The controlled study of diffuse idiopathic skeletal hyperostosis for the assessment of physical function in elderly populations

Effect of Diffuse Idiopathic Skeletal Hyperostosis on the Occurrence of Thoracolumbar Vertebral Fragility Fractures at Different Ages

STUDY DESIGN

Retrospective Case control Study.

OBJECTIVES

To analyze the effect of diffuse idiopathic skeletal hyperostosis (DISH) on the occurrence of new thoracolumbar vertebral fragility fractures (VFFs) at different ages.

METHODS

A retrospective analysis of 564 patients, including 189 patients who presented with new-onset thoracolumbar VFFs and 375 patients without spinal fractures, was performed in 4 age groups (50-59 years, 60-69 years, 70-79 years, and 80+ years). DISH was diagnosed based on computed tomography findings, and the Mata score of each disc space level combined with the maximum number of consecutive ossified segments (MNCOS) for each patient was recorded. Data were compared between the fracture and control groups, and odds ratios (ORs) were calculated for each of the 4 age groups using logistic regression.

RESULTS

Both the crude ORs and the adjusted ORs of DISH for VFFs decreased with age, with statistical significance shown in the 50-59 years group (crude OR = 4.373, P = 0.017; adjusted OR = 7.111, P = 0.009) and the 80+ years group (crude OR = 0.462, P = 0.018; adjusted OR = 0.495, P = 0.045). The Mata scores and the MNCOS were significant risk factors for VFFs (P < 0.05) in the 50-59 years group, but they were protective factors in the 80+ years group, which was more significant in the T11/12-L5/S1 subsegment.

CONCLUSIONS

The effect of DISH on the occurrence of thoracolumbar VFFs is complex, and in patients above 50 years, it changes from a risk factor to a protective factor with increasing age.

Long-term effects of diffuse idiopathic skeletal hyperostosis on physical function: A longitudinal analysis

BACKGROUND

Cross-sectional studies on diffuse idiopathic skeletal hyperostosis have focused on its incidence and related factors. However, the long-term changes caused by the disease remain unclear. This longitudinal cohort study aimed to elucidate the progression of diffuse idiopathic skeletal hyperostosis and its effects on physical function, health-related quality of life, and spinal alignment.

METHODS

We recruited 255 older adults (87 men and 168 women; average age, 71.3 years in 2014) who attended local health checkups in 2014 and 2020. Height, body weight, body mass index, blood pressure, grip strength, functional reach, and bone mineral density were measured. The prevalence, location, number of ossified contiguous vertebrae, and spinopelvic parameters were estimated using whole-spine standing radiographs. For health-related quality of life assessment, the Oswestry disability index and EuroQuol-5D were obtained. We performed a 1:1 case-control study with age and sex-matched patients with and without diffuse idiopathic skeletal hyperostosis and analyzed progression over a 6-year period.

RESULTS

In 2014, 39 (15.3%) of 255 patients were diagnosed with diffuse idiopathic skeletal hyperostosis (24 males and 15 females), which occurred more frequently in the elderly and males. In 2020, 12 (4.3%) patients were newly diagnosed with diffuse idiopathic skeletal hyperostosis, and 28 (71.7%) of 39 patients diagnosed in 2014 showed varying degrees of progression. Compared with age- and sex-matched patients without diffuse idiopathic skeletal hyperostosis, patients with the condition had higher body mass index and lumbar bone mineral density, larger sagittal vertical axis, and greater T1-pelvic angle. Changes in physical function and spinal-pelvic parameters during the 6-year period did not differ between the groups.

CONCLUSIONS

Over a 6-year period, the prevalence of diffuse idiopathic skeletal hyperostosis increased by 4.3%, and it progressed in 71.7% of patients. However, it had little effect on longitudinal physical function, health-related quality of life, and spinopelvic parameters in older adults.

