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Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms

Key Points

  • Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by entheseal ossification and/or calcification involving mainly the thoracic spine

  • Peripheral joints and adjacent entheses can also be involved

  • The pathogenesis of DISH is not clear, but several factors may promote the differentiation of mesenchymal cells into bone-forming cells

  • DISH is often associated with a variety of metabolic derangements, which may increase cardiovascular morbidity

  • Patients with DISH also have an increased risk of complicated spinal fractures, with associated morbidities

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the ossification and calcification of ligaments and entheses. DISH is observed on all continents and in all races, but most commonly in men over 50 years of age. Although DISH is asymptomatic in most individuals, the condition is often an indicator of underlying metabolic disease, and the presence of spinal or extraspinal ossifications can sometimes lead to symptoms including pain, stiffness, a reduced range of articular motion, and dysphagia, as well as increasing the risk of unstable spinal fractures. The aetiology of DISH is poorly understood, and the roles of the many factors that might be involved in the development of excess bone are not well delineated. The study of pathophysiological aspects of DISH is made difficult by the formal diagnosis requiring the presence of multiple contiguous fully formed bridging ossifications, which probably represent advanced stages of DISH. In this Review, the reader is provided with an up-to-date discussion of the epidemiological, aetiological and clinical aspects of DISH. Existing classification criteria (which, in the absence of diagnostic criteria, are used to establish a diagnosis of DISH) are also considered, together with the need for modified criteria that enable timely identification of early phases in the development of DISH.

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Figure 1: The characteristic radiological features of DISH.
Figure 2: A typical spinal fracture in a patient with DISH.
Figure 3: Suggested factors that promote entheseal calcification and ossification in DISH.

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Mader, R., Verlaan, JJ. & Buskila, D. Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms. Nat Rev Rheumatol 9, 741–750 (2013). https://doi.org/10.1038/nrrheum.2013.165

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