Figure 1. Anteroposterior radiograph of the lumbar spine.
Figure 2. Lateral radiograph of the lumbar spine.
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Figure 3. Lateral radiograph of the left knee.
A 75-year-old man presents to the office with a history of chronic low back pain and left knee pain. He reports experiencing frequent episodes of dysphagia. Anteroposterior and lateral radiographs of the lumbar spine are obtained (Figures 1 and 2) as well as a lateral radiograph of the left knee (Figure 3). Images reveal severe ossification of the ligamentous structures around the spine and knee.
This patient’s condition is associated with which of the following?
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Diffuse idiopathic skeletal hyperostosis (DISH) is a relatively common condition in patients aged ≥50 years. DISH is characterized by the ossification of bone, tendon, and ligaments within the spine and extremities. This presents on radiographic imaging as large joint osteophytes and calcified ligaments. Most patients remain asymptomatic, and the condition is often found incidentally on radiography. DISH is more common in the spine but can have multiple musculoskeletal manifestations. Hyperostosis of the cervical spine can impinge on the esophagus and cause symptoms of dysphagia, as the esophagus lies adjacent to the fourth through . Patients should be aware that DISH of the cervical spine can make it difficult to undergo intubation should surgery be required or an emergency situation arise. Instead, awake fiberoptic intubation may be necessary. Unlike ankylosing spondylitis, DISH isn’t associated with HLA-B27.
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).
1. Kortyna R. Diffuse idiopathic skeletal hyperostosis: a review. J Bone Joint Surg. 2017;5(4):e27.
2. Woon C. DISH (Diffuse idiopathic skeletal hyperostosis). OrthoBullets website. https://www.orthobullets.com/spine/2045/dish-diffuse-idiopathic-skeletal-hyperostosis. Update March 3, 2018. Accessed August 16, 2019.