Association
of Diffuse
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Calcification
and Ossification
DONALD
Diffuse
ossifying
idiopathic
diathesis
Idiopathic
RESNICK,1
skeletal
JOSE
hyperostosis
in middle-aged
JR.,1
CHARLES
Is a common
and elderly
patients
malities
in this
hyperostosis (DISH) by bone proliferation The most characteristic
condition
are
ligamentous
Case
results.
work
June 30, 1978; was supported
D. Resnick I
Department
of Radiology,
spine,
including
0 1978 American
began
and
C. VINT3
as a tingling
progressed
sensation
to
involve
on the
the
ankle,
physical
and
examination
pronounced muscle
outlined
herpes
zos-
restriction of motion of the and decreased pain and
atrophy
calcification
and
ossification
along
the
anterior
aspect
of the entire vertebral column (fig. iA), bony excrescences about the pelvis, and panaacetabular osteophytes. Prominent calcification and ossification of the posterior longitudinal liga-
ment was noted
calcification
in the cervical
naphy
demonstrated
canal
was not examined.
was that involvement
Lumbar
abnormalities;
The final
that they were accentuated Case
spine (fig. iB).
no significant
neurobogic evaluation related to nerve root
myebog-
the
impression
cervical
after
extensive
the symptoms were probably in the lumbosacral spine, and
by the presence
of herpes
zoster.
2
A 57-year-old which
white
included
man had a complicated
pulmonary
coccidioidomycosis,
resection
adult-onset
medical
for a granuboma
diabetes
history related
mellitus,
type
to
IV hy-
perlipoproteinemia, hypertension, and a hydrocele of the left testicle. His current evaluation at the Hospital of Scripps Clinic for increasing pain and stiffness in the neck and lower back for several years revealed marked restriction of motion of the cervical
of
spine
motion
lordosis
with
paraspinous
in the
lumbar
muscle
spine
was also evident.
with
spasm.
Some
flattening
Laboratory
restriction
of the
examination
lumbar
was unre-
markable.
Radiographic
evaluation
outlined
findings
of DISH, including
new bone formation along the antenolatenal aspect vertebral column, paraacetabular bony excrescences, joint
osteophytosis,
including
and
ment
2A
(figs.
patellar
of the
ossification and
computed
tomography
appropriate
physical
2B)
Radiography
cervical
spine
of the
posterior
longitudinal
further
documented
on
was referred
for
which
(fig.
hyperostosis.
of the entire sacroiliac
was
outlined
2C). The patient
exuberant
liga-
therapy.
3
A 64-year-old
Reports
and
tomography
calcification
Case
white
man was seen at the Hospital
of Scripps
of low back and lower extremity pain for about 13 years which had required lower lumbar laminectomy for , ‘three slipped discs.” Additional musculoskeletal complaints were numbness and tingling of both thighs, pain and stiffness because
no. 7406.
of the Picker Foundation. University
of California
School
of Medicine,
Veterans
California 92161 . Address reprint requests to D. Resnick. a Department of Internal Medicine, Hospital of Scripps Clinic, San Diego, 3 Department of Radiology, Hospital of Scripps Clinic, San Diego, California Am J Roentgenol
VINTON
in the left lower extremity. Laboratory evaluation was unremarkable , although nonspecific electromyographic altenations were apparent in the left leg. Radiographic examination revealed the findings of DISH,
is a comin axial abnor-
accepted after revision August 28, 1978. in part by Veterans Administration grant
foot
Ligament
sensation
man was evaluated at the Hospital of of left lower extremity pain and weak-
is a Picker Scholar
left
The present
cervical
1
Received
The pain
the
ten on the left buttock,
Clinic
A 71-year-old white Scripps Clinic because
This
of
AND
and
knee, hip, and left buttock. An extensive neunologic and onthopedic evaluation 4 years prior to the current evaluation included myebography and electromyography with inconclusive
and ossification along the anterolateral aspect of the vertebral bodies with localized osteophytosis. Changes in extraspinal locations are also frequent, including ligament and tendon calcification and ossification, panaarticulan osteophytes, and bony excrescences at sites of ligament and tendon attachment to bone. Alterations along the posterior aspect of the vertebrae are rarely mentioned in this condition. Ossification of the posterior longitudinal ligament of the cervical spine has been reported in a large number of Japanese patients and in a few non-Japanese individuals [4-13]. This ossification, which has a characteristic appearance on radiognaphs, may be associated with cervical myelopathy [4, 5, 7, 8, 10, 12] on produce no symptoms and signs [5, 1 0, 1 1 , 13-1S]. Recently we investigated four patients who demonstnated extensive posterior longitudinal ligament calcification in the cervical spine on initial evaluation. Subsequently, additional nadiognaphs revealed findings of DISH. We present these four patients in detail and describe the incidence of radiographic abnormalities along the posterior aspect of cervical vertebral bodies and intervertebral discs in a large number of patients with DISH. Case
A. ROBINSON,2
dorsum
(DISH)
Longitudinal
ness for 15 years.
