Diffuse Idiopathic Skeletal Hyperostosis (DISH) Forestier Disease

"DISH" is a type of degenerative arthritis which is characterized by flowing calcifications along the vertebrae of the spine. It is commonly associated with inflammation (tendinitis) and calcification of tendons at their attachments points to bone. This also leads to formation of bony spurs. Marked calcification and ossification of paraspinous ligaments occur in this disease. Although it is characterized as a variant of Osteoarthritis, diarthrodial joints are not involved. Ligamentous calcification and ossification in the anterior spinal ligaments give the appearance of "flowing wax" on the anterior vertebral bodies. However, a radiolucency may be seen between deposited bone and the vertebral body, differentiating DISH from the marginal osteophytes in spondylosis. Intervertebral disk spaces are preserved, and sacroiliac and apophyseal joints appear, helping to differentiate DISH from spondylosis and from ankylosing spondylitis, respectively.

DISH occurs in the middle-aged and elderly and is more common in men than in wome. Patients are frequently asymptomatic but may have musculoskeletal stiffness. The radiographic changes are generally much severe than might be predicted from the mild symptoms.

Signs & Symptoms

The signs and symptoms you experience depend on what part of your body is affected by diffuse idiopathic skeletal hyperostosis. The upper portion of your back (thoracic spine) is most commonly affected. Signs and symptoms may include:

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  Stiffness in the spine. Stiffness may be most noticeable in the morning.


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  Pain in the spine. You may feel pain when someone presses on your spine. Not everyone with diffuse idiopathic skeletal hyperostosis in the spine will experience pain.


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  Loss of range of motion in the spine. Loss of lateral range of motion may be most noticeable. You flex your spine laterally when you do side stretches, for example.

Diffuse idiopathic skeletal hyperostosis in other parts of your spine or other parts of your body may cause stiffness and pain. Additionally, diffuse idiopathic skeletal hyperostosis in your neck (cervical spine) may cause difficulty swallowing or a hoarse voice.

Frequency

According to study [Rothschild, 1985]

Approximately

Men 19%

Women 4%

in population older than 50 years

Imaging Studies

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  Thoracic vertebrae are involved in 100% of affected individuals, lumbar vertebrae in 68-90% of these persons, and cervical vertebrae in 65-78% of affected individuals. Ligamentous ossification affects both sides of the lumbar vertebral column but tends to be unilateral in the human spine. Prominence of DISH on the right lateral aspect of the thoracic spine is apparently related to aortic pulsations. Left-sided overgrowth is much reduced, also probably because of the influence of aortic pulsations, an idea supported by the notation of left-sided prominence in individuals with situs inversus (left-sided thoracic aorta).


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  The earliest sign of DISH appears to be new bone formation adjacent to the midportion of the vertebral body, a phenomenon often below the limits of radiologic detection. Recognition of DISH is facilitated by its separation from the body of the vertebrae. This gives rise radiologically to the appearance of a radiodense line paralleling the longitudinal axis of the spine but separated by a clearly definable space.


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  The general term DISH emphasizes that the ligamentous ossification phenomenon is not limited to the spine. Exuberant ossification at sites of tendon, ligamentous, or joint capsule insertion (enthesitis) is strongly suggestive of the diagnosis. A tendency toward such ossification at any site of ligament and perhaps tendon insertion appears to exist. Enthesial reaction at the iliac crest and ischial tuberosities often is referred to as pelvic whiskering and typically is quite exuberant. Such whiskering was noted in two thirds of iliac crests studied and in 53% of ischial tuberosities. Enthesial reaction was noted in 42% of lesser and 36% of greater trochanters of the femur. Enthesial spurs at the site of insertion of the quadriceps mechanism into the patella were present in 29% of patients studied. Osseous bridging of fibula and tibia was noted in 10% of patients. Distal metacarpal and phalangeal capsular hyperostosis were present in 13% of patients with DISH (Rothschild, 1985).

Diffuse Idiopathic Skeletal Hyperostosis (DISH). There is flowing ossification (black arrows)that spans more than four contiguous vertebral bodies while the disc height is maintained andthe flowing ossification is separated from the anterior aspect of the vertebral body (blue arrows).

Complications

1. 
   
   Overgrowth of ligamentous calcification could impinge on other structures (eg, the esophagus). Reports of this are rare and often represent inadvertently discovered, neurologically mediated swallowing deficits.


