A Man With Stooped Posture and Mysterious Back and Neck Pain

Nirupam Prakash, MD, MBBS


November 19, 2020


The lumbosacral spine radiograph shows large osteophytes arising from the contiguous surfaces of L5 and the sacral vertebrae (Figure 1).

Figure 1.

Continuous flowing ossification on the anterior surfaces of the L2-L5 vertebrae bridging the intervertebral spaces is seen. A radiolucent line is visible on the anterior aspect of the L3 vertebra separating the ossified new bone from the vertebral body. This classic "candle wax pattern" is suggestive of calcification of the anterior longitudinal ligament and is characteristic of diffuse idiopathic skeletal hyperostosis (DISH). The disc spaces are well maintained, and no findings are suggestive of sacroiliac joint sclerosis or facet joint ankylosis. Similarly, the anteroposterior pelvis radiograph shows calcification of the attachments to the acetabular margin indicating entheseal ossification. Exuberant ossification is also seen on the anterior aspect of the cervical vertebrae. A subsequently performed HLA-B27 assay was negative, lending further support to the diagnosis of DISH.

The microvascular and macrovascular complications of diabetes are well described; however, the musculoskeletal manifestations of the disease, such as shoulder periarthritis, Dupuytren's contractures, and DISH, often receive less attention from healthcare professionals, despite the morbidity associated with these musculoskeletal conditions. In fact, these conditions can limit the implementation of and adherence to advised lifestyle modifications.

DISH is a disease characterized by exuberant ossification of ligaments (enthesopathy) in both the axial (predominantly affected) and the appendicular skeleton. It was originally described by Forestier and Rotes-Querol[1] as senile ankylosing hyperostosis with characteristic involvement of the thoracic spine. Later, the disease was found to involve the peripheral joints as well, leading researchers to label it a diffuse disease.[2]

DISH is characterized by enthesopathy with new bone formation and stiffening of the joints. The diagnosis is primarily based on radiologic features, including the following:[3]

  • Flowing ossification along the anterolateral aspect of at least 4 contiguous vertebrae

  • Preserved disc height, with absence of significant degenerative changes (marginal sclerosis in the vertebrae)

  • Absence of any significant facet joint ankylosis, sacroiliac erosions, or intra-articular osseous fusion

In a slight modification of these criteria, Arlet and Mazières suggested that the involvement of 3 contiguous vertebral bodies at the lower thoracic level is sufficient for the diagnosis of DISH.[4] Diagnostic criteria as suggested by Utsinger and colleagues, however, also include the presence of peripheral enthesopathies.[5]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: