Diffuse idiopathic skeletal hyperostosis

a case report of DISH, differential diagnosis with Paget's disease, Skeletal Fluorosis, and Ankylosing spondylitis.

1. Diffuse idiopathic skeletal hyperostosis Vinod Naneria Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research Centre, Indore, India

2. DISH Diffuse idiopathic skeletal hyperostosis or  Forestier disease  is a common condition characterized by bone proliferation at sites of tendinous and ligamentous insertion. Epidemiology It most commonly affects the elderly (especially 6 th  to 7 th  decades). Its estimated frequency in the elderly is at ~ 5-15% 

3. Pathology Pathologic features of spinal DISH include:  Focal and diffuse calcification and ossification of the anterior longitudinal ligament, Paraspinal connective tissue and annulus fibrosis, Degeneration in the peripheral annulus fibrosis fibers , Anterolateral extensions of fibrous tissue, Hypervascularity , Chronic inflammatory cellular infiltration, Periosteal new bone formation on the anterior surface of the vertebral bodies.

4. Associations Ossification of the posterior longitudinal ligament (OPLL) Hyperglycaemia. Approximately one-third of patients test positive for human leukocyte antigen ( HLA)B27.

5. Spinal features: Florid, flowing ossification along the anterior or right anterolateral aspects of at least   four  contiguous vertebrae. Disc spaces are usually well preserved. Ankylosis is more commonly seen in the thoracic than in the cervical or lumbar spine. Frequently incomplete can have interdigitating areas of protruding disk material in the flowing ossifications.

6. Extra spinal features Enthesopathy of: iliac crest, ischial tuberosities , greater trochanters , spur formation in the appendicular skeleton ( olecranon , calcaneum ).

7.  Dr Noyan Zenger Dr Andrew Ho &   Dr Radswiki   .

8. Dr Andrew Ho

9. DISH

10. DISH

11. DISH

12. DISH

13. Ankylosing Spondylitis – Radiological features early spondylitis is characterized by small erosions at the corners of vertebral bodies with reactive sclerosis squaring of the vertebral body diffuse syndesmophyitic ankylosis can give a "bamboo spine" appearance interspinous ligament calcification can give a "dagger spine" appearance ossification of spinal ligaments, joints and discs. Psuedoarthroses  may form at fracture sites. enthesophyte formation from enthesopathy . Romanus lesions of the spine - shiny corner sign.

14. Ankylosing spondylitis

15. Ankylosing spondylitis

16. Fluorosis - radiological features: The earliest radiological findings appear within six mouths of continuous exposure to high intakes of fluoride and include periosteal and endosteal reactions, coarse axial trabcculations and osteopenia in the metaphyseal regions, sclerosis, and modelling abnormalities of the epiphyses, carpal and other bones of the hand, more particularly observed in growing children. The incidence of spinal osteoporosis is significantly low and of osteomalacia and secondary hyperparathyroid bone disease significantly higher in women residing in endemic fluorosis villages.

17. Fluorosis

18. Fluorosis

19. Paget’s disease – Spine Radiology Spine: cortical thickening encasing the vertebral margins, which gives rise to the picture frame sign on radiographs in mixed phase disease. On lateral radiographs flattening or squaring of the normal concavity of the anterior margin of the vertebral body also adds to the rectangular appearance.  The osteoblastic activity is seen along all four margins of the vertebral body cortices. The vertical trabecular thickening pattern in Paget disease is coarser than the more delicate pattern seen in hemangiomas with which it can be confused .

20. Paget’s disease – Radiology Pelvis Paget disease of the pelvis usually manifests with cortical thickening and sclerosis of the iliopectineal and ischiopubic lines. These findings are often asymmetric and for some reason, may be more commonly seen on the right side. Enlargement of the pubic rami and ischium are also often seen.

21. Paget

22. Paget

23. Paget

24. Paget

25. Osteopetrosis X-ray findingsDiffuse  osteosclerosis Cortical thickening with medullary encroachment Erlenmeyer flask deformity =  clublike  long bones due to lack of  tubulization  + flaring of ends Bone-within-bone appearance "Sandwich" vertebrae=alternating sclerotic + radiolucent transverse metaphyseal lines (phalanges, iliac bones) indicate fluctuating course of disease Longitudinal metaphyseal striations Mandible least involved

26. Osteopatrosis

27. DISCLAIMER Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India. Some of the representative x-rays and relevant text is taken from Radiopaedia.org It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact [email protected]