Mid-Back (Thoracic)
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
미만성 특발성 골격 과골증 (DISH)
Non-inflammatory ossification of anterior longitudinal ligament — Forestier's disease
- How common
- 6–12% of adults >50
- Typical age
- Men aged 50+
What is it?
Non-inflammatory ossification of anterior longitudinal ligament and soft tissues produces flowing 'candle wax' hyperostosis.
Commonly affected: Thoracic (T7-T11) most common
How it develops
- Metabolic FactorsAssociated with DM, obesity (elevated IGF-1)
- Ligament OssificationGradual ossification of ALL
- Bridging OssificationMultiple levels bridge, causing stiffness
- Disc PreservationUnlike AS, disc space preserved
Symptoms
- Thoracic stiffnessStiffness morning and after activity
- DysphagiaCervical DISH compresses esophagus
- Reduced ROMLimited thoracic rotation/flexion
- Mild back painTypically mild
How it is examined
- Reduced ROMLimited thoracic rotation and lateral bending
- Normal SI jointsSI joints normal, unlike AS — key differentiator
- Metabolic findingsOften with DM, obesity, dyslipidemia
- HLA-B27 negativeDifferentiates from AS
Imaging
Lateral X-ray diagnostic — 'flowing candle wax' ossification.
- ≥4 consecutive anterior bridging (Resnick)
- Disc spaces preserved
- SI joints normal
- Cervical DISH may compress esophagus
MRI rare; CT better for ossification detail.
- Anterior ossification
- Preserved discs
- Possible concomitant OPLL
Non-surgical care
- Mobility exercisesDaily thoracic extension/rotation
- NSAIDsMild pain control
- Metabolic managementDiabetes/weight control slows progression
- Fall preventionRigid spine at risk of fracture from minor trauma
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Severe dysphagia, cord compression, cervical DISH fracture
Procedures that may be discussed
- Anterior osteophyte removal (dysphagia)
- Cervical decompression/fixation
Outlook
Mostly mild symptoms; rigidity increases fracture risk from trauma.