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A finding and an explanation are different

DISH can be discovered on imaging taken for another reason. Some people notice stiffness or reduced movement; others have pain, an attachment-site problem or a compressive complication. The presence of a characteristic bone pattern does not prove that every symptom comes from it. Assessment needs the history, examination and the position of the abnormality relative to the symptom.1

“Hyperostosis” describes excess bone formation. In DISH it commonly involves the anterolateral spine, meaning the front and side, especially in the thoracic region. Entheses are places where tendons or ligaments attach to bone. Changes may also occur around the pelvis, heels, elbows or other peripheral sites. These terms describe anatomy; they do not explain a patient's cause of pain by themselves.2

What imaging criteria are for

Commonly used Resnick and Niwayama classification criteria describe flowing bone formation across at least four contiguous vertebral bodies, relative preservation of disc height, and absence of certain facet and sacroiliac changes typical of competing diagnoses. They were designed to identify established radiographic disease. Their use is part of professional interpretation rather than a checklist for someone to apply to a scan at home.2

Early-phase criteria proposed by Kuperus were developed from retrospective thoracic CT cohorts and assessed against later imaging. Their endpoint was the evolution of the bone pattern over approximately five years. That work does not show that an early imaging classification predicts pain, disability, swallowing difficulty or a need for surgery. It also does not mean everyone needs repeated CT to look for DISH.3

Radiographs may show the overall pattern, while CT can clarify bone anatomy and MRI can answer different questions about soft tissue, nerves or injury. A clinician chooses a test for the question being investigated, balancing what it adds with its limitations. No single scan independently establishes why an individual hurts.2

Diagnosis includes the differential

Ordinary degeneration, ankylosing spondylitis and ossification of the posterior longitudinal ligament are distinct conditions that may coexist with DISH. Sacroiliac joints are not invariably normal: a CT study in selected lumbar surgery patients found paraarticular bridging and other changes in DISH. The whole pattern and clinical context matter more than one absolute rule.4

Age and metabolic conditions can be relevant context, but there is no rigid birthday threshold that confirms or excludes DISH. Associations with diabetes or obesity do not establish a single reversible cause. Nor should “noninflammatory” be read as proof that no inflammatory process can ever be present.2

Prepare for the consultation

Bring the imaging report and, where feasible, the images themselves. Describe when symptoms began, what limits daily activities, whether symptoms are changing and whether an injury preceded them. Ask which findings are incidental, which could explain symptoms, and what alternative diagnosis or coexisting condition remains possible.

Significant new neck or back pain after a fall or other trauma needs prompt professional assessment in a rigid spine. New weakness, numbness or difficulty walking after injury needs urgent assessment. An earlier DISH diagnosis should not lead anyone to dismiss a new symptom as ordinary stiffness.5

References

Cleveland Clinic. Diffuse Idiopathic Skeletal Hyperostosis. Updated 28 April 2024. Source ↩
Mader R et al. RMD Open. 2017;3:e000472. doi:10.1136/rmdopen-2017-000472. Source ↩
Kuperus JS et al. Radiology. 2019;291:420–426. doi:10.1148/radiol.2019181695. PubMed ↩
Yahara Y et al. BMC Musculoskeletal Disorders. 2020;21:93. doi:10.1186/s12891-020-3105-z. Source ↩
Reinhold M et al. Global Spine Journal. 2018;8(2 Suppl):56S–68S. doi:10.1177/2192568217736268. Source ↩