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Pain and Spine Medicine

Considering New Diagnostic Criteria: Diffuse Idiopathic Skeletal Hyperostosis

Thursday, November 16, 2023

    Primary Author(s)

  • Richard Tran, MD

    Resident Physician
    University of Colorado Internal Medicine
    Aurora, Colorado

  • ZA

    Zachary Abbott, DO

    Resident Physician
    University of Colorado PM&R Program
    Aurora, Colorado

    • Co-Author(s)

  • Adele Meron, MD

    Assistant Professor
    University of Colorado Denver School of Medicine PM&R Program
    Aurora, Colorado

Case Diagnosis: Identification of Diffuse Idiopathic Skeletal Hyperostosis (DISH) despite coexisting degenerative disc disease

Case Description or Program Description: A 78-year-old man presented with persistent neck pain that started a few weeks following a fall onto his right shoulder. He initially underwent workup for rotator cuff tendinopathy, but he continued to have difficulty turning his head and increased morning soreness. He had no dysphagia, hoarseness, stridor, radicular pain, unsteady gait, or other red flag signs. Cervical x-ray was obtained to evaluate for further pathology.

Setting: Outpatient Spine Clinic

Assessment/Results: X-ray of the cervical spine demonstrated prominent bridging ossification of the anterior longitudinal ligament from C2-C6, consistent with DISH. Previous CT scan of the thoracic spine was also suggestive of anterior vertebral bridging as well as discogenic changes. The patient was ultimately referred to physical therapy without need for further intervention.

Discussion (relevance): DISH is a non-inflammatory disease process characterized by ossification of tendons and ligaments at their bony attachments, particularly in the spine. Plain radiographs are the initial imaging of choice. The Resnick criteria are frequently used to diagnose DISH, which include: 1) involvement of at least four contiguous vertebral bodies, 2) relative preserved intervertebral disc height, and 3) absence of apophyseal joint ankylosis and sacroiliac joint erosion, sclerosis, or fusion. In this case, imaging had elements of both degenerative disc disease and DISH, complicating a definitive diagnosis. Recent reviews have afforded greater leniency in diagnostic criteria for DISH in cases where degenerative disc disease coexists, allowing for mild changes in intervertebral disc height that may accompany late stage disease.

Conclusions: This case adds to the examples of DISH identified through the updated diagnostic criteria. While changes in intervertebral disc height detract against a diagnosis of DISH by the Resnick criteria, as seen in this patient, DISH may coexist with signs of degenerative disc disease.