Diffuse Idiopathic Skeletal Hyperostosis

DISH, previously known as ankylosing hyperostosis of the spine and Forestier's disease, is characterized by bony proliferation at the site of tendon and ligament attachment to bone (entheses), calcification and ossification of the anterior longitudinal ligaments, and diskover-tebral osteophytosis. This is a common but not insignificant disease of the spine and extraspinal skeleton. The etiology has not been established, but some investigators consider that it may be associated with degenerative process. There are three radiographic features proposed by Resnick and Niwayama (1976) as important prerequisites for the diagnosis of DISH (Figs. 9.54A and 9.55A). They include (1) the presence of flowing type calcification and ossification along the anterolateral aspects of four

Fig. 9.54A, B Diffuse idiopathic skeletal hyperostosis (DISH). A Anteroposterior radiograph of the thoracolumbar spine in a 45-year-old man with DISH shows flowing ossification along the lateral aspects of T8-L1 vertebrae (arrows). Vertebral endplates and disk spaces appear preserved and the sacroiliac joints are not involved (not shown here). The radiograph is printed with the right side on the left to match the scintigraph. B Posterior pinhole scan shows intense tracer uptake in the costovertebral-apophyseal joints as well as the spinous processes of the thoracolumbar spine and less intense tracer uptake in the other vertebral elements (arrows). The individual vertebrae and disk spaces are not clearly discernible. Tracer uptake is disproportionately intense compared to relatively unimpressive radiographic changes (see Fig. 9.55)

Fig. 9.54A, B Diffuse idiopathic skeletal hyperostosis (DISH). A Anteroposterior radiograph of the thoracolumbar spine in a 45-year-old man with DISH shows flowing ossification along the lateral aspects of T8-L1 vertebrae (arrows). Vertebral endplates and disk spaces appear preserved and the sacroiliac joints are not involved (not shown here). The radiograph is printed with the right side on the left to match the scintigraph. B Posterior pinhole scan shows intense tracer uptake in the costovertebral-apophyseal joints as well as the spinous processes of the thoracolumbar spine and less intense tracer uptake in the other vertebral elements (arrows). The individual vertebrae and disk spaces are not clearly discernible. Tracer uptake is disproportionately intense compared to relatively unimpressive radiographic changes (see Fig. 9.55)

Diffuse Idiopathic

Fig. 9.55A, B Relatively low tracer uptake in more mature diffuse idiopathic skeletal hyperostosis (DISH). A Anteroposterior radiograph of the thoracolumbar spine in a 74-year-old man with DISH shows dense, flowing, paraspinal ossifications diffusely involving T9 through L2 vertebrae. The ossification is much more advanced than that of the case shown in Fig. 9.54. The radiograph is printed with the right side to the left to match the scintigraph. B Posterior pinhole scintigraph paradoxically shows generally reduced tracer uptake. The individual vertebrae and disk spaces are discernible. Isolated, intense tracer uptake in the costovertebral-apophyseal joints of T12 may denote the residual foci with an active pathology (arrows)

Fig. 9.55A, B Relatively low tracer uptake in more mature diffuse idiopathic skeletal hyperostosis (DISH). A Anteroposterior radiograph of the thoracolumbar spine in a 74-year-old man with DISH shows dense, flowing, paraspinal ossifications diffusely involving T9 through L2 vertebrae. The ossification is much more advanced than that of the case shown in Fig. 9.54. The radiograph is printed with the right side to the left to match the scintigraph. B Posterior pinhole scintigraph paradoxically shows generally reduced tracer uptake. The individual vertebrae and disk spaces are discernible. Isolated, intense tracer uptake in the costovertebral-apophyseal joints of T12 may denote the residual foci with an active pathology (arrows)

or more contiguous vertebral bodies with or without associated focal excrescences at the intervertebral level, (2) relatively preserved disk spaces without radiographic evidence of extensive disk degeneration such as the vacuum phenomenon or sclerosis, and (3) the absence of apophyseal and sacroiliac joint obliteration due to erosion, sclerosis, and bony fusion. The last feature distinguishes DISH from ankylosing spondylitis. In addition to the spine, the pelvis, trochanter, patella, calcaneus, and olec-ranon process are frequently involved. Osseous proliferation occurs at the entheses, producing the characteristic "whisker" sign.

Generally, scintigraphic manifestations of DISH are too subtle and complex to be recognized by ordinary scintigraphy (Paquin et al. 1983). With the aid of pinhole scintigraphy, however, DISH can be indicated more specifically by tracer uptake in the anterior and lateral aspects of vertebral bodies and disk spaces as well as the spinous processes, most commonly in the thoracic and lumbar spine. Interestingly, tracer accumulates relatively more intensely in the anterolateral aspect of the vertebral bodies than the disk spaces where radiographic hy-perostosis with a bumpy contour occurs most prominently (Fig. 9.54B). Like hyperostoses elsewhere, anatomically unimpressive bony excrescences in DISH intensely accumulate tracer, obscuring the vertebral contour and disk spaces (Fig. 9.54), but larger ones accumulate little tracer rendering the spinal contour and disk spaces clearly portrayed (Fig. 9.55).

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Responses

  • carita
    Is diffused idiopathic skeletal hyperostosis (DISH) associated with low blood platletes?
    3 years ago

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