Clin Osteol 2025; 30(2): 100-107

Forestiere disease and fracture riskReview articles

Pavol Masaryk
Národný ústav reumatických chorôb, Piešťany

Diffuse idiopathic skeletal hyperostosis (DISH, Forestier's disease) is a systemic non-inflammatory disease of the musculoskeletal system, causing ossification and calcification of the spinal ligaments and attachments around the joints. Although the spine appears robust with richly formed bone, it is actually more prone to fracture in individuals with DISH compared to unaffected individuals. Fractures are caused by a unique "lever-like" mechanism created by bone bridges. Spinal fractures in DISH can be easily missed with plain X-rays, so a CT or MRI scan is recommended if a fracture is suspected. Spinal bone density measured by both DXA and QCT tends to be increased, but TBS is decreased, which could explain the increased risk of fractures. PINP can be considered a potential indicator of hyperostosis.

Keywords: hyperostosis, fractures, densitometry.

Published: June 1, 2025  Show citation

ACS AIP APA ASA Harvard Chicago Chicago Notes IEEE ISO690 MLA NLM Turabian Vancouver
Masaryk P. Forestiere disease and fracture risk. Clinical Osteology. 2025;30(2):100-107.
Share...
Download citation
  • BibTeX (.bib)
  • Bookends (.ris)
  • EasyBib (.ris)
  • EndNote (.enw)
  • EndNote 8 (.xml)
  • ISI WoS (.isi)
  • Medlars (.medlars)
  • Mendeley (.ris)
  • MODS (.xml)
  • Papers (.ris)
  • RefWorks (.txt)
  • RefManager (.ris)
  • RIS (.ris)
  • MS Word (.xml)
  • Zotero (.ris)
    • Purchase PDF - 50 CZK
    will be unlocked 1.6.2026

