Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by characteristic ossification patterns that can occur in the spine and peripheral entheses.[rx] DISH most commonly affects the spine and often presents as back pain and stiffness.[rx] Resnick et al. originally coined the term DISH in 1975 and is now the most commonly used term to describe this condition in the literature.[rx] The term is both inclusive and descriptive of the disorder. Forestier and Rotes-Querol initially described the underlying pathology in specimens and a series of 200 patients in 1950, who called it “senile ankylosing hyperostosis.”[rx]
Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterized by abnormal calcification/bone formation (hyperostosis) of the soft tissues surrounding the joints of the spine, and also of the peripheral or appendicular skeleton.[rx] In the spine, there is bone formation along the anterior longitudinal ligament and sometimes the posterior longitudinal ligament, which may lead to partial or complete fusion of adjacent vertebrae. The facet and sacroiliac joints tend to be uninvolved. The thoracic spine is the most common level involved.[rx] In the peripheral skeleton, DISH manifests as a calcific enthesopathy, with pathologic bone formation at sites where ligaments and tendons attach to bone.
The ossifications are classically described in the spine as flowing ossifications along the anterolateral aspect in at least three successive vertebral levels, or four contiguous vertebrae. Although less common, peripheral enthesopathy can occur at the shoulder, elbow, knee, or calcaneus.[rx] DISH in the spine most commonly occurs on the right side of the thoracic spinal segment.
While the etiology remains poorly defined, various risk factors have been identified in the literature, including gout, hyperlipidemia, and diabetes. HLA-B8 is common in both DISH and diabetes mellitus.[rx] As such, high rates of diabetes mellitus, hyperuricemia, and hyperlipidemia have been present in patients with DISH.[rx] Unlike other seronegative spondyloarthropathies, no apparent relationship has been identified between DISH and HLA-B27.
Other Names
Causes of Diffuse Idiopathic Skeletal Hyperostosis
Several recent studies have revealed a significant association between DISH and metabolic disorders, such as diabetes mellitus, hyperinsulinemia, obesity, dyslipidemia, and hyperuricemia.[rx][rx][rx] While these proposed clinical associations have been suggested in the literature, the pathogenesis and proposed mechanism contributing to these characteristic ossification patterns remain debatable. Some authors have attempted to describe underlying causes related to mechanical stress and strain patterns, exposure to various toxic factors, and genetic contributions.[rx] Further, angiogenesis remains a relatively popular investigative common denominator that, at least in theory, provides a feasible pathophysiologic linkage in various clinical manifestations of DISH. For example, carotid atherosclerosis and DISH correlate at higher rates in patients with metabolic syndrome. Furthermore, higher prevalence rates of aortic valve sclerosis have been previously identified as an independent risk factor predicting cardiovascular events in patients with DISH.[rx]
Here are the main causes of the problem
DISH is caused by the buildup of calcium salts in the ligaments and tendons and the hardening and overgrowth of bone. But what causes these to occur is unknown. DISH is caused by the build-up of calcium salts in the tendons and ligaments (calcification) and abnormal new bone growth (ossification) but the reason this happens is unknown. Researchers believe some combination of mechanical, genetic, environmental, and metabolic factors are involved. DISH is more common in people over 50 and in men. While there is no known cure for DISH, there are treatments that can help control symptoms.[rx][rx][rx][rx]
- Process of The Ageing – As the human body ages, it hardens. The same happens with the discs too. And Age is not just the number here. Age means the speed of wear and tear in the vertebral body. How fast this wear and tear happens that is our age. Simply this is carelessness that ages us faster than our years.
- Underlying diseases – There are certain diseases of diffuse idiopathic skeletal hyperostosis that cause problems of aging. Generally, these are the diseases that impact the blood supply.
- Postural Problems – The spine has its own curvature that causes diffuse idiopathic skeletal hyperostosis. This curvature is known as lordotic curvature. Lordotic curvature ensures flexibility of the spine and also gives space to the discs when we bent and move our spine. When this curvature straightens- it exerts pressure on the cartilages. Problem with the ENDPLATES impacts the blood supply. And lack of nutrition turns into the desiccation of the disc and causes diffuse idiopathic skeletal hyperostosis.
