dish: diffuse idiopathic skeletal hyperostosis of the spine
TRANSCRIPT
DISH
Upper Chesapeake Medical Center Spine Conference
October 10, 2014
R
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!