Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Overview

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is the hardening of tendon and ligaments (calcification) that are connected to the spine. This condition can be eliminated both non-surgically and surgically. Surgical treatments are only required when the spinal cord and/or nerve roots are being compressed or if stability in the spine has been lost and needs repair.

ANATOMY

The spine consists of 33 individual bones (vertebrae) that interlock. The vertebrae are categorized into five regions:

• Cervical
• Thoracic
• Lumbar
• Sacrum
• Coccyx

The cervical and thoracic regions can be found in the upper back and neck. Ligaments (short bands of tough, flexible, fibrous connective tissue that connects two bones or cartilages or holds together a joint) and tendons (the flexible but inelastic cord of strong fibrous collagen tissue attaching a muscle to a bone) are attached to the spine and allow for movement and stability.

DESCRIPTION

Diffuse Idiopathic Skeletal Hyperostosis (DISH), also known as Forestier’s disease, is the hardening of tendons and ligaments (calcification) where they are attached to the spine. Once these tendons and ligaments have hardened, parts of these tissues can turn into bone, resulting in the development of bone spurs (an outgrowth of bone that develops along the edges of the bone).

DISH most commonly affects the upper portion of the back, but can also affect the neck, lower back, shoulders, elbows, knees and heels. Over time, DISH can progress and worsen, resulting in serious complications. While the causes of DISH are unclear, several factors have been linked to the development of this condition. These risk factors include:

• People over the age of 50.
• Conditions such as diabetes, acromegaly, and obesity.
• Long term exposure to high amounts of Vitamin A.
• Metabolic conditions, such as diabetes mellitus, acromegaly, and obesity.
• Abnormalities of fat derived hormones (possibly leptin) and growth hormones.
• Long-term use of medications known as retinoids, such as isotretinoin, which are similar to vitamin A, can increase risks.
• Genetic factors, such as genetic predisposition.

SYMPTOMS

DISH does not always have symptoms. However, if symptoms do occur, they usually develop when the bone spurs begin to compress on the nerves of the spine. These symptoms may include:

• Stiffness (most noticeable in the morning or evening).
• Pain in the back, specifically the upper back.
• Pain in the shoulders, elbows, knees or heels.
• Pain when pressure is applied to the affected area.
• If DISH has affected the neck, difficulty swallowing or hoarse voice may be present.
• Loss of range of motion specifically in the neck or back.
• Tingling, numbness or weakness in the legs.

DIAGNOSIS

Your Florida Orthopaedic Institute physician will take a look your symptoms and perform a physical examination of the spine. Usually, a diagnosis can be made based on the signs and symptoms present. Your physician may also perform various tests to rule out other conditions. These tests include:

• X-ray
• Computed tomography scan (CT scan)
• Magnetic resonance imaging scan (MRI)

TREATMENT (OVERVIEW)

Usually, treatment involves medication as well as physical therapy to help reduce stiffness. Nonsurgical treatments are effective and can help to greatly reduce symptoms. However, if DISH has caused compression of the spinal cord and/or nerve roots, surgery may be necessary. Your Florida Orthopaedic Institute physician will help craft the best treatment plan specifically for you.

NON-SURGICAL TREATMENTS

Your physician will try to decrease inflammation which will help prevent any further calcification from occurring. Non-steroid anti-inflammatory medications such as ibuprofen (Advil, Motrin) and naproxen (Aleve), can be used to both relieve pain and decrease inflammation caused by DISH. Additionally, since there is a connection between DISH and endocrine disorders such as diabetes, addressing the underlying condition can help stop the progression of DISH. Once the inflammation is under control, physical therapy is typically used to help reduce stiffness.

SURGICAL PROCEDURES/TREATMENTS

Surgery may be recommended if:

• The bone spurs begin to compress the spinal cord or nerve roots.
• Dish has resulted in fractures that compress the spinal cord or nerve roots.
• DISH has resulted in any structural problems in the spine.

These problems may be fixed by any of the following procedures:

• Laminectomy. A procedure that removes part of the lamina (the bony roof of the spinal canal) to create more space.
• Laminoplasty. A procedure that creates more space for the spinal cord and nerve roots to relieve abnormal pressure on the spinal cord.
• Corpectomy. A procedure where all or part of the vertebral body is removed, usually as a way to decompress the spinal cord and nerves.
• Discectomy. A procedure where abnormal disc material that presses on a nerve root or the spinal cord is removed.
• Spinal fusion. A procedure where two or more vertebrae are fused together to make the spine more stable.

NEXT STEPS

Talk to your fellowship trained Florida Orthopaedic Institute physician to learn more about DISH and surgical and non-surgical solutions.