A radiological study of the natural history of diffuse idiopathic skeletal hyperostosis (DISH): a story of incomplete fusion

Introduction: DISH is an ankylosing disease, when fractured can be challenging to manage. A retrospective radiological study was conducted to evaluate the natural history and radiological characteristics of DISH on Computed tomography (CT).Methods: Paired CT scans with DISH that are separated at least two years apart were used to perform the following radiological measurements: Degree of disc space fusion, Osteophyte and vertebral body linear attenuation coefficients (LAC), and Osteophyte axial area size and location.Results: 164 patients were analysed with a mean duration of 4.49 years between scans. 38.14% (442/1159) of disc spaces had at least partial calcification. Most osteophytes were right sided before becoming more circumferential over time. The average fusion score was 54.17. Most of the changes in fusion occurred in the upper and lower thoracic regions. The thoracic region when compared to the lumbar region had a greater proportion of its disc spaced being fully fused. Disc level osteophyte areas were larger than Body level osteophytes. Disc osteophytes size growth rate drops over time from 10.89mm2/year in Stage 1 to 3.56mm2/year in Stage 3. Stage 3 disc spaces (-11.01HU/year) was also found to have had a reduction in their LAC over time when compared to Stage 1 disc spaces (17.04HU/year). This change in osteophyte LAC was not mirrored in the change in vertebral body LAC. We predict that the age of onset and complete thoracolumbar ankylosis of DISH to be 17.96 years and 100.59 years, respectively.Conclusion: DISH ankylosis of the spine a slow process that starts in the mid to lower thoracic region before extending cranially and caudally. After the bridging osteophyte has fully formed, remodelling of the osteophyte occurs.