char-
acterized by bone proliferation along the anterior aspect of the spine and at extraspinal sites of ligament and tendon attachment to bone. Four patients with DISH revealed extensive calcification and ossification of the posterior longitudinal ligament In the cervical spine. Review of cervical spine radiographs in 74 additIonal patIents with DISH demonstrated bony hyperostosis of the posterior aspect of the vertebrae In 41%, posterior spinal osteophytosis in 34%, and posterior longitudlnal ligament calcification and ossification In 50%. These Ilgamentous findings, which have previously been described almost exclusively In Japanese people, appear to be an additional skeletal manifestation of DISH.
Diffuse idiopathic skeletal mon disorder characterized and extraaxial sites [1-3].
Hyperostosis
of the Posterior
GUERRA,
(DISH)
Skeletal
131 :1049-1053, December Roentgen Ray Society
1978
California
1049
Administration
Hospital,
3350
La Jolla
Village
Drive,
5an
Diego.
92037.
92037. 0361
-803X/78/i
200-i
049
$00.00
1050
RESNICK
ET
AL.
in the
cervical
achilles
tendon
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included
spine,
and
mild
associated
significant
restriction
of
spinous
muscle
spasm
of the
forward
flexion
in the
lumbar
and laboratory
analysis
Radiography nent anterior
spine.
motion,
and
normal
pana-
restriction
Neunologic
of iliolumban
Cervical
spine
and ossification
calcification
(fig.
spine
region,
were within
calcification
excrescences.
ment
cervical
cervical
of
examination
limits.
outlined the changes of DISH, including promispinal new bone formation (fig. 3A), paraacetabu-
Ian osteophytes, bony
discomfort in the region of the “ heel spurs.” Physical findings
with
3B).
The patient
ligaments,
radiography
of the posterior was referred
and pelvic
demonstrated
longitudinal
for physical
liga-
therapy.
Case 4 A-57-yean-old
white
ministration
the
Hospital
neck
for
numbness
several
along
sation 1. A, Flowing calcification and ossification along anteof mid and lower thoracic spine. B, Note calcification and of posterior longitudinal ligament in cervical spine (arrow).
1.-Case
nor aspect ossification
of the
years.
right
Radiography of
arm
along
Cervical Review
of
met
the
of motor
aspect
vertebral
abnormalities
also
Ad-
of motion
noted
of the right
in
pain
arm.
and
Previous
of the
antenolatenal
ulnar
of DISH
aspect
Changes
spine
of
nerve.
with
the
radiographs
in
for
abnormalities
along
the
patients DISH
[2]
posterior
in 55 patients
(74%).
These
into
types
which
together: (fig. 5). Bony
posterior
of the (fig. 4). was lost
74
criteria
bodies
dep-
vertebral
in DISH
published
be divided
were found hyperostosis the
distribution
nadiculopathy.
calcification and ossification ligament in the cervical spine was recommended, the patient
could
along
Veterans
range
the alterations
the
previously
definite
rosis
patient
Spine
documented
frequently 1 . Bony
The
aspect
along
cervical
our
of the
at the
decreased
demonstrated
bone
column, and extensive posterior longitudinal Although myelography to follow-up.
who
evaluated
and
included M#{233}ni#{232}ne’s disease. Laboratory analysis but electromyognaphy outlined absent sen-
There was no evidence osition
was
pain
the lateral
medical history was unrewarding, Fig.
man for
aspect
three eburnation
of the
or scle-
vertebral
bodies
was apparent in 30 patients (41%). This abnormality was most apparent in the upper cervical vertebrae and produced “highlighting” or “whitening” of the posterior cortex.
2. Osteophytosis. posterior
aspect
Osteophytes of the
patients (34%). They lower cervical region cences,
typically
canal. 3. Posterior ossification. were apparent
vertebral
were
were most frequent where they produced
small,
which
longitudinal Ligamentous in 37
protruding bodies
protruded
ligament
calcification patients (50%).
from noted
the in 25
in the mid and bony excresinto
the
calcification
spinal
and
and ossification These deposits,
particularly frequent in the upper cervical spine, were of variable size, linear in distribution, bumpy in contour, and typically were separated from the subjacent vertebral body by a radiolucency of variable thickness. These three types of radiographic abnormalities were Fig. 2.-Case 2. A, Lateral radiograph ofcervical spine demonstrating extensive calcification and ossification of posterior longitudinal ligament. Observe nadiolucency between radiodense ligament and posterior surface of second cervical vertebral body. B, Tomogram demonstrating calcified and ossified posterior longitudinal ligament. C, CT scan at level of one cervical vertebral body outlining radiodense ligament separated from posterior aspect of vertebral body.