The prevalence and characteristics of diffuse idiopathic skeletal hyperostosis in the community-living middle-aged and elderly population: The Yakumo study

BACKGROUND

The incidence of diffuse idiopathic skeletal hyperostosis (DISH) is increasing with the aging of the population. Asymptomatic DISH can decrease the spinal range of motion (ROM) and cause fractures. However, the prevalence or physical function of patients with DISH before experiencing fractures and other serious conditions is unclear. This study aimed to investigate the prevalence of DISH in the community residents on the basis of age and sex and characterize their physical function, ROM, and bone fragility.

METHODS

The subjects were community volunteers who attended a health checkup in 2018 and 2019. Overall, 455 subjects (mean age, 64.2 ± 9.7 years; 177 men) were included for analysis. We performed whole-spine lateral radiography for detecting DISH according to the criteria reported by Resnick. We compared the age, sex, body mass index (BMI), results of muscle strength and walking tests, ROM measured by SpinalMouse®, and quantitative ultrasound (QUS) of calcaneus with and without DISH.

RESULTS

DISH was detected in 83 (18.2%) cases. The DISH group was older (69.8 y.o. vs. 63.0 y.o.; p < 0.05) and comprised more men (prevalence: men, 27.7%; women, 12.2%; p < 0.001). BMI was high in the DISH group (24.8 vs. 23.3 kg/m2, p < 0.05). SpinalMouse measurements showed the DISH group had a significantly decreased ROM in the lumbar spine (43.2°, 57.2°, p < 0.05). The DISH group had a significantly lower T-score on the QUS measurement in the calcaneus (-2.0, -1.5, p < 0.05). There were, however, no significant differences between groups in both muscle strength test and walking test.

CONCLUSION

Subjects with DISH had decreased ROM in the lumbar spine and bone mineral density in calcaneal QUS. However, physical functions such as muscle strength and walking ability were similar among subjects with and without DISH without subjective symptoms.

Prevalence and characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in Italy

Purpose

Diffuse idiopathic skeletal hyperostosis (DISH) is a benign condition characterized by ossification of the spine and prominent enthesopathies. Highly heterogeneous epidemiological figures have been reported in the literature, while in Italy the largest study has been conducted in 1992. The aim of our research is to contribute updated information about prevalence of DISH in Italy and to describe the clinical and radiographic characteristics associated with the disorder.

Material and methods

A retrospective review of lumbosacral spine, thoracic spine and pelvis radiographs was performed. Consecutive patients visiting the emergency department of our Institution over 3 years were enrolled. Presence of DISH was evaluated applying the Resnick and Niwayama criteria. Clinical and radiological features were also assessed.

Results

We included 1012 individuals (60.6% women), and DISH was present in 130 cases. The overall prevalence of DISH was 12.8% (95% CI 10.8–15.1), with higher figures in the male sample (16.8%) than in females (10.3%). In binary logistic regression adjusted for age, BMI (OR 1.50, p < 0.001) diabetes (OR 1.85, p = 0.003), hypertension (OR 2.04, p = 0.007) ischiopubic enthesopathy (OR 7.08, p < 0.001), iliac crest enthesopathy (OR 4.63, p < 0.001) and greater trochanter enthesopathy (OR 3.51, p < 0.001), were significantly associated with the condition.

Conclusion

The prevalence of DISH observed in our study is consistent with previous literature, and we confirm that the disorder is more frequently retrieved in men and that it is associated with the presence of metabolic disorders and pelvic enthesopathy. Knowledge about the epidemiology and characteristics of DISH is needed to properly identify the condition.

Association between diffuse idiopathic skeletal hyperostosis and thoracic kyphosis in patients with cervical myelopathy: a retrospective observational study

Background

Diffuse idiopathic skeletal hyperostosis (DISH) is a structural abnormality of the thoracic spine that is known to impair posture. However, the relationship between DISH and sagittal balance in the whole spine is unclear. The aims of this study were to investigate the prevalence of DISH in patients with cervical myelopathy caused by cervical ossification of the posterior longitudinal ligament (OPLL) or cervical spondylosis and to compare sagittal alignment of the spine between patients with and without DISH.