2. 
   
   Posterior longitudinal ligament ossifications may impinge on the spinal cord on rare occasions.


3. 
   
   Reduced vertebral column flexibility predisposes to vertebral fracture.

Differential Diagnosis

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  Ankylosing spondylitis
  Has involvement of SI joints
  Syndesmophytes are thinner


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  Degenerative disc disease
  Osteophytes form only at corners of vertebral bodies
  Narrowing and desiccation of disc


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  Acromegaly
  May produce osteophytes but they are not flowing


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  Fluorosis may produce osteophytes, whiskering and ligamentous ossification
  But all bones are uniformly increased in density

Treatment

Because areas of the spine and tendons can become inflamed, anti-inflammatory medications (NSAIDs), such as ibuprofen and Naproxen, can be helpful in both relieving pain and inflammation of DISH. It is hoped that by minimizing inflammation in these areas, further calcification of tendons and ligaments of the spine leading to calcific bony outgrowths (osteophytes) will be prevented.

PROSTATE - the silent time bomb

Fifty to sixty percent of men between the ages of 40 and 60 will develop an enlarged prostate gland, a condition known as benign prostatic hypertrophy or hyperplasia (BPH).(1,2) The U.S. National Institutes of Health claims that "more than 80 per cent of adult males 50-60 years of age have benign enlargement of the prostate gland," and at least 10 per cent of them will require surgery.(3) Cancer of the prostate causes 35,000 deaths annually in the United States, equivalent to approximately 2-3% of all male deaths.(2,3)

Thousands more suffer from either acute or chronic prostatitis. About 300,000 American men (or one in five) will undergo prostate surgery each year.(3) Prostate problems often cause great frustration, as well as disruption of normal activities, and contribute to several billion dollars a year in health care costs.(2) Although most men anticipate prostate troubles with aging, they are by no means inevitable.

PROSTATE ANATOMY AND PHYSIOLOGY

The walnut-size prostate gland, consisting of three main lobes, lies beneath the bladder surrounding the urethra like a collar. It secretes a thin, milky, alkaline fluid containing substances which neutralize bacteria, citric acid, calcium, acid phosphate, fructose, zinc, a cocktail of enzymes and prosta-glandins. Interestingly, the prostatic fluid is normally ejaculated in the first contraction of orgasm, before the bulk of the seminal fluid, to enhance sperm motility and fertility. It also possibly prepares the cervix to receive the sperm by causing slight dilation and provides a more alkaline environment necessary for fertilization.(3,4)


The prostate grows under the influence of testosterone following puberty until production begins to dwindle around the age of forty.(4) By the age of fifty, the conversion of testosterone to dihydrotestosterone (DHT) increases, causing enlargement of the gland.(1,2,3,4) As the enlargement progresses, the prostate pressure squeezes the urethra, causing obstruction of urine flow. Damage to the kidneys, bladder and ureters, as well as infection from residual urine, may occur when the flow backs up.(1,3) The most common problems associated with the prostate are BPH, prostatitis and cancer. Men over 40 should receive yearly examinations of the prostate, including a digital rectal examinaton (DRE), a blood test for prostate specific antigen (USA), urinalysis and rectal ultrasound (if other tests prove positive).

COMMON SYMPTOMS OF BPH

Most men know the symptoms of BPH: progressive urinary frequency; urgency, especially at night; hesitancy or lack of control in passage of urine; difficulty in cessation of passage of urine (terminal dribbling); reduced force of urine stream; enlarged non-tender, non-lumpy prostate; possible presence of blood in urine with prolonged obstruction; associated infection of bladder due to stagnant urine (retention); discomfort in lower back or legs when urinating; and possible sexual problems due to urethral obstruc-tion. (1,2,3) BPH normally occurs in men over 50. Conventional treatment usually dictates partial removal of the gland, called transurethral resection (TUR or TURP); hydrotherapy; or pills that block 5-alpha reductase, the enzyme which converts testosterone to DHT. (1,3)

PROSTATITIS

Prostatitis refers to infection, inflammation or pain in the prostate. In contrast to BPH, prostatitis usually occurs in younger men between 20 and 50 and can be acute or chronic. (1,3) Bacteria or chlamydia commonly cause the condition, although autoimmune disorders may also play a part. Excessive sexual activity may deplete glandular zinc, ascorbic acid and proteolytic enzymes which normally sterilize the urethra and protect the gland from infection. (2) Symptoms include difficulty, frequency and urgency with a burning sensation or pain during uriniation, and a discharge from the penis after bowel movements. (2) Untreated prostatitis may lead to bladder outlet obstruction and prostate stones. Conventional treatment calls for antibiotics and anti-inflammatory drugs.


