DISH

Upper Chesapeake Medical Center Spine Conference

October 10, 2014

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QUINTESSENTIAL RIGHT ANTEROLATERAL THORACIC SYNDESMOPHYTES T7-T11; bone forming

DISH: diffuse idiopathic skeletal hyperostosis• Foresteir and Rotes-Querol• Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann

• Rheum Dis 1950;9:321-30.

• Senile ankylosing hyperostosis

• Generalized juxta-articular ossification of vertebral ligaments

• Spondylosis hyperostotica

• DISH D. Resnick Radiology 1975; 115:513-524

Diagnosis

• Diagnostic Criteria for DISH

• 1. Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae

• 2. Preservation of disk height in the involved vertebral segment; the relative absence of significant degenerative changes, such as marginal sclerosis in vertebral bodies or vacuum phenomenon

• 3. Absence of facet-joint ankylosis; absence of SI joint fusion

prevalence

• >30 years old 7% men 4% women

• >50 most prevalent

• 28% autopsy specimens avg age 65 years

RISK FACTORS

• Metabolic syndrome• Diabetes• Age• High BMI• Uric acid

Symptoms

• Pain

• Stiffness

• Dysphagia

• Rhinophonia

• Neurologic stenosis

Imaging Characteristics of Diffuse Idiopathic Skeletal Hyperostosis

• Mihra S. Taljanovic et al

• AJR 2009; 193 S10-S19

• The University of Arizona Helath Sciences Center in Tucson, Arizona

Diffuse Idiopathic Skeletal Hyperostosis: Musculoskeletal Manifestations Belanger, Theodore and Rowe, Dale JAAOS 2011; 9:258-267

Michigan State University, Kalamazoo, Michigan

• Extra-articular ankylosis

AS Radiographic features

• Squaring vertebra

• Bridging syndesmophytes

• Bamboo spine

• Bone scan can mimickmetastatic disease

Dysphagia

• 28% have large cervical syndesmophytes

• Hoarseness

• Sleep apnea

• Difficult intubation

Rib expansion < 2.5cm

DDX

• Ankylosingspondylitis

• Reactive arthritis (Reiter’s)

• Spondylosisdeformans

• Psoriatric arthritis• Rheumatoid arthritis• Acromegaly• Hypervitaminosis A

Chronic LBP with Clinical Features make Dxof AS Likely:

1. Sx<45 years of age2. Dactylitis, enthesitis3. Nongranulomatous Acute anterior uveitis4. FH 15-20%5. HLA B276. Sacroiliitis/spondylitis7. Proximal aortic disease, MV, conduction, aortitis8. Inflammatory Bowel Disease9. Pulmonary Fibrosis

Whatdirectionare the

syndesmophytes?

• Are the joints fused?

Fear of the unknown

Delay in diagnosis

Chronic spondylodiscitis

• Calcification of the sacrotuberous and iliolumbar ligaments

• Periarticular osteophytes of the hip, SI joint, symphysis pubis

• Bone proliferation “whiskering” at site of ligament and tendon attachment

Type: JPG

64 year old man with R shoulder pain to the acromium

Does the aortic pulsation affect the location of bone formation is DISH?

• Bilateral and symmetrical

• Arrowhead tufts

Medical treatment

• NSAID: short/long acting, Cox2 selective

• Bisphophonates for osteoporosis• DMARDs such

as ciclosporin, methotrexate, sulfasalazine, and corticosteroids, used to reduce the immune system response through immunosuppression

• TNFα blockers (antagonists) such as etanercept, infliximab and adalimumab

66 year old man with four month history of mid thoracic back pain not Improving despite NSAID and PT

Thanks!!

THANKS!!

THANKS!