Methods

A total of 103 consecutive patients with a diagnosis of cervical myelopathy due to cervical OPLL or spondylosis were retrospectively enrolled in this single-center study. DISH was defined as an ossified lesion that was seen to be completely bridging at least four contiguous adjacent vertebral bodies in the thoracic spine on computed tomography scans. Cervical and spinopelvic sagittal parameters were measured in whole spine radiographs.

Results

The study population included 28 cases with DISH [DISH (+) group] and 75 without DISH [DISH (−) group]. OPLL was more prevalent in the DISH (+) group than in the DISH (−) group; however, there were no significant differences in other clinical findings. Propensity score matching produced 26 pairs. C7 slope, C2-7 sagittal vertical axis (C-SVA), whole thoracic kyphotic angles, upper thoracic kyphosis, and T5-T12 thoracic kyphosis values were significant higher in the DISH (+) group than in the DISH (−) group. There was no significant between-group difference in the other sagittal spinopelvic parameters.

Conclusions

This study is the first to compare sagittal alignment in patients with cervical myelopathy according to whether or not they have DISH. Patients with DISH are more likely to have excessive kyphosis in the thoracic spine, a high C7 slope, and a high C2-7 SVA.

The effectiveness of chemonucleolysis with condoliase for treatment of painful lumbar disc herniation

BACKGROUND

Chemonucleolysis with condoliase, which degrades chondroitin sulfate, could be a new, minimally invasive therapeutic option for patients with lumbar disc herniation (LDH). The purpose of this study was to analyze prognostic factors for clinical outcomes in LDH patients subjected to chemonucleolysis with condoliase.

METHODS

Inclusion criteria for this procedure were 1) 18-70 years of age; 2) unilateral leg pain and positive straight leg raise (SLR) (<70°) or femoral nerve stretching test; 3) subligamentous extrusion verified on magnetic resonance imaging; 4) neurological symptoms consistent with a compressed nerve root on magnetic resonance imaging (MRI) images; and 5) minimum six months of follow-up. In total, 82 patients (55 men, 27 women; mean age, 47.2 ± 15.5 years; mean follow-up, 9.1 ± 3.0 months) who underwent chemonucleolysis with condoliase for painful LDH were included. An improvement of 50% or more in the Visual analogue scale (VAS) of leg pain was classified as effective.

RESULTS

Seventy patients (85.4%) were classified into the effective (E) group and 12 patients (14.6%) into the less-effective (L) group. Surgical treatment was required in four patients. No severe adverse complications were reported; 41.3% of the patients developed disc degeneration of Pfirrmann grade 1 or more at the injected disc level. Univariate analysis revealed that young age (p = 0.036), without history of epidural or nerve root block (p = 0.024), and injection into the central portion of the intervertebral disc (p = 0.014) were significantly associated with clinical effectiveness. A logistic regression analysis revealed that injection into the central portion of the intervertebral disc (p = 0.049; odds ratio, 4.913; 95% confidence interval, 1.006-26.204) was significantly associated with clinical effectiveness.

CONCLUSIONS

Chemonucleolysis with condoliase is a safe and effective treatment for painful LDH; 85.4% of the patients showed improvement after the treatment without severe adverse events. To obtain the best outcome, condoliase should be injected into the center of the intervertebral disc.

Differences in Bone Mineral Density and Bone Turnover Markers Between Subjects With and Without Diffuse Idiopathic Skeletal Hyperostosis

STUDY DESIGN

Japanese resident cohort study based on a municipal registry.

OBJECTIVE

This study of a community-dwelling elderly Japanese population employed random sampling from the basic resident registry of a rural town for subject selection to investigate the differences in bone mineral density (BMD) and bone turnover markers between subjects with and without diffuse idiopathic skeletal hyperostosis (DISH).

