population: The Yakumo study