PROSTATE CANCER

About 20 per cent of enlarged prostates develop cancer. At least 80 percent of those cases do not metastasize, or grow slowly such that they cause few problems. However, other forms may spread to the bones of the spine or the lymph nodes. (2) Prostate cancer most commonly strikes males over 50 years of age, particularly black Americans, and may not reveal itself through symptoms until metastasis occurs. (1,2,3) Genetics, hormonal factors, late puberty, and vasectomies seem to be associated with prostate cancer. Most physicians select surgery as the treatment of choice for prostate cancer, along with radiation and chemotherapy.


PREVENTATIVE AND NUTRITIONAL SUPPORT


Any condition of the prostate needs attention by a qualified health practitioner. However, the patient must assume responsibility for his nutritional status, since poor nutritional status may significantly and adversely affect the prostate gland. For instance, enlarged prostate tissue contains elevated levels of cholesterol and its metabolites, which can encourage cancer. (1,2,3) Cultures that consume high-fat diets, particulary with high red meat content, have higher rates of prostate cancer.(2) Decreasing sugar consumption contributes to lower prostate cancer rates.(2) Therefore, prevention measures should emphasize a low-fat, low-sugar and high-fiber diet. The patient should also avoid excess caffeine, alcohol and spicy foods as they deplete the prostate of vital nutrients and lower immune function.(2)

Various vitamins, minerals and herbs also may contribute to overall prostate health. Essential nutrients include optimal levels of zinc (which decreases 5-alpha reductase activity and helps prevent oxidation and infection), vitamin B-6 (which maximizes the activity of zinc by enhancing absorption), essential fatty acids (which help combat cholesterol and can dramatically improve the condition of men with BPH), vitamins C and E (antioxidants), and amino acids (particularly glycine, glutamic acid and alanine which seem to protect against prostate disease).(1,2,3,5)
Several herbs have demonstrated extraordinary results in the treatment of prostate disease, the most promising of which is Serenoa repens also known as saw palmetto. It reduces swelling of BPH, stimulates immune function and inhibits 5-alpha reductase activity to prevent conversion of testosterone to DHT.(2,3) Its action parallels that of PROSCAR, the leading drug prescribed for BPH. However, in clinical trials, saw palmetto produced extremely effective results without the side effects of the drug, such as loss of libido and impotency.(3,5,6) Extract of saw palmetto has increased urine flow rates by 50%, substantially reduced residual urine and nocturnal urination, and reduced symptoms of frequency and urgency.(3) Effective dosage of 4:1 saw palmetto extract would be approximately 300 mg. per day vs. 20 grams of the crude berries.(5)
Pygeum africanum produces anti-inflammatory, anti-edema and cholesterol- lowering properties and may inhibit the binding of hormones to receptors in the prostate to contain BPH.(2,3) Uva ursi, a powerful urinary tract antiseptic, helps increase blood flow in the prostate.(2) Pumpkins seeds and flaxseed oil provide excellent sources of essential fatty acids.


REFERENCES

1. Chaitow, Leon, N.D., D.O. Prostate Troubles: A Druq-Free Programme to Help Alleviate Prostate Problems. London:Thorsons Publishers, 1988.2. Burton Goldberg Group, ed. Male Health. Alternative Medicine: The Definitive Guide. Puyallup, WA: Future Medicine Publishing, Inc., 1993, pp. 733-743.3. Hamand, Jeremy. Prostate Problems: The Complete Guide to Treatment. London: Thorsons Publishers, 1991.4. Guyton, Arthur C., M.D. Textbook of Medical physiology 8thth ed. Philadelphia: W. B. Saunders Company, 1991.5. Murray, Michael, N.D. and Pizzorno, J., N.D. "Prostate Enlargement," Encyclopedia of Natural Medicine. Rocklin, CA: Prima Publishing, 1991.6. Champlault, G., Patel J.C, and Bonnard, A.M. A double-blind trial of an extract of the plant Serenoa repens in benign prostatic hyperplasia. Br. J. Chin. pharmacy., vol 18, 1984, 461-2.