Round #4

• Back to Clinical History and Radiographs
• Back to Radiographic Findings

Diagnosis and Discussion

Correct Diagnosis: Diffuse Idiopathic Skeletal Hyperostosis (DISH) with Ossification of the Posterior Longitudinal Ligament (OPLL)

Discussion:
Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a common cause of regional pain syndromes in patients over the age of 40. It is more commonly seen in men than women, and reaches its peak incidence in the 6th and 7th decades of life. Patients who are obese or dyslipidemic appear to be at increased risk. DISH can affect the cervical, thoracic, or lumosacral spine, and it typically presents as localized pain and stiffness with decreased range of motion of the affected area. It is often confused radiographically with the changes seen in ankylosing spondylitis, as bridging osteophytes are seen in both conditions. However, the lack of facet joint arthritis and fusion, sacroiliitis, and syndesmophytes in DISH help to confirm the diagnosis. Treatment is conservative and involves physical therapy, stretching and range of motion exercises, and NSAIDs.

DISH of the cervical spine can often present as progressive dysphagia, due to esophageal compression by the underlying osteophytes. Ossification of the posterior longitudinal ligament (OPLL) can also be seen. While roughly 30% of patients of patients with OPLL present with cervicalgia alone, the remainder usually experience some degree of cervical myelopathy. If myelopathy is present, surgical decompression may be necessary.

References:

1. Havelka S, Vesela M, Pavelkova A, Ruzickova S, Koga H, Maeda S, Inoue I, Halman L. Are DISH and OPLL genetically related? Ann Rheum Dis 60(9): 902-3, 2001.
2. Meyer PR Jr. Diffuse idiopathic skeletal hyperostosis in the cervical spine. Clin Orthop 359: 49-57, 1999.
3. Trojan, DA, Pouchot, J, Pokrupa, R, et al. Diagnosis and treatment of ossification of the posterior longitudinal ligament of the spine: Report of eight cases and literature review. Am J Med 92: 296, 1992.
4. Resnick D. Calcification and ossification of the posterior spinal ligaments and tissues. In: Resnick D, ed. Diagnosis of bone and joint disorders 3rd ed. Philadelphia, London, Toronto, Montreal, Sydney, Tokyo: Saunders, 1496-1507, 1995.

All information contained within the Johns Hopkins Arthritis Center website is intended for educational purposes only. Physicians and other health care professionals are encouraged to consult other sources and confirm the information contained within this site. Consumers should never disregard medical advice or delay in seeking it because of something they may have read on this website.