Diffuse Idiopathic Skeletal Hyperostosis (DISH)



  • Characterized by calcification and ossification of soft tissues, primarily ligaments and entheses; most commonly in the spine, especially thoracic segments
  • Typically defined as flowing calcification across four or more contiguous vertebral segments with preservation of disc spaces
  • Synonym(s): Forestier disease; vertebral ankylosing hyperostosis

Geriatric Considerations

  • Diffuse idiopathic skeletal hyperostosis (DISH) is typically asymptomatic; it may, however, decrease spinal mobility and predispose patients to fractures after only mild trauma.
  • DISH and osteoarthritis (OA) may coexist. Both affect the same population (elderly and obese).
  • Bone mineral density (BMD) measurements obtained by dual energy x-ray absorptiometry (DEXA) and quantitative CT may not be accurate (falsely high) due to lumbar ossification/calcification in DISH.
  • DISH should be considered in elderly patients with unexplained respiratory distress or dysphagia (1).


  • Most common in elderly, obese males
  • Prevalence varies geographically.

Incidence increases with age and is higher in men.


  • Difficult to calculate due to variable classification criteria used across literature
  • Japan: 19.5% (2)
  • Thought to be similar in other populations

Etiology and Pathophysiology

  • The etiology is unknown. Increased levels of insulin, insulin-like growth factor 1, and transforming growth factor-β1 are believed to stimulate osteoblasts and bone proliferation (1).
  • Low serum levels of bone formation inhibitors (e.g., bone morphogenetic protein 2 or Dickkopf-1 [DKK-1], an inhibitor of the Wnt pathway required for new bone formation) may also play a role in DISH and are associated with more severe spinal involvement (1).

Risk Factors

  • Age
  • Male gender
  • Increased BMI
  • Hypertension
  • Metabolic syndrome
  • Diabetes
  • Hyperuricemia
  • Dyslipidemia
  • Lumbar spondylosis and knee OA

General Prevention

Control modifiable risk factors and the associated metabolic diseases.

Commonly Associated Conditions

Metabolic derangements associated with DISH:

  • Obesity; large waist circumference
  • Diabetes; hyperinsulinemia/insulin resistance
  • Metabolic syndrome
  • Hypertension
  • Dyslipidemia
  • Hyperuricemia

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