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Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 282-284  

Diffuse idiopathic skeletal hyperostosis of cervical spine: An unusual cause of dysphagia

Department of Neurosurgery, Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Vikas Maheshwari
Department of Neurosurgery, Armed Forces Medical College, Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Gill M, Maheshwari V, Narang A, Mukherjee A. Diffuse idiopathic skeletal hyperostosis of cervical spine: An unusual cause of dysphagia. Med J DY Patil Vidyapeeth 2018;11:282-4

How to cite this URL:
Gill M, Maheshwari V, Narang A, Mukherjee A. Diffuse idiopathic skeletal hyperostosis of cervical spine: An unusual cause of dysphagia. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2021 Jun 12];11:282-4. Available from: https://www.mjdrdypv.org/text.asp?2018/11/3/282/235557


A 47 year male presented with neck pain radiating to the right shoulder of 1 year duration along with progressive dysphagia of 4 month duration. There was a history of dysphagia more for solids than liquids. There was no history of cough after swallowing or odynophagia. There was no history of early morning stiffness, involvement of other joints, or history of sacroiliitis. General and neurological examination revealed no anomaly. X-ray and noncontrast computed tomography cervical spine showed extensive anterior osteophyte of cervical spine [Figure 1] and [Figure 2]a, [Figure 2]b. Magnetic resonance imaging cervical spine did not show any cord compression or canal stenosis. Upper gastrointestinal endoscopy did not show any stenosis, intraluminal growth, or ulcer. However, modified barium swallow showed some retention in the vallecular and pyriform region. This along with the X-ray cervical spine and the presence of progressive dysphagia enabled in diagnosis of “diffuse idiopathic skeletal hyperostosis” (DISH). The patient was counselled for surgery, but he declined.
Figure 1: X-ray cervical spine (lateral view) showing extensive anterior osteophytes with maintained disc spaces

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Figure 2: Noncontrast computed tomography-cervical spine (a) sagittal and (b) axial cuts showing extensive anterior osteophytes involving more than four continuous vertebrae with maintained disc spaces

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Forestier's disease is characterized by the ligamentous ossification of the anterolateral spine. It was first described by Forestier and Rotes-Querol in 1950.[1] Currently utilized term (DISH), for this disease, was coined by Resnick and Niwayama in 1976.[2] It is a common but underdiagnosed skeletal disease.

DISH is mostly an asymptomatic disease although various clinical symptoms have been described in literature including pain, limited range of spinal motion, and increased susceptibility to spinal fractures after trivial trauma. Cervical and lumbar segments of the spine are frequently affected by DISH and rarely manifest as dysphagia or airway obstruction at cervical levels and radiculopathy or painful stiffness at lumbar levels.[3]

The etiology of DISH remains uncertain. Environmental exposures, mechanical stress, metabolic conditions, and genetic factors have been reported as possible underlying causes. Most of the existing theories focus on the pathologic calcification of the anterior longitudinal ligament of the spine. The majority of these theories advocate that this process is due to the abnormal growth and function of the osteoblasts in the osteoligamentary binding. However, not all authors accept the association between pathologic calcification and increased bone mineral density.[4]

The diagnosis of DISH is chiefly based on imaging findings. The most widely used diagnostic criteria were proposed by Resnick and Niwayama in the 1970s, including calcification and ossification along the anterolateral aspect of at least four contiguous vertebral bodies, maintenance of intervertebral disc height at the involved segments, absence of apophyseal joint ankylosis and sacroiliac inflammatory changes.[2]

DISH is more frequent in men, 12%–28% of adult population is affected by it, and the incidence increases with age mainly affecting patients over the age of 40 years. Dysphagia from cervical spine osteophytes affects only 0.1%–6% of adults.[5]

Treatment for DISH is based on symptomatic relief of symptoms. There have been no well-designed studies evaluating the effectiveness of any therapy in this disease. In general, analgesics, sedation, nonsteroidal anti-inflammatory drug and muscle relaxants, and diet modification have all been advocated in the management of patients with DISH. However, anterior cervical resection of osteophyte has a role in patients with, worsening airway obstruction and/or dysphagia, in whom conservative approach has failed.[4],[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sarzi-Puttini P, Atzeni F. New developments in our understanding of DISH (diffuse idiopathic skeletal hyperostosis). Curr Opin Rheumatol 2004;16:287-92.  Back to cited text no. 1
Resnick D, Niwayama G. Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 1976;119:559-68.  Back to cited text no. 2
Mader R, Sarzi-Puttini P, Atzeni F, Olivieri I, Pappone N, Verlaan JJ, et al. Extraspinal manifestations of diffuse idiopathic skeletal hyperostosis. Rheumatology (Oxford) 2009;48:1478-81.  Back to cited text no. 3
Nascimento FA, Gatto LA, Lages RO, Neto HM, Demartini Z, Koppe GL, et al. Diffuse idiopathic skeletal hyperostosis: A review. Surg Neurol Int 2014;5:S122-5.  Back to cited text no. 4
Kmucha ST, Cravens RB Jr. DISH syndrome and its role in dysphagia. Otolaryngol Head Neck Surg 1994;110:431-6.  Back to cited text no. 5
Urrutia J, Bono CM. Long-term results of surgical treatment of dysphagia secondary to cervical diffuse idiopathic skeletal hyperostosis. Spine J 2009;9:e13-7.'  Back to cited text no. 6


  [Figure 1], [Figure 2]


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