DISH... The progressive "hardening" of the spine that may appear after age 50.

Diffuse Idiopathic Skeletal Hyperostosis (DISH or Forestier's disease) is a condition that mainly "hardens" the spine in older age. It is typically a slow, chronic condition rather than something that develops suddenly.

Simple Explanation

In DISH, excess bone forms on the ligaments and tendons around the spine. This makes the spine more "rigid", as if some vertebrae are "stuck" together.

Who Is Most at Risk

The condition mainly affects people over 50–60 years old and is more common in men. It is often linked to increased weight, diabetes, and general metabolic problems, though the exact cause is unknown.

Possible Symptoms

Many people have no symptoms at all, and the issue is found incidentally on an X-ray. When there is discomfort, it is usually:

• Stiffness and rigidity in the back or lower back, especially in the morning

• Mild to moderate chronic pain that worsens with fatigue or immobility

• In advanced cases in the neck, bones may press on the oesophagus or trachea, causing difficulty swallowing or hoarseness.

  
  

How It Appears on Tests

Diagnosis is mainly via X-rays or CT scans of the spine. The doctor sees bone "tongues" or "bridges" in front of many consecutive vertebrae, while the discs and small joints often remain relatively intact. Blood tests are usually normal.

Not the Same as Other Rheumatic Conditions

DISH is not a classic inflammatory rheumatic disease. Unlike ankylosing spondylarthritis, it occurs in older age and is not usually accompanied by strong inflammatory findings on tests or characteristic involvement of the sacroiliac joints.

Should I Worry About My Children?

It is not considered typically hereditary, although there may be a general predisposition in some families. There are no specific genetic tests done for DISH in everyday practice.

Treatment Options

No pill dissolves the extra bone or reverses it to its previous state. For most people, simple conservative management suffices:

• Painkillers and/or anti-inflammatories when the back or lower back hurts

• Physiotherapy and exercises for better flexibility and muscle strengthening

• Weight, sugar, and cholesterol control with the doctor's help

  
  

Surgery is rarely needed, only when extra bone severely presses on nerves, the oesophagus, or trachea, or when a fracture occurs in a very rigid spine. It is very important to emphasise that patients with DISH have some significant peculiarities when spinal surgery is required. These affect both preoperative planning and the technique and safety of the operation:

• Because large sections of the spine in DISH are fused, functioning like a single "long bone", it becomes more fragile to fracture even after minor trauma, and fractures are often unstable with increased risk of neurological damage.

• Patients with DISH are usually elderly with co-existing metabolic diseases (diabetes, obesity, cardiac issues), so they have higher anaesthetic and surgical risk. There is greater likelihood of infections, delayed healing, and complications from prolonged bed rest, hence requiring meticulous multidisciplinary planning and emphasis on early mobilisation.

• Limited mobility (neck, thoracic, lumbar sections) complicates anaesthesia (intubation) and patient positioning on the operating table without causing fracture. Careful screening for "silent" fractures, detailed imaging (CT/MRI of large spine sections), and special attention to handling during anaesthesia and position changes are needed.

• When there is a fracture or decompression, longer spinal fusion (many vertebrae above and below the injury) is usually required compared to other patients.

• Co-existing osteoporosis increases the risk of implant loosening or failure, so enhanced techniques are needed (e.g. more screws, cement, stronger implants).

  
  

Daily Life Tips

• Mild, regular exercise (walking, swimming, simple stretches)

• Avoid many hours in the same position, especially sitting

• Caution with falls and sudden impacts, especially in older age

• Regular check-ups with a doctor (orthopaedic, rheumatologist, or neurosurgeon, depending on the issue)

  
  

Although the X-ray appearance can look impressive, in many people DISH remains mild and allows a normal life with a bit more care and good habits.

Photo resource: Kuperus, Jonneke S et al. “The Natural Course of Diffuse Idiopathic Skeletal Hyperostosis in the Thoracic Spine of Adult Males.” The Journal of rheumatology vol. 45,8 (2018): 1116-1123. doi:10.3899/jrheum.171091

Three-dimensional CT reconstruction of the thorax performed on the same patient in 2005, 2008, and 2010, depicting the progressive ossification of the spine.