- Excessive Weight Loss – When we shed weight, this is not just about our tummy or hips. It impacts deeper tissues too.
- Trauma and Injury – Any sudden trauma can lead to the problem of desiccation. This happens due to injury to the tissues.
- Vertebral Instability – This is usually secondary to an inciting event or gradual progression of degenerative disease and diffuse idiopathic skeletal hyperostosis. Patients will have their spine evaluated by laxity or surrounding muscles and stabilization techniques.
- Scheuermann Disease – Scheuermann disease is a juvenile condition usually occurring before puberty where kyphotic changes become present.
- Ankylosing Spondylitis – AS is an inflammatory condition usually associated with other systemic disorders such as psoriasis, inflammatory bowel disease, diffuse idiopathic skeletal hyperostosis, and reactive arthritis. X-ray findings are also unique to this condition and help diagnose the condition.
- Osteoporosis – Osteoporosis is a progressive degenerative disease of loss of bone mineralization evident throughout all bones in varying degrees. Bone scan, X-ray, and MRI can help diagnose and qualify these findings.
- Vertebral Fracture – Fractures can also cause kyphosis, diffuse idiopathic skeletal hyperostosis through an inciting traumatic event, or even cancer-causing the loss of bone integrity. Proper history and medications will help delineate the etiology of the kyphosis.
- Location – The cervical and thoracic (particularly T7-11 ) spines, in particular, are affected. Additionally, enthesopathy may be identified in the pelvis and extremities.
Causes with Risk Factors
- ankylosing spondylitis
- syndesmophytes: thinner, form over the annulus, and are vertically oriented (“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)
Symptoms of Diffuse Idiopathic Skeletal Hyperostosis
You might have no signs or symptoms with DISH. For those who have signs and symptoms, the upper portion of the back is most commonly affected. Signs and symptoms might include
- Weakness Stiffness
- Reduced or painful movements
- Numbness in the legs or feet
- Burning or tingling sensation, especially in the back region
- Change in the knee and foot reflexes
- Loss of range of motion
- Tingling, numbness, and/or weakness in the legs
- Spinal fractures and increased risk of breaking other affected bones
- Compressed or pinched nerves (radiculopathy)
- Compressed spinal cord (myelopathy) can lead to partial or complete paralysis of the legs and/or arms (paraparesis, tetraparesis)
- Difficulty swallowing (dysphagia)
- Hoarse voice or difficulty speaking (dysphonia)
- Sleep apnea
- Decreased lung capacity (if DISH affects the ribs)
- Difficulty breathing possibly due to airway obstruction
- Sciatica (pain caused by the irritation of the sciatic nerve)
- Stiffness in the back is the most common symptom, which appears in the early stage of the disc that may diffuse idiopathic skeletal hyperostosis.
- Problems in standing for long When a patient stays in a posture for long, it leads to pain and uneasiness and that may indicate diffuse idiopathic skeletal hyperostosis.
- Pain in the lower back
- Radiation of pain in lower limb
- Feeling of heaviness in back.
- Loss of range of motion might notice this most when stretching side to side.
- Difficulty swallowing or a hoarse voice might have these if you have DISH in your neck.
Diagnosis of Diffuse Idiopathic Skeletal Hyperostosis
A physical exam for diagnosing disc pain may include one or more of the following tests
- Palpation – Palpating (feeling by hand) certain structures can help identify the pain source. For example, worsened pain when pressure is applied to the spine may indicate sensitivity caused by a damaged disc, diffuse idiopathic skeletal hyperostosis, and disc desiccation.
- Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a disc desiccation lumbar herniated disc (straight leg raise test), diffuse idiopathic skeletal hyperostosis.
- Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by diffuse idiopathic skeletal hyperostosis. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
- Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine, disc desiccation.
Lab Test
- A medical history – in which you answer questions about your health, symptoms, and activity.
- A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
- Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
- Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
- Elevated CRP – levels are associated with infection.