commonly, but not invariably, associated with alterations along the anterior aspect of the cervical spine which included osteophytes and flowing ossification anterior to the vertebral bodies and intervertebral discs. Although
thoracolumbar
changes
were
invariably
present
allowing
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DISH/CALCIFICATION
AND
OSSIFICATION
OF
POSTERIOR
1051
LIGAMENT
the diagnosis of DISH, there was no definite correlation between the extent of abnormality along the posterior aspect of the cervical vertebrae and that in the thoracolumbar region. Discussion
Although
DISH
calcification
and
and
posterior
ossification
longitudinal
have
received
ligament considerable
attention in the medical literature, their possible association has rarely been mentioned. Arlet et al. [16] analyzed 40 patients with cervical myelopathy and noted the frequency of vertebral hypenostosis in these patients. Of the 40 patients, 17 (43%) had both DISH and acquired stenosis of the cervical canal related to bony prolifenation
along
the
posterior
aspect
of the
vertebral
bodies.
The pattern of proliferation included findings similar to those noted in our investigation, such as hyperostosis, osteophytosis, and ligament calcification and ossification. Ono et al. [17] investigated 166 patients with ossification of the posterior longitudinal ligament. Symptoms in these patients, including motor and sensory disturbances in the lower extremity, were particularly prominent when the ossified posterior longitudinal ligament occupied 60% of the sagittal diameter of the cervical spine. Of 160 patients in that report, 71 (44%) demonstrated concomitant hyperostosis on the anterior aspect of the vertebral column. Postmortem examination of two patients with both posterior longitudinal ligament calcification and DISH revealed that the ossification of the posterior longitudinal ligament was particularly prominent in its superficial layer, whereas the unossified deep layer was thickened, creating a radiolucency between the
ossified
ligament
the craniocervical lined proliferation of the
matrix
These which though
findings occurs anterior
cification
within
and
Although
[4-12]. tions,
underlying
vertebral
the
posterior
ossification
and
with
posterior
Parasthesias
may
vary
numbness
from
or tingling
be encountered symptoms
stiffness,
,
pathology
definite
can
longitudinal
may be asymptomatic [13], signs have been associated
including
and
ligament.
coexist
in their
be
ligament
a variety with this intermittent
of sympdisorder sensa-
of several
one or both upper extremities, to extensive anesthesia of the trunk and lower extremities disturbances, such as weakness, incoordination,
pain
At out-
hyperplasia
longitudinal
frequently
differences
patients
stability, may ties. Additional
body.
evaluation
did not document the sequence of events in this condition, but suggested that aland posterior longitudinal ligament cal-
and remarkable noted. ossification toms and
and
junction , histologic of cartilagelike cells
digits
of
and severe [6]. Motor and in-
in upper and lower extremmay include head and neck
urinary
and
rectal
incontinence
and
-
A and B, Lateral and frontal nadiographs of cervical spine demonstrating widespread calcification and ossification of postenor longitudinal ligament (arrows). C and D, Lateral and frontal tomoFig.
4.-Case
4.
grams better delineating
these
findings.
Fig.
3.-Case
Calcification of second
3.
A, Typical
and ossification and
third
cervical
flowing
ossification
of posterior vertebral
bodies
in thoracic
longitudinal (arrow).
ligament
B, at level
spine.
1052
RESNICK
ET
AL.
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and
senosry
loss
in
case
1
numbness
,
the thigh in case 3, and upper sensory loss in case 4 may have longitudinal spine
of our the
ligament
may
be
patients, of
and
Human
patient with tomography ossification
within
It is apparent bral vical
with
revealed
but
the
extent
al.
[19]
previously
posterior
from
this will
review
that
we have an age-
population, examinations
bony hyperostosis and Posterior longitudinal
tion and ossification these latter changes
DISH
is considered an
incidence
a frequent that
may
and elderly patients [18], the posterior longitudinal regarded
as
findings
calcification ligament almost
and should
confined
of
number
of verte-
analyzed cersex-matched
minor ligament
12%
a
computed extent
review patients
disease reach
canal
ligament.
not and
were not apparent, are indeed associated
only
described
posterior
our brief in elderly
the one
calcifi-
spinal
a great
abnormalities. Although spine radiographs in
some with osteophytosis.
of
longitudinal significant
control spine
not
ligament
reveal
“normal” 20 cervical
with
in
myelopathy in whom the presence and
the
DISH
of
longitudinal
cervical documented
of
evaluation;
tomography
et
tingling
Tomography
adequate
posterior
ossification
impingement.
patients
for
computed
presence
cation
ossification.
necessary
and
extremity numbness and been reiated to posterior
of about yielded
degrees calcifica-
of
suggesting that with DISH. If
in this of
country
middle-aged
ossification no longer to
of be
Japanese
individuals. Fig. 5.-Hyperostosis ond,
third,
dysfunction,
and fourth
and
patients
may
loss
reveal
of posterior cervical
surface
vertebral
of libido.