SUMMARY OF BACKGROUND DATA

DISH is a condition characterized by the calcification and ossification of soft tissues. Although some reports have addressed BMD in DISH, the precise status of BMD and bone metabolism in individuals with DISH remains unclear.

METHODS

Eight groups based on age (50s, 60s, 70s, and 80s) and sex after random sampling from the resident registry of Obuse town were established. A total of 411 participants (202 males and 209 females) were enrolled for the evaluation of BMD and bone turnover markers. All subjects underwent a single whole-spine lateral radiographic examination for the existence of DISH. The BMD and bone turnover markers of subjects with and without DISH were analyzed for associations with the disorder using multivariate analysis.

RESULTS

DISH was detected in 66 (16.1%) participants in our population cohort. According to multivariate analysis, increased lumbar and hip BMD were significantly related to DISH (odds ratio: 7.47 and 22.8, respectively).

CONCLUSION

This study clarified the differences in BMD and bone turnover markers between subjects with and without DISH on a general population basis. Multivariate analysis revealed increased lumbar and hip BMD to be significantly associated with DISH, with no remarkable findings for bone turnover markers.

LEVEL OF EVIDENCE

4.

Metabolic Syndrome is a Predisposing Factor for Diffuse Idiopathic Skeletal Hyperostosis

OBJECTIVE

Diffuse idiopathic skeletal hyperostosis (DISH) causes spinal ankylosis, which can result in patients suffering specific spinal fractures that lead to a reduction in the activities of daily life in older patients. Currently, DISH is associated with diabetes mellitus and cardiovascular disease; however, the association between DISH and metabolic syndrome has not been established. The purpose of this study was to investigate a potential association between DISH and metabolic syndrome.

METHODS

We retrospectively reviewed clinical data from consecutive subjects undergoing the musculoskeletal health medical checkups, and enrolled 327 subjects (174 men and 153 women; mean, 63.4 ± 13.7-years). Subjects who had spinal ankylosis at least 4 contiguous vertebral bodies were classified as the DISH group (n = 39) while the others were part of the non-DISH group (n = 288). The definition of the metabolic syndrome comes from diagnostic criteria used by the Japanese Society for Internal Medicine. Age, sex, body max index (BMI), hematological evaluation, blood pressure, presence of metabolic syndrome, the visceral fat area on abdominal computed tomography, and spinal epidural lipomatosis (SEL) on magnetic resonance imaging were evaluated.

RESULTS

Compared to the non-DISH group, in the DISH group, mean age (DISH group, 74.3 years; non-DISH group, 1.9 years; p < 0.001), male prevalence were higher (DISH group, 82.1%; non-DISH group, 49.3%; p < 0.001), and BMI was greater (DISH group, 24.8; non-DISH group, 23.0; p = 0.006). the metabolic syndrome was more frequently observed in DISH group (28.9%) than in the non-DISH group (16.0%) (p = 0.045). The visceral fat area was significantly larger in the DISH group than in the non-DISH group (DISH group, 130.7 ± 58.2 cm2; Non-DISH group, 89.0 ± 48.1 cm2; p < 0.001). The prevalence of SEL was similar between the 2 groups (10.3% in the DISH group vs. 8.7% in the nonDISH group; p = 0.464). Poisson regression analysis revealed that the metabolic syndrome was significantly associated with DISH with odds ratio of 2.0 (95% confidence interval, 1.0-3.7; p = 0.004).

CONCLUSION

Metabolic syndrome was significantly associated with DISH. Our data showed metabolic syndrome is potentially related to DISH.

