• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
bone and spine logo

Bone and Spine

Your Trusted Resource for Orthopedic Health Information

  • Home
  • About
  • Contact Us
  • Policies
  • Show Search
Hide Search
You are here: Home / Spine disorders / Diffuse Idiopathic Skeletal Hyperostosis or DISH

Diffuse Idiopathic Skeletal Hyperostosis or DISH

Dr Arun Pal Singh ·

Last Updated on March 16, 2025

Diffuse idiopathic skeletal hyperostosis also called Forestier’s disease is characterized by unique, flowing (wave-like in shape) calcification along the sides of the vertebrae of the spine. It is also commonly associated with inflammation and calcification of tendons at their attachment points to bone, a condition called enthesitis. Enthesitis can frequently lead to bone spurs such as heel spurs.

DISH usually presents with back pain and spinal stiffness.

It occurs in 6-12 percent of people and is not common before 50 years of age. Females are affected slightly more than males.

Though it can occur anywhere in the spine, it is more common in the thoracic spine, followed by the lumbar and cervical spine.

The facet joint and sacroiliac joints are not involved in diffuse idiopathic skeletal hyperostosis.

Contents hide
1 Cause of Diffuse Idiopathic Skeletal Hyperostosis
2 Clinical Presentation
3 Diagnosis
4 Treatment
5 Complications of Diffuse Idiopathic Skeletal Hyperostosis
6 References

Cause of Diffuse Idiopathic Skeletal Hyperostosis

At present no cause is known. There is a tendency toward ossification of ligament, tendon, and joint capsule. These are also broadly termed as enthesial insertions.

The various known risk factors are

  • Obesity
  • Hypertension
  • Metabolic syndrome
  • Type 2 diabetes mellitus
  • Hyperuricemia

Clinical Presentation

Diffuse idiopathic skeletal hyperostosis is a completely asymptomatic phenomenon.

The condition is discovered inadvertently.

However, there are reported presentations and most of these symptoms arise due to impingement by bony overgrowth.

In the back, the patient may complain of mild chronic back pain and stiffness. The symptoms could be worse in the morning or in cold weather, that could be worse in the morning.

Other symptoms can be

  • Pain in the joints
  • Neck pain
  • Difficulty in swallowing- dysphagia (Due to neuropathy or impingement)

There is an increased susceptibility to spinal fractures because of the ankylosis of the spine.

Diagnosis

No laboratory tests are indicated.

X-rays

AP and lateral views of the spine are the recommended views. The usual findings suggestive of DISH are syndesmophytes at 3 successive levels (4 contiguous vertebrae).

  • Thoracic spine
    • Involved almost in all cases
    • Right-sided involvement
      • Absence on one side of the thoracic spine is thought to be due to the influence of aortic pulsations.
    • T7-T11 are particularly involved
  • Cervical spine
    • Bone formation on the anterior side
    • Disc spaces are preserved (versus ankylosing spondylitis where disc spaces would be ossified)
  • Lumbar spine
    • Symmetrical syndesmophytes (compare with one-sided involvement of thoracic)
  • Peripheral joints – will show degenerative changes
  • Other changes
    • Ossification of the nuchal ligaments in the skull
    • Enthesopathy at the ischial tuberosities
    • ossification of the sacrotuberous ligament and symphysis pubis
    • Ossification of the quadriceps and infrapatellar tendons
    • Ossification of the Achilles tendon and the plantar aponeurosis
    • Ossification of the triceps tendon
    • Subcutaneous calcification

Radiographs demonstrate typical changes in the spine as discussed earlier in this article. Other findings in other regions may be

Recognition of diffuse idiopathic skeletal hyperostosis facilitated by its separation from the body of the vertebrae. This gives rise radiologically to the appearance of a radiodense line paralleling the longitudinal axis of the spine but separated by a clearly definable space.

Ossification at sites of the tendon, ligamentous, or joint capsule insertion (enthesitis) is strongly suggestive of the diagnosis. Enthesial reaction at the iliac crest and ischial tuberosities, quadriceps insertion, metacarpal, and phalangeal capsule insertion may be present.

Usually, the X-rays are sufficient to reach the diagnosis.

CT or MRI are indicated in patients with a history of trauma to evaluate for the presence of occult fractures.

Computed tomography may also be performed to evaluate complications, such as fracture, or to conform pressure effects on the trachea, esophagus, and veins.

Criteria for Diffuse Idiopathic Skeletal Hyperostosis

  • Resnick and Niwayama
    • Flowing calcifications and ossifications along the anterolateral aspect of at least 4 contiguous vertebral bodies, with or without osteophytes
    • Preservation of disc height in the involved areas and an absence of excessive disc disease
    • Absence of bony ankylosis of facet joints and absence of sacroiliac erosion, sclerosis, or bony fusion.
  • Julkunen et al
    • Definite
      • Bridging of four contiguous vertebral bodies
      • Minimal intervertebral disc disease
      • No facet joint ankylosis
    • Probable
      • Bridging of two contiguous vertebral bodies
      • Bilateral patellar tufting
      • Heel spur
      • Olecranon tufting.
    • Possible [Either of two situations]
      • Two vertebrae joined  and no extraspinal enthesophytes
      • Symmetrical extraspinal enthesophytes without any spinal involvement

Unlike ankylosing spondylitis, Diffuse idiopathic skeletal hyperostosis does not involve the sacroiliac joint.