On physical
muscle
toms
atrophy,
and
signs
are,
in general,
in other disorders of the Our previous investigations not emphasize abnormalities
the
cervical
tients
vertebrae,
with
ligament
DISH ossification,
small
posterior
tosis
[18].
these
and
tions recent
are frequent experience
suggests tion and
fasciculations,
additional
bodies integrity logic
we did
revealed
posterior
along
in with
Some
the the
pres-
DISH
some
and
hyperos-
evaluation that
such
of alteraour here
ligament calcificaspine may become
as deposition aspect
discs leading
pa-
demonstrated
disease. Furthermore, four patients reported
posterior
did of
longitudinal
closer
longitudinal in the cervical
of the
note
who
our with
disorder. is important, the
being
osteophytes
from
and intervertebral of the spinal cord, findings.
others
spine patients
that posterior ossification
bone
nonspecific,
and
cervical
hy-
incidence of and the symp-
spinal canal and cord. of patients with DISH of the posterior aspect
although
It is apparent
extensive in this This observation and
who
REFERENCES
examination,
perreflexia, and sensory loss. The reported these findings has varied considerably, ent
of sec-
bodies.
of
of calcium the
vertebral
may compromise to significant
neurologic
abnormalities
the neuroin
three of these four patients (cases 1 , 3, and 4) may indeed have resulted from such ossification; it is therefore imperative that the radiologist search diligently for these changes. Thus, lower extremity muscle atrophy
1 . Resnick D, Shaul SR, Robins JM: Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 1 15 : 51 3-524 , 1975 2. Resnick D, Niwayama C: Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 119:559-568, 1976 3. Forestier J, Rotes-Querol J: Senile ankylosing hyperostosis of the spine. Ann Rheum Dis 9 :321-330, 1950 4. Nakanishi T, Mannen T, Toyokura Y. Sakaguchi R, Tsuyama N: Symptomatic ossification of the posterior longitudinal ligament of the cervical spine. Neurology 24:1139-1143, 1974 5. Bakay L, Cares HL, Smith RJ: Ossification in the region of the posterior longitudinal ligament as a cause of cervical myelopathy. J Neurol Neurosurg Psychiatr 33 : 263-268, 1970 6. Takahashi M, Kawanami H, Tomonaga M, Kitamura K: Ossification of the posterior longitudinal ligament. A roentgenologic and clinical investigation. Acta Radio! [Diagn] (Stockh) 13:25-36, 1972 7. Soo YS, Sachdev AS: Calcification in the posterior longitudinal ligament as a cause of cervical myelopathy. Med J Aust 1 :743-744, 1971 8. Op den Orth JO: Die Verkalkung bzw. Verknocherung des Ligamentum Longitudinale Postenius den Halswirbelsaule. Fortschr Geb Roentgenstr Nuk!earmed 1 22 : 442-445 , 197 9, Lagemann VK: Hintere Langsbandverkalkungen kombiniert mit virbelkorperexkavationen. Fortschr Gob Roentgenstr Nuklearmed 116:834-835, 1972 10. Minagi H, Gronner AT: Calcification of the posterior longitudinal ligament: a cause of cervical myelopathy. Am J Roentgeno! 105:365-369, 1969
DISH/CALCIFICATION ii
.
Hiramatsu
Y,
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 04/05/15 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
longitudinal 12.
Nobechi
ligament
T:
Calcification
of
of the spine among
ogy 100:307-312, 1971 Nagashima C: Cervical the posterior longitudinal 660, 1972
posterior Radiol-
due to ossification of J Neurosurg 37:653-
14.
cation of the posterior longitudinal ligament of the cervical spine. J Neurol Sci 19 :375-381 , i973 Yanagi T: Ossification of the posterior longitudinal liga-
A clinical
T, Toyokuna
and
i6.
17.
OF
radiological
Y: Asymptomatic
analysis
ossifi-
of
forty-six
cases. Brain Nerve 22 : 909-921 , 1970 Palacios E, Brackett CE, Leany DJ: Ossification of the posterior longitudinal ligament associated with a herniated intervertebral disc. Radiology 1 00 : 31 3-31 4 , 1971
18.
19.
POSTERIOR
LIGAMENT
1053
Anlet PJ, Pujol M, Buc A, Genaud G, Gaynand M, Latorzeff S: Role de l’hyperostose vertebrale dans es myelopathies cervicales. Rev Rhum Mal Osteoartic 43 : 167-175, 1976 Ono K, Ota H, Tada K, Hamada H, Takaoka K: Ossified posterior longitudinal ligament. A clinicopathologic study. Spine
Nakanishi
15.