    References

    1. Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann Rheum Dis. 1950;9:321-330.
    2. Resnick D, Shaul SR, Robins JM, et al. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations. Radiology. 1975;115:513-524.
    3. Resnick D, Niwayama G. Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology. 1976;119(3):559-568.
    4. Harlianto NI, Kuperus JS, Muhamed Hoesein FAA, et al. Diffuse idiopathic skeletal hyperostosis of the cervical spine causing dysphagia and airway obstruction: an updated systematic review. Spine J. 2022 Sep;22(9):1490-1503.
    5. Utsinger PD, Resnich D, Shapiro M. Diffuse skeletal abnormalities in Forestier disease. Arch Intern Med. 1976;136(7):763-8.
    6. Mata S, Chkem RK, Fortin PR, et al. Comprehensive radiographic evaluation of diffuse idiopathic skeletal hyperostosis: development and interrater reliability of a scoring system. Semin Arthritis Rheum. 1998;28:88-96.
    7. Julkunen H, Knekt P, Aromaa A, et al. Spondylosis deformans and diffuse idiopathic skeletal hyperostosis (DISH) in Finland. Scand J Rheumatol. 1981;10(3):193-203.
    8. Scheinost M, Němejcova K, Pudlač A, et al. Difuzní skeletální idioopatická hyperostoza, Vnit Lek. 2014;60(5-6):442-447.
    9. Cassim B, Mody GM, Rubin DL. The prevalence of diffuse idiopatic skeletal hyperostosis in African blacks. Br J Rheumatology. 1990;29(2):131-132.
    10. Westerveld LA, Quarles van Ufflord HME, Varlan JJ, et al. The prevalence of diffuse idiopathic skeletal hyperostosis in an outpatient population in The Netherlands. J Rheumatol. 2008;35(8):1635-1638.
    11. Ahmed O, Ramachandran K, Patel J, et al. Diffuse Idiopathic Skeletal Hyperostosis Prevalence, Characteristics, and Associated Comorbidities: A Cross-Sectional Study of 1815 Whole Spine CT Scans. Global Spine J. 2024 May;14(4):1201-1209.
    12. Kiss C, O Neil TW, Mituszova M, et al. The prevalence of diffuse idiopathic skeletal hyperostosis in a population-based study in Hungary. Scand J Rheumatol. 2002;31(4):226-9.
    13. Kagotani R, Yoshida M, Muraki S, et al. Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) of the whole spine and its association with lumbar spondylosis and knee osteoarthritis: the ROAD study. J Bone Miner Metab. 2015 Mar;33(2):221-9.
    14. Weinfeld RM, Olson PN, Maki DD, et al. The prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in two large American Midwest metropolitan hospital population. Skeletal Radiol. 1997;26(4):222-5.
    15. Harlianto NI, Ezzafzafi S, Foppen W, et al. The prevalence of vertebral fractures in diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: A systematic review and meta-analysis. North American Spine Society Journal (NASSJ). 2024;17:100312.
    16. Okada E, Yoshii T, Yamada T, et al. Spinal fractures in patients with Diffuse idiopathic skeletal hyperostosis:A nationwide multi-institution survey. Case Reports J Orthop Sci. 2019 Jul;24(4):601-606.
    17. Gerber LH, Helfgott RK, Gross ER, et al. Vertebral abnormalities associated with synthetic retinoid use. J Am Acad Dermatol. 1984 May;10(5 Pt 1):817-23.
    18. Kim SK, Soi BR, Kim CHG, et al. The prevalence of diffuse idiopathic skeletal hyperostosis in Korea. J Rheumatol. 2004;31(10):2032-2035.
    19. Tsukahara S, Miyazawa N, Akagawa H, et al. COL6A1, the candidate gene for ossification of the posterior longitudinal ligament, is associated with diffuse idiopathic skeletal hyperostosis in Japanese. Spine (Phila Pa 1976). 2005 Oct 15;30(20):2321-4.
    20. Šenolt L, Hulejová H, Krištufkova O, et al. Low circulating Dickkopf-1 and its link with severity of spinal involvement in diffuse idiopathic skeletal hyperostosis. Ann Rheum Dis. 2012 Jan;71(1):71-4.
    21. Murakami Y, Machima N, Morino T, et al. Association Between Vertebral Fracture and Diffuse Idiopathic Skeletal Hyperostosis. Spine (Phila Pa 1976). 2019 Sep;44(18):E1068-E1074.
    22. Okada E, Ishihara S, Azuma K, et al. Metabolic Syndrome is a Predisposing Factor for Diffuse Idiopathic Skeletal Hyperostosis Neurospine. 2021;18(1):109-116.
    23. Guiot A, Estublier CH, Gaude M, et al. Relationship between diffuse idiopathic skeletal hyperostosis and fragility vertebral fracture: a prospective study in older men. Rheumatology (Oxford). 2021 May 14;60(5):2197-2205.
    24. Furukawa M, Okuyama K, Ninomiya K, et al. Association of Continuous Vertebral Bone Bridges and Bone Mineral Density with the Fracture Risk in Patients with Diffuse Idiopathic Skeletal Hyperostosis. Asian Spine J. 2022;16(1):75-81.
    25. Schwartz JB, Rackson M. Diffuse idiopathic skeletal hyperostosis causes artificially elevated lumbar bone mineral density measured by dual X-ray absorptiometry. J Clin Densitom. 2001;4:385-388.
    26. Sahin G, Polat G, Bagis S, et al. Study of axial bone mineral density in postmenopausal women with diffuse idiopathic skeletal hyperostosis related to type 2 diabetes mellitus. J Women's Health. 2002;11:801-804.
    27. Di Franco M, Mauceri MT, Silli-Scavalli A, et al. Study of peripheral bone mineral density in patients with diffuse idiopathic skeletal hyperostosis. Clin Rheumatol. 2000;19(3):188-92.
    28. Diederichs G, Engelken F, Marshall LM, et al. Diffuse idiopathic skeletal hyperostosis (DISH): relation to vertebral fractures and bone density. Osteoporos Int. 2011 Jun;22(6):1789-97.
    29. Kuperus J, Samsour L, Buckens CF, et al. Bone mineral density changes over time in diffuse idiopathic skeletal hyperostosis of the thoracic spine. Bone. 2018 Jul;112:90-96.
    30. Horie S, Sawaji Y, Endo K, et al. Factors associated with bone metabolism in patients with cervical ossification of the posterior longitudinal ligament accompanied with diffuse idiopathic skeletal hyperostosis. SICOT J. 2018 Mar 16;4:7.
    31. Fassio A, Adami G, Idolazzi L, et al. Diffuse Idiopathic Skeletal Hyperostosis (DISH) in Type 2 Diabetes: A New Imaging Possibility and a New Biomarker. Calcif Tissue Int. 2021 Feb;108(2):231-239.
    32. Niu Ch, Lin SS, Yuan LJ, et al. Correlation of blood bone turnover biomarkers and Wnt signaling antagonists with AS, DISH, OPLL, and OYL BMC. Musculoskelet Disord 2017 Feb. 2;18(1):61.
    33. Furukawa M, Shibata R, Okuyama K, et al. Number of contiguous vertebral cross-links in the spine indicates bone formation: a cross-sectional study BMC Musculoskeletal Disorders. 2023;24:736.
    34. Furukawa M, Okuyama K, Ninomiya K. Association of Continuous Vertebral Bone Bridges and Bone Mineral Density with the Fracture Risk in Patients with Diffuse Idiopathic Skeletal Hyperostosis. Asian Spine J. 2022;16(1):75-81.
    35. Pini SF, Sgaramella GA, Pariente-Rodrigo E, et al Trabecular bone score and bone turnover markers in men with DISH: Data from the Camargo Cohort study. Semin Arthritis Rheum. 2020 Dec;50(6):1521-1524.
    36. Pini SF, Pariente E, Olmos JM, et al. Diffuse idiopathic skeletal hyperostosis (DISH) and trabecular bone score (TBS) in postmenopausal women: The Camargo cohort. Semin Arthritis Rheum. 2023 Aug;61:152217.
    37. Pacifici M. Acquired and congenital forms of heterotopic ossification: New pathogenic insights and therapeutic opportunities. Curr Opin Pharmacol. 2018 June;40:51-58.

    Return to the content


    Clinical Osteology

    Madam, Sir,
    please be aware that the website on which you intend to enter, not the general public because it contains technical information about medicines, including advertisements relating to medicinal products. This information and communication professionals are solely under §2 of the Act n.40/1995 Coll. Is active persons authorized to prescribe or supply (hereinafter expert).
    Take note that if you are not an expert, you run the risk of danger to their health or the health of other persons, if you the obtained information improperly understood or interpreted, and especially advertising which may be part of this site, or whether you used it for self-diagnosis or medical treatment, whether in relation to each other in person or in relation to others.

    I declare:

    1. that I have met the above instruction
    2. I'm an expert within the meaning of the Act n.40/1995 Coll. the regulation of advertising, as amended, and I am aware of the risks that would be a person other than the expert input to these sites exhibited

    No
    Yes

    If your statement is not true, please be aware
    that brings the risk of danger to their health or the health of others.