Anteroposterior X-ray of the spine
Lateral X-ray of the spine
A 66-year-old man presents to the office with “years” of on and off lower back pain and stiffness. His stiffness is worse in the morning and seems to be aggravated by cold weather. His pain is predominately located across his mid to lower back. He denies radiation of pain to the lower extremities. Anteroposterior and lateral X-rays show non-marginal syndesmophytes at three successive levels of the lumbar spine.
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Diffuse idiopathic skeletal hyperostosis (DISH) is an idiopathic condition characterized by calcification of the tendons and ligaments around the spine. The tendons and ligaments can progressively calcify and turn into bone. DISH can also occur in several other locations in the body, including the knees, elbows, foot and ankles, and shoulders. DISH is a relatively common condition, occurring in up to 25% of persons older than 50 years of age. Many patients with DISH are asymptomatic, and the condition is often found incidentally on X-ray. Diagnostic criteria include osteophytes along the anterolateral borders of at least four contiguous segments. Other X-ray findings include preservation of disc height and absence of degenerative changes and ankylosis at the facet and sacroiliac joints. The thoracic spine is the most frequently involved, followed by the lumbar spine and cervical spine. DISH patients are more prone to fracture and spinal instability as a result of stiff spinal ankylosis. DISH patients with even minor neck trauma should be worked up closely with X-ray and CT to rule out fracture. Treatment of DISH involves NSAIDS, physical therapy for core strengthening and flexibility, corset bracing, and bisphosphonate therapy. Surgery is not indicated for the treatment of DISH, and fortunately pain is usually maintained well with conservative treatment.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Belanger TA, Rowe DE. Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations. J Am Acad Orthop Surg. 2001;9:258-267.
- Woon C. DISH (Diffuse idiopathic skeletal hyperostosis). https://www.orthobullets.com/spine/2045/dish-diffuse-idiopathic-skeletal-hyperostosis. Accessed December 19, 2017.