Mannen
myelopathy ligament.
the
Japanese.
OSSIFICATION
13.
ment.
T,
AND
2:126-138,
1977
AF, Wiesner KB, Niwayama G, Utsingen PD, Shaul SA: Diffuse idiopathic skeletal hyperostosis (DISH). Ankylosing hyperostosis of Fonestien and RotesQuerol. Semin Arthritis Rheum 7 : i53-i87, 1978 Hyman RA, Merten CW, Liebeskind AL, Naidich JB, Stein HL: Computed tomography in ossification of the posterior longitudinal spinal ligament. Neuroradiology 13 : 227-228, Aesnick
1977
D, Shapiro
of Diffuse
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 04/05/15 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Calcification
and Ossification
DONALD
Diffuse
ossifying
idiopathic
diathesis
Idiopathic
RESNICK,1
skeletal
JOSE
hyperostosis
in middle-aged
JR.,1
CHARLES
Is a common
and elderly
patients
malities
in this
hyperostosis (DISH) by bone proliferation The most characteristic
condition
are
ligamentous
Case
results.
work
June 30, 1978; was supported
D. Resnick I
Department
of Radiology,
spine,
including
0 1978 American
began
and
C. VINT3
as a tingling
progressed
sensation
to
involve
on the
the
ankle,
physical
and
examination
pronounced muscle
outlined
herpes
zos-
restriction of motion of the and decreased pain and
atrophy
calcification
and
ossification
along
the
anterior
aspect
of the entire vertebral column (fig. iA), bony excrescences about the pelvis, and panaacetabular osteophytes. Prominent calcification and ossification of the posterior longitudinal liga-
ment was noted
calcification
in the cervical
naphy
demonstrated
canal
was not examined.
was that involvement
Lumbar
abnormalities;
The final
that they were accentuated Case
spine (fig. iB).
no significant
neurobogic evaluation related to nerve root
myebog-
the
impression
cervical
after
extensive
the symptoms were probably in the lumbosacral spine, and
by the presence
of herpes
zoster.
2
A 57-year-old which
white
included
man had a complicated
pulmonary
coccidioidomycosis,
resection
adult-onset
medical
for a granuboma
diabetes
history related
mellitus,
type
to
IV hy-
perlipoproteinemia, hypertension, and a hydrocele of the left testicle. His current evaluation at the Hospital of Scripps Clinic for increasing pain and stiffness in the neck and lower back for several years revealed marked restriction of motion of the cervical
of
spine
motion
lordosis
with
paraspinous
in the
lumbar
muscle
spine
was also evident.
with
spasm.
Some
flattening
Laboratory
restriction
of the
examination
lumbar
was unre-
markable.
Radiographic
evaluation
outlined
findings
of DISH, including
new bone formation along the antenolatenal aspect vertebral column, paraacetabular bony excrescences, joint
osteophytosis,
including
and
ment
2A
(figs.
patellar
of the
ossification and
computed
tomography
appropriate
physical
2B)
Radiography
cervical
spine
of the
posterior
longitudinal
further
documented
on
was referred
for
which
(fig.
hyperostosis.
of the entire sacroiliac
was
outlined
2C). The patient
exuberant
liga-
therapy.
3
A 64-year-old
Reports
and
tomography
calcification
Case
white
man was seen at the Hospital
of Scripps
of low back and lower extremity pain for about 13 years which had required lower lumbar laminectomy for , ‘three slipped discs.” Additional musculoskeletal complaints were numbness and tingling of both thighs, pain and stiffness because
no. 7406.
of the Picker Foundation. University
of California
School
of Medicine,
Veterans
California 92161 . Address reprint requests to D. Resnick. a Department of Internal Medicine, Hospital of Scripps Clinic, San Diego, 3 Department of Radiology, Hospital of Scripps Clinic, San Diego, California Am J Roentgenol
VINTON
in the left lower extremity. Laboratory evaluation was unremarkable , although nonspecific electromyographic altenations were apparent in the left leg. Radiographic examination revealed the findings of DISH,
is a comin axial abnor-
accepted after revision August 28, 1978. in part by Veterans Administration grant
foot
Ligament
sensation
man was evaluated at the Hospital of of left lower extremity pain and weak-
is a Picker Scholar
left
The present
cervical
1
Received
The pain
the
ten on the left buttock,
Clinic
A 71-year-old white Scripps Clinic because
This
of
AND
and
knee, hip, and left buttock. An extensive neunologic and onthopedic evaluation 4 years prior to the current evaluation included myebography and electromyography with inconclusive
and ossification along the anterolateral aspect of the vertebral bodies with localized osteophytosis. Changes in extraspinal locations are also frequent, including ligament and tendon calcification and ossification, panaarticulan osteophytes, and bony excrescences at sites of ligament and tendon attachment to bone. Alterations along the posterior aspect of the vertebrae are rarely mentioned in this condition. Ossification of the posterior longitudinal ligament of the cervical spine has been reported in a large number of Japanese patients and in a few non-Japanese individuals [4-13]. This ossification, which has a characteristic appearance on radiognaphs, may be associated with cervical myelopathy [4, 5, 7, 8, 10, 12] on produce no symptoms and signs [5, 1 0, 1 1 , 13-1S]. Recently we investigated four patients who demonstnated extensive posterior longitudinal ligament calcification in the cervical spine on initial evaluation. Subsequently, additional nadiognaphs revealed findings of DISH. We present these four patients in detail and describe the incidence of radiographic abnormalities along the posterior aspect of cervical vertebral bodies and intervertebral discs in a large number of patients with DISH. Case
A. ROBINSON,2
dorsum
(DISH)
Longitudinal
ness for 15 years.