Differences between diffuse idiopathic skeletal hyperostosis and spondyloarthritis

Diffuse idiopathic skeletal hyperostosis (DISH) is a skeletal syndrome that has been known for more than 70 years. Yet, its pathogenesis and treatment options are still under investigation. DISH and spondyloarthritidies may manifest itself clinically as very similar disorders causing impaired axial flexibility, axial pain and peripheral tendinopathies. On the other hand, these two processes are different in many ways, from different genetic and metabolic predispositions, to different clinical and imaging manifestations, and at last, a different attitude toward treatment. The knowledge of the similarities and differences between DISH and spondyloarthritidies can guide the clinician toward a better diagnostic and treatment approach. This review tries to emphasize these details.

Prevalence of Diffuse Idiopathic Skeletal Hyperostosis in the General Elderly Population: A Japanese Cohort Survey Randomly Sampled From a Basic Resident Registry

STUDY DESIGN

This is a Japanese resident cohort study based on a municipal registry.

OBJECTIVES

In this study of an aged Japanese population, we used random sampling from the basic resident registry of a rural town for subject selection to investigate the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) and effect of subject-related factors.

SUMMARY OF BACKGROUND

DISH is a condition characterized by the calcification and ossification of soft tissues. Interest is mounting on DISH as the elderly rate increases, but its pathogenetic mechanism remains unknown.

DATA

A total of 413 aged people randomly sampled from the resident registry of Obuse town.

MATERIALS AND METHODS

We established 8 groups on the basis of age (50s, 60s, 70s, and 80s) and sex after random sampling from the resident registry of Obuse town. A total of 411 participants (202 male and 209 female) were enrolled and underwent a single whole-spine lateral radiographic examination. We assessed for the existence of DISH and analyzed the effects of clinical factors using multivariate analysis.

RESULTS

A total of 72 (17.5%) participants were identified to have DISH in our population cohort. The prevalence of DISH tended to increase with age, being 3.1% in subjects in their 50s, 14.0% in their 60s, 24.3% in their 70s, and 29.0% in their 80s. According to multivariate analysis, hypertension (HT), male, bone mineral density (BMD), and aging were independent factors associated with DISH. The odds ratios of HT, male, and BMD were 1.93, 2.88, and 19.1, respectively.

CONCLUSIONS

This is the first study examining DISH in detail according to age and sex groups on a general population basis. Multivariate analysis revealed HT, male, BMD, and aging to be independent factors associated with DISH in the healthy community-dwelling elderly.

Lumbar spinal canal stenosis in patients with diffuse idiopathic skeletal hyperostosis: Surgical outcomes after posterior decompression surgery without spinal instrumentation

BACKGROUND

To evaluate surgical outcomes after posterior decompression surgery for lumbar spinal canal stenosis (LSS) in patients with diffuse idiopathic skeletal hyperostosis (DISH).

METHODS

The patients (n = 184; 132 males and 52 females; mean age 72.0 years; mean follow-up 30.7 months) who underwent posterior decompression surgery for LSS were identified and classified as either DISH (D) or non-DISH (N) based on whole spine radiograph findings. Data on age, gender, American Society of Anesthesiologists (ASA) classification, operation time, and estimated blood loss, were evaluated, while radiographic parameters were measured from radiographs obtained pre- and post-operatively.

RESULTS

Mean age and ASA classification were comparable between the two groups, while the proportion of males was significantly higher in the D group (87.5%) than in the N group (67.6%) (p = 0.016). Further, mean operation time was longer in the D group (89.0 min) than in the N group (73.7 min) (p = 0.036) and mean estimated blood loss was larger in the D group (98.7 g) than in the N group (51.9 g) (p = 0.006). At two years after surgery, the development of anterior translation was significantly higher in the D group (33.3%) than in the N group (17.3%) (p = 0.021). Improvements in ODI and SF-8 after the surgery were better in the N group than in the D group.

CONCLUSIONS

Compared to LSS patients without DISH who also underwent posterior decompression surgery for LSS, surgery in patients with DISH was characterized by greater blood loss, longer operation time, increased translation at the decompressed segment, and poor recovery.