Imaging
- X-rays – view the bony vertebrae in your spine and can tell your doctor if any of them are too close together or whether you have arthritic changes, bone spurs, diffuse idiopathic skeletal hyperostosis, or fractures narrowing of the spinal canal. It’s not possible to diagnose diffuse idiopathic skeletal hyperostosis disc desiccation with paracentral disc herniation in this test alone.
- Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with disc desiccation, diffuse idiopathic skeletal hyperostosis, and paracentral disc herniation. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression disc desiccation, diffuse idiopathic skeletal hyperostosis. It can also detect bony overgrowth, spinal cord tumors, abscesses, or narrowing of the spinal canal.
- A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, a bulging disc paracentral disc herniation, disc desiccation in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, narrowing of the spinal can spinal cord tumors, disc desiccation, and abscesses.
- Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc and narrowing of the spinal canals are damaged.
- Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc, disc desiccation, paracentral disc herniation.
- Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure. Electrodiagnostic evidence of fibrillation potentials and the absence of a tibial H-wave may aid in further confirming the diagnosis of lumbar canal stenosis and disc desiccation.[rx]
Treatment of Diffuse Idiopathic Skeletal Hyperostosis
Non-Pharmacological
- Exercise and physical therapy – These are essential for getting back pain under control and improving stiffness and range of motion. Swimming is especially beneficial because it provides a full-body workout without the risk of injury. Physical therapy can reduce the stiffness associated with DISH. Exercises might also increase the range of motion in your joints. Ask your doctor about specific exercises you can do. He or she might refer you to a physical therapist for further guidance.
- Heat – This can help relieve early-morning pain and stiffness.
- Weight and blood sugar control – Because DISH is often associated with obesity and diabetes, keeping your weight and blood sugar in a healthy range is key. Treating these conditions is the closest thing to a cure for DISH.
- Orthotics (special shoe inserts) – These may make walking easier if you have bone spurs on your heels.
- Stay hydrated – Not drinking enough water each day can cause the body to function less well or not retain enough water, including the discs and diffuse idiopathic skeletal hyperostosis.
- Don’t smoke – Cigarette use can directly affect the discs in the back and increase the rate of disc degeneration.
- Maintain a healthy weight – Being overweight or obese puts extra pressure on the back and spine, which can cause the desiccation and decay of the intervertebral discs.
- Take regular exercise – Participating in regular cardio and weight-training exercises can strengthen the bones and muscles and promote a good range of motion in the back. People can ask their doctor or a physical therapist for specific exercises that support the back muscles.
- Spine-Specialized physical therapy – typically includes a combination of stretching, strengthening, and aerobic exercise to provide better stability and support for the spine.
- Massage therapy – can help reduce muscle tension and muscle spasms, which may add to back or neck pain. Muscle tension is especially common around an unstable spinal segment where a disc is unable to provide the necessary support
- Ice & Moist Heat Application – Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.
- Use of lumbosacral back support – Generally, back braces are categorized as flexible, semi-rigid, and rigid. Rigid braces tend to be used for moderate to severe cases of pain and/or instability, such as to assist healing of spinal fractures or after back surgery. Semi-rigid and flexible braces are used for more mild or moderate pain.
- Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal back pain of all types of lumbar disc disease. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID, and narrowing of the spinal canal. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
Medications
- Analgesics – Such as paracetamol and prescription-strength drugs that relieve pain but not inflammation.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen.
- Calcium & vitamin D3 – To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
- Dietary supplement – to remove general weakness & improved health.
- Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Oral Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation throughout the skin.
- Steroid injections The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves. About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.
- epidural steroid injection. A steroid solution is injected into the epidural space (outer layer of the spinal canal) to reduce inflammation. This injection is by far the most common one used for herniated discs.
- Selective nerve root injection. A steroid solution and anesthetic are injected near the spinal nerve as it exits through the intervertebral foramen. This injection is also used to help diagnose which nerve root might be causing pain.
Surgery
There are many different ways that surgery can help with diffuse idiopathic skeletal hyperostosis . Possible procedures may include
Surgery might be needed in rare cases when diffuse idiopathic skeletal hyperostosis causes severe complications. People who have difficulty swallowing due to large bone spurs in the neck might need surgery to remove the bone spurs. Surgery might also relieve pressure on the spinal cord caused by DISH.
References