char-
acterized by bone proliferation along the anterior aspect of the spine and at extraspinal sites of ligament and tendon attachment to bone. Four patients with DISH revealed extensive calcification and ossification of the posterior longitudinal ligament In the cervical spine. Review of cervical spine radiographs in 74 additIonal patIents with DISH demonstrated bony hyperostosis of the posterior aspect of the vertebrae In 41%, posterior spinal osteophytosis in 34%, and posterior longitudlnal ligament calcification and ossification In 50%. These Ilgamentous findings, which have previously been described almost exclusively In Japanese people, appear to be an additional skeletal manifestation of DISH.
Diffuse idiopathic skeletal mon disorder characterized and extraaxial sites [1-3].
Hyperostosis
of the Posterior
GUERRA,
(DISH)
Skeletal
131 :1049-1053, December Roentgen Ray Society
1978
California
1049
Administration
Hospital,
3350
La Jolla
Village
Drive,
5an
Diego.
92037.
92037. 0361
-803X/78/i
200-i
049
$00.00
1050
RESNICK
ET
AL.
in the
cervical
achilles
tendon
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included
spine,
and
mild
associated
significant
restriction
of
spinous
muscle
spasm
of the
forward
flexion
in the
lumbar
and laboratory
analysis
Radiography nent anterior
spine.
motion,
and
normal
pana-
restriction
Neunologic
of iliolumban
Cervical
spine
and ossification
calcification
(fig.
spine
region,
were within
calcification
excrescences.
ment
cervical
cervical
of
examination
limits.
outlined the changes of DISH, including promispinal new bone formation (fig. 3A), paraacetabu-
Ian osteophytes, bony
discomfort in the region of the “ heel spurs.” Physical findings
with
3B).
The patient
ligaments,
radiography
of the posterior was referred
and pelvic
demonstrated
longitudinal
for physical
liga-
therapy.
Case 4 A-57-yean-old
white
ministration
the
Hospital
neck
for
numbness
several
along
sation 1. A, Flowing calcification and ossification along anteof mid and lower thoracic spine. B, Note calcification and of posterior longitudinal ligament in cervical spine (arrow).
1.-Case
nor aspect ossification
of the
years.
right
Radiography of
arm
along
Cervical Review
of
met
the
of motor
aspect
vertebral
abnormalities
also
Ad-
of motion
noted
of the right
in
pain
arm.
and
Previous
of the
antenolatenal
ulnar
of DISH
aspect
Changes
spine
of
nerve.
with
the
radiographs
in
for
abnormalities
along
the
patients DISH
[2]
posterior
in 55 patients
(74%).
These
into
types
which
together: (fig. 5). Bony
posterior
of the (fig. 4). was lost
74
criteria
bodies
dep-
vertebral
in DISH
published
be divided
were found hyperostosis the
distribution
nadiculopathy.
calcification and ossification ligament in the cervical spine was recommended, the patient
could
along
Veterans
range
the alterations
the
previously
definite
rosis
patient
Spine
documented
frequently 1 . Bony
The
aspect
along
cervical
our
of the
at the
decreased
demonstrated
bone
column, and extensive posterior longitudinal Although myelography to follow-up.
who
evaluated
and
included M#{233}ni#{232}ne’s disease. Laboratory analysis but electromyognaphy outlined absent sen-
There was no evidence osition
was
pain
the lateral
medical history was unrewarding, Fig.
man for
aspect
three eburnation
of the
or scle-
vertebral
bodies
was apparent in 30 patients (41%). This abnormality was most apparent in the upper cervical vertebrae and produced “highlighting” or “whitening” of the posterior cortex.
