Diffuse idiopathic skeletal hyperostosis
Diffuse idiopathic skeletal hyperostosis (DISH) (also known as Forestier disease) is characterised by ligamentous ossification in the spine resulting in progressive stiffness and, sometimes, pain. In some patients, it may be asymptomatic. This condition typically affects the thoracic spine, but can also affect the cervical and lumbar spine. It can also cause enthesitis (inflammation at the sites of tendon and ligament attachment to bone) at peripheral sites. Axial spondyloarthritis is a differential diagnosis, but can be distinguished on the basis of radiographic appearance. The aetiology of DISH is unknown, but the condition is associated with metabolic disorders such as hyperuricaemia, dyslipidaemia, obesity, glucose intolerance and diabetes, as well as the use of oral retinoids.
There are no specific treatments for DISH and management is as for nonspecific thoracic spine pain, including exercise and analgesia. It is prudent to avoid vigorous manipulation of the spine in case this causes fracturing of ossified ligaments. Metabolic conditions associated with DISH should be managed as indicated; however, it is uncertain if this affects the progression of DISH. If DISH is associated with the use of an oral retinoid, treatment should be stopped.