Background Diffuse Idiopathic Skeletal Hyperostosis (DISH) was described based on vertebral radiological signs (Resnick-Niwayama 1976). Subsequently, Utsinger presented other criteria that add extraspinal involvement that allowed DISH diagnosis even without vertebral signs . Mader et al have tried to develop a new set of criteria without a final consensus about the inclusion of multiple peripheral enthesopathies .
Objectives To identify in our patients affected from DISH the existence of different clinicoradiological patterns based on the spinal and/or extraspinal involvement.
Methods We conducted a descriptive analysis of our cohort of patients who met Resnick and/or Utsinger classification criteria for DISH. Demographic, clinical, radiographic and comorbidity data were collected. Radiographic scans and medical records were reviewed since 2004. Patients were divided into 3 clinicoradiological patterns: 1) Axial pattern 2) Peripheral pattern 3) Mixed pattern. We excluded patients with positivity of HLA27 and/or past o present psoriasis and/or inflammatory bowel disease although radiographic features met the criteria described.
Results We included 93 patients, 57% were male. The average age at diagnosis was 65.5 y (47–84) but the age of onset of symptoms was 58.5 y (36–80). In women the age at onset and diagnosis was earlier, 62.8 and 55.7 y, respectively. The delay in diagnosis was 6.36 years (0–25). All patients met Utsinger criteria: 72% definite; 20.5% probable and 7.5% possible, 28% did not meet Resnick's definition. The symptoms that led to the diagnosis were: 46.2% pain and/or limitation of thoracic-lumbar spine, 15.4% pain and/or limitation cervical spine, 22% a peripheral enthesopathy, 5.4% hip pain and 11% was a radiological finding. We identified: a) predominantly axial pattern (69.5%); b) predominantly peripheral pattern (19.6%); and a mixed pattern (10.9%). We also observed that women predominated in peripheral pattern (66%) and men in axial (65%). We didn't find any sex differences in the mixed pattern. Moreover, patients with peripheral pattern were diagnosed at earlier ages. We found hyperostotic signs in: 63.4% cervical spine, 93% thoracic spine and 55.4% lumbar spine, 51.9% had bony excrescencies of acetabulum, 80% enthesopathies of pelvic girdle and/or trochanter, 65% in knees, 68.4% elbows, 82% in Achilles tendon and 62% in fascia plantaris. Although the value of retrospective data is limited, the clinical history of enthesopathy was collected in a 46.2%.
Conclusions We propose three patterns in DISH based on clinical symptoms and characteristic radiological signs. We need prospective studies to elucidate if they correspond to different stages of the disease or if they are different patterns related to sex or age.Because our evidence we consider the importance to investigate the extraspinal involvement when we establish the diagnosis of DISH.
Resnick, Niwayama G: Radiographic and pathologic features of spinal Involvement in DISH. Radiology. 1976; 119: 559.
Utsinger P.D. Diffuse idiopathic skeletal hyperostosis PD. Rheum Dis Clin. 1985, 11 (2): 325–51.
Mader R; Buskila D; Verlaan JJ et al. Developing new classification criteria for diffuse idiopathic skeletal hyperostosis: back to square one. Rheumatology 2013; 52: 326–330.
Disclosure of Interest None declared