2. Osteophytosis. posterior
aspect
Osteophytes of the
patients (34%). They lower cervical region cences,
typically
canal. 3. Posterior ossification. were apparent
vertebral
were
were most frequent where they produced
small,
which
longitudinal Ligamentous in 37
protruding bodies
protruded
ligament
calcification patients (50%).
from noted
the in 25
in the mid and bony excresinto
the
calcification
spinal
and
and ossification These deposits,
particularly frequent in the upper cervical spine, were of variable size, linear in distribution, bumpy in contour, and typically were separated from the subjacent vertebral body by a radiolucency of variable thickness. These three types of radiographic abnormalities were Fig. 2.-Case 2. A, Lateral radiograph ofcervical spine demonstrating extensive calcification and ossification of posterior longitudinal ligament. Observe nadiolucency between radiodense ligament and posterior surface of second cervical vertebral body. B, Tomogram demonstrating calcified and ossified posterior longitudinal ligament. C, CT scan at level of one cervical vertebral body outlining radiodense ligament separated from posterior aspect of vertebral body.
commonly, but not invariably, associated with alterations along the anterior aspect of the cervical spine which included osteophytes and flowing ossification anterior to the vertebral bodies and intervertebral discs. Although
thoracolumbar
changes
were
invariably
present
allowing
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DISH/CALCIFICATION
AND
OSSIFICATION
OF
POSTERIOR
1051
LIGAMENT
the diagnosis of DISH, there was no definite correlation between the extent of abnormality along the posterior aspect of the cervical vertebrae and that in the thoracolumbar region. Discussion
Although
DISH
calcification
and
and
posterior
ossification
longitudinal
have
received
ligament considerable
attention in the medical literature, their possible association has rarely been mentioned. Arlet et al. [16] analyzed 40 patients with cervical myelopathy and noted the frequency of vertebral hypenostosis in these patients. Of the 40 patients, 17 (43%) had both DISH and acquired stenosis of the cervical canal related to bony prolifenation
along
the
posterior
aspect
of the
vertebral
bodies.
The pattern of proliferation included findings similar to those noted in our investigation, such as hyperostosis, osteophytosis, and ligament calcification and ossification. Ono et al. [17] investigated 166 patients with ossification of the posterior longitudinal ligament. Symptoms in these patients, including motor and sensory disturbances in the lower extremity, were particularly prominent when the ossified posterior longitudinal ligament occupied 60% of the sagittal diameter of the cervical spine. Of 160 patients in that report, 71 (44%) demonstrated concomitant hyperostosis on the anterior aspect of the vertebral column. Postmortem examination of two patients with both posterior longitudinal ligament calcification and DISH revealed that the ossification of the posterior longitudinal ligament was particularly prominent in its superficial layer, whereas the unossified deep layer was thickened, creating a radiolucency between the
ossified
ligament
the craniocervical lined proliferation of the
matrix
These which though
findings occurs anterior
cification
within
and
Although
[4-12]. tions,
underlying
vertebral
the
posterior
ossification
and
with
posterior
Parasthesias
may
vary
numbness
from
or tingling
be encountered symptoms
stiffness,
,
pathology
definite
can
longitudinal
may be asymptomatic [13], signs have been associated
including
and
ligament.
coexist
in their
be
ligament
a variety with this intermittent
of sympdisorder sensa-
of several
one or both upper extremities, to extensive anesthesia of the trunk and lower extremities disturbances, such as weakness, incoordination,
pain
At out-
hyperplasia
longitudinal
frequently
differences
patients
stability, may ties. Additional
body.
evaluation
did not document the sequence of events in this condition, but suggested that aland posterior longitudinal ligament cal-
and remarkable noted. ossification toms and
and
junction , histologic of cartilagelike cells
digits
of
and severe [6]. Motor and in-
in upper and lower extremmay include head and neck
urinary
and
rectal
incontinence
and
-
A and B, Lateral and frontal nadiographs of cervical spine demonstrating widespread calcification and ossification of postenor longitudinal ligament (arrows). C and D, Lateral and frontal tomoFig.
4.-Case
4.
grams better delineating
these
findings.
Fig.
3.-Case
Calcification of second
3.
A, Typical
and ossification and
third
cervical
flowing
ossification
of posterior vertebral
bodies
in thoracic
longitudinal (arrow).
ligament
B, at level
spine.
1052
RESNICK
ET
AL.
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and
senosry
loss
in
case
1
numbness
,
the thigh in case 3, and upper sensory loss in case 4 may have longitudinal spine
of our the
ligament
may
be
patients, of
and
Human
patient with tomography ossification
within
It is apparent bral vical
with
revealed
but
the
extent
al.