The most commonly involved spine is lower thoracic spine involvement which is also typical of diffuse idiopathic skeletal hyperostosis, but the lumbar and cervical spine also can be affected. The right side of the spine is more commonly involved. The lesser involvement of the left side of the spine is attributed to the pulsation of the aorta on this side.

diffuse idiopathic skeletal hyperostosis or DISH
Diffuse Idiopathic Skeletal Hyperostosis, Image Credit: Wikipedia

 

Treatment

There is no specific treatment and the patients are treated symptomatically with anti-inflammatory drugs, local heat, and physical therapy. Any complication is treated accordingly.

Nonoperative treatment

  • Modification of activities of daily life
  • Physical therapy
  • Use of orthotics like brace
  • Drugs to relieve pain

 Operative Treatment

Surgery is done to relieve the spinal cord of any compression. Stabilization often accompanies spinal decompression.

Some conditions that may require decompression are

  • Lumbar stenosis
  • Cervical myelopathy
  • Deformity that warrants correction

Complications of Diffuse Idiopathic Skeletal Hyperostosis

  • Posterior longitudinal ligament ossifications may impinge on the spinal cord on rare occasions.
  • Reduced vertebral column flexibility predisposes to vertebral fracture.
  • Diffuse idiopathic skeletal hyperostosis is not a source of morbidity or mortality. However, increased mortality is noted in cervical injury in DISH

References

  • Nascimento FA, Gatto LA, Lages RO, Neto HM, Demartini Z, Koppe GL. Diffuse idiopathic skeletal hyperostosis: A review. Surg Neurol Int. 2014. 5 (Suppl 3):S122-5. [Link].
  • Luo TD, Varacallo M. Diffuse Idiopathic Skeletal Hyperostosis (DISH). 2020 Jan. [Link]
  • Kaffel D, Kchir H. Dysphagia related to diffuse idiopathic skeletal hyperostosis (DISHphagia). Clin Case Rep. 2019 Nov. 7 (11):2265-2266 [Link]

Spine disorders This article has been medically reviewed by Dr. Arun Pal Singh, MBBS, MS (Orthopedics)

About Dr Arun Pal Singh

Dr. Arun Pal Singh is a practicing orthopedic surgeon with over 20 years of clinical experience in orthopedic surgery, specializing in trauma care, fracture management, and spine disorders.

BoneAndSpine.com is dedicated to providing structured, detailed, and clinically grounded orthopedic knowledge for medical students, healthcare professionals, patients and serious learners.
All the content is well researched, written by medical expert and regularly updated.

Read more....

Primary Sidebar

Know Your Author

Dr. Arun Pal Singh is an orthopedic surgeon with over 20 years of experience in trauma and spine care. He founded Bone & Spine to simplify medical knowledge for patients and professionals alike. Read More…

Explore Articles

Anatomy Anatomy Fractures Fractures Diseases Diseases Spine Disorders Spine Disorders Patient Guides Patient Guides Procedures Procedures
featured image of gower sign for segmenatal instability of lumbar spine

Clinical Tests for Lumbar Segmental Instability

Lumbar segmental instability may not always be visible on standard …

mesurement of scoliosis for braces

Braces for Scoliosis- Types, Uses and Results

Braces for scoliosis are recommended to prevent the scoliotic curve …

discogenic back pain

Discogenic Back Pain Causes, Diagnosis and Treatment

Discogenic back pain is a common cause of axial low back pain [the …

Elbow arthrodesis using internal fixation

Elbow Arthrodesis- Indications, Methods and Complications

Elbow arthrodesis refers to the surgical fusion of the elbow joint. It …

skeletal traction in upper tibial pin

Skeletal Traction – Indication, Uses and Complications

Skeletal traction is a type of traction where the force is applied …

Popular articles

infectious myositis of quadriceps

Infectious Myositis Causes and Treatment

Infectious myositis is an acute, …

Ischial Bursitis - Location

Ischial Bursitis or Ishiogluteal Bursitis

Ischial bursitis or ischiogluteal …

chronic exertional comparment syndrome

Chronic Exertional Compartment Syndrome

Chronic exertional compartment syndrome …

Intra-articular Fracture of First Metacarpal Base With Subluxation Of First Metacarpophalangeal Joint

Thumb Injuries Types, Presentation and Treatment

Thumb injuries or fractures and …

Bone and Spine

© 2025 BoneAndSpine.com · All Rights Reserved
The content provided on BoneAndSpine.com is intended for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Read Disclaimer in detail.