A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status.

Diffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of unknown etiology that is characterized by back pain and spinal stiffness. There may be mild pain if ankylosis has occurred. The condition is recognized radiographically by the presence of "flowing" ossification along the anterolateral margins of at least four contiguous vertebrae and the absence of changes of spondyloarthropathy or degenerative spondylosis. Even in patients who present with either lumbar or cervical complaints, radiographic findings are almost universally seen on the right side of the thoracic spine. Thus, radiographic examination of this area is critical when attempting to establish a diagnosis of DISH. The potential sequelae of hyperostosis in the cervical and lumbar spine include lumbar stenosis, dysphagia, cervical myelopathy, and dense spinal cord injury resulting from even minor trauma. There may be a delay in diagnosis of spinal fractures in a patient with DISH because the patient often has a baseline level of spinal pain and because the injury may be relatively trivial. The incidence of delayed neurologic injury due to such fractures is high as a result of unrecognized instability and subsequent deterioration. Extraspinal manifestations are also numerous and include an increased risk of heterotopic ossification after total hip arthroplasty. Prophylaxis to prevent heterotopic ossification may be indicated for these patients.

Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations

OBJECTIVE: To identify the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in a large Asian population group. METHODS: A total of 3595 subjects (1616 men and 1979 women) over 50 years of age, residing in 2 cities in Korea, were included in this study. The mean age of the study population was 64.25 +/- 9.06 years. We reviewed lateral chest radiographs through Picture Archiving and Communication Systems (PACS) and identified DISH according to Resnick9s and Julkunen9s criteria. RESULTS: One hundred and four (2.9%) of the 3595 subjects were diagnosed with DISH according to classical Resnick criteria. A slight increase in prevalence (4.1%) could be seen using Julkunen9s criteria. The prevalence of DISH increased with age, except for the 90-99 year age group. Men were approximately 7 times more likely to have DISH than women using Resnick9s criteria. CONCLUSION: DISH is an age-related skeletal disorder whose overall prevalence is much lower in Koreans than in other Western populations. Interestingly, the prevalence of DISH was 7 times higher in men. We propose that ethnic factors are important elements in the prevalence of DISH.

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The prevalence of diffuse idiopathic skeletal hyperostosis in Korea.

Metabolic syndrome and cardiovascular risk in patients with diffuse idiopathic skeletal hyperostosis.

Background: Ossification of the posterior longitudinal ligament is commonly associated with cervical myelopathy. Surgical treatment is a matter of controversy. We report on a series of patients who were managed with anterior cervical decompression and arthrodesis for the treatment of cervical myelopathy associated with ossification of the posterior longitudinal ligament. Methods: We retrospectively reviewed the records for all sixty-five patients who had been managed with anterior decompression and arthrodesis for the treatment of cervical ossification of the posterior longitudinal ligament and associated neurologic compression from 1982 to 2001. Sixty-one patients (thirty-nine men and twenty-two women) were followed for at least two years (or until the time of death). The average number of vertebrae resected was 2.2. The average duration of follow-up for the sixty surviving patients was four years (range, two years to fifteen years and four months). The preoperative, six-week postoperative, and final follow-up clinical status (including neurological function as assessed with the Nurick grading system) was recorded for each patient. Results: Fifty-six of the sixty-one patients had neurological improvement, with an average improvement of 1.5 Nurick grades at the time of the final follow-up. Eight patients had absent dura at the time of surgery and, of these, five had development of a cerebrospinal fluid fistula. Eight patients had development of new neurological signs and/or symptoms in the upper extremity postoperatively. Eight patients required reoperation because of a painful pseudarthrosis (one patient), strut-graft dislodgment (three), cerebrospinal fluid leakage (three), or compression of a nerve root caudad to the area of the original procedure (one). One patient died as the result of cardiac arrest on the third postoperative day. Fifty-eight patients had an osseous fusion, one had an asymptomatic nonunion, and one had a symptomatic pseudarthrosis that was treated with revision surgery. Conclusions: Anterior decompression and arthrodesis is an effective way to achieve pain relief and neurological improvement in North American patients of non-Asian descent who have cervical myelopathy associated with ossification of the posterior longitudinal ligament. The risk of durocutaneous fistula, graft dislodgment, and postoperative neurological symptoms appears to be high in patients with cervical myelopathy associated with this condition. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Ossification of the posterior longitudinal ligament. Results of anterior cervical decompression and arthrodesis in sixty-one North American patients.

OBJECTIVE: To evaluate the sensitivity, specificity, predictive value, interrater reliability and intrarater reliability of using chest radiographs as a screening tool for the diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). METHODS: After review of thoracic spine radiographs by 2 "gold standard" physicians, 45 patients with DISH meeting the criteria of Resnick and Niwayama were contrasted with 106 control patients consisting of 45 with thoracic spondylosis, 45 who lacked spondylosis and whose thoracic spine radiographs were otherwise normal for the age of the patient, and 16 with ankylosing spondylitis. The chest radiographs on the 151 subjects were placed in random order and read independently using an ordinal diagnostic certainty scale by 2 "test" radiologists, experienced in reading bone radiographs. Two months later the order of chest radiographs was rerandomized and the films reassessed by the same test radiologists. RESULTS: The averages for the diagnostic and population test characteristics were sensitivity = 77%; specificity = 97%; positive predictive value = 91%; and, negative predictive value = 91%. The area under the receiver operating characteristic curves was 0.975 and 0.976 for the radiologists, and kappa was 0.93, demonstrating that interrater reliability was high. On rereading the chest radiographs, intrarater reliability was exceptional (weighted kappa of 0.90 and 0.96 for the two test radiologists). DISH patients whose chest radiographs were read as not demonstrating DISH had significantly less extensive disease. CONCLUSIONS: We conclude that chest radiographs are a reliable and valid screening tool for the diagnosis of DISH.

Kaplan P

Papers

Chest radiographs as a screening test for diffuse idiopathic skeletal hyperostosis.