[19]
previously
posterior
from
this will
review
that
we have an age-
population, examinations
bony hyperostosis and Posterior longitudinal
tion and ossification these latter changes
DISH
is considered an
incidence
a frequent that
may
and elderly patients [18], the posterior longitudinal regarded
as
findings
calcification ligament almost
and should
confined
of
number
of verte-
analyzed cersex-matched
minor ligament
12%
a
computed extent
review patients
disease reach
canal
ligament.
not and
were not apparent, are indeed associated
only
described
posterior
our brief in elderly
the one
calcifi-
spinal
a great
abnormalities. Although spine radiographs in
some with osteophytosis.
of
longitudinal significant
control spine
not
ligament
reveal
“normal” 20 cervical
with
in
myelopathy in whom the presence and
the
DISH
of
longitudinal
cervical documented
of
evaluation;
tomography
et
tingling
Tomography
adequate
posterior
ossification
impingement.
patients
for
computed
presence
cation
ossification.
necessary
and
extremity numbness and been reiated to posterior
of about yielded
degrees calcifica-
of
suggesting that with DISH. If
in this of
country
middle-aged
ossification no longer to
of be
Japanese
individuals. Fig. 5.-Hyperostosis ond,
third,
dysfunction,
and fourth
and
patients
may
loss
reveal
of posterior cervical
surface
vertebral
of libido.
On physical
muscle
toms
atrophy,
and
signs
are,
in general,
in other disorders of the Our previous investigations not emphasize abnormalities
the
cervical
tients
vertebrae,
with
ligament
DISH ossification,
small
posterior
tosis
[18].
these
and
tions recent
are frequent experience
suggests tion and
fasciculations,
additional
bodies integrity logic
we did
revealed
posterior
along
in with
Some
the the
pres-
DISH
some
and
hyperos-
evaluation that
such
of alteraour here
ligament calcificaspine may become
as deposition aspect
discs leading
pa-
demonstrated
disease. Furthermore, four patients reported
posterior
did of
longitudinal
closer
longitudinal in the cervical
of the
note
who
our with
disorder. is important, the
being
osteophytes
from
and intervertebral of the spinal cord, findings.
others
spine patients
that posterior ossification
bone
nonspecific,
and
cervical
hy-
incidence of and the symp-
spinal canal and cord. of patients with DISH of the posterior aspect
although
It is apparent
extensive in this This observation and
who
REFERENCES
examination,
perreflexia, and sensory loss. The reported these findings has varied considerably, ent
of sec-
bodies.
of
of calcium the
vertebral
may compromise to significant
neurologic
abnormalities
the neuroin
three of these four patients (cases 1 , 3, and 4) may indeed have resulted from such ossification; it is therefore imperative that the radiologist search diligently for these changes. Thus, lower extremity muscle atrophy
1 . Resnick D, Shaul SR, Robins JM: Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 1 15 : 51 3-524 , 1975 2. Resnick D, Niwayama C: Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 119:559-568, 1976 3. Forestier J, Rotes-Querol J: Senile ankylosing hyperostosis of the spine. Ann Rheum Dis 9 :321-330, 1950 4. Nakanishi T, Mannen T, Toyokura Y. Sakaguchi R, Tsuyama N: Symptomatic ossification of the posterior longitudinal ligament of the cervical spine. Neurology 24:1139-1143, 1974 5. Bakay L, Cares HL, Smith RJ: Ossification in the region of the posterior longitudinal ligament as a cause of cervical myelopathy. J Neurol Neurosurg Psychiatr 33 : 263-268, 1970 6. Takahashi M, Kawanami H, Tomonaga M, Kitamura K: Ossification of the posterior longitudinal ligament. A roentgenologic and clinical investigation. Acta Radio! [Diagn] (Stockh) 13:25-36, 1972 7. Soo YS, Sachdev AS: Calcification in the posterior longitudinal ligament as a cause of cervical myelopathy. Med J Aust 1 :743-744, 1971 8. Op den Orth JO: Die Verkalkung bzw. Verknocherung des Ligamentum Longitudinale Postenius den Halswirbelsaule. Fortschr Geb Roentgenstr Nuk!earmed 1 22 : 442-445 , 197 9, Lagemann VK: Hintere Langsbandverkalkungen kombiniert mit virbelkorperexkavationen. Fortschr Gob Roentgenstr Nuklearmed 116:834-835, 1972 10. Minagi H, Gronner AT: Calcification of the posterior longitudinal ligament: a cause of cervical myelopathy. Am J Roentgeno! 105:365-369, 1969
DISH/CALCIFICATION ii
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Hiramatsu
Y,
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longitudinal 12.
Nobechi
ligament
T:
Calcification
of
of the spine among
ogy 100:307-312, 1971 Nagashima C: Cervical the posterior longitudinal 660, 1972
posterior Radiol-
due to ossification of J Neurosurg 37:653-
14.
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A clinical
T, Toyokuna
and
i6.
17.
OF
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Y: Asymptomatic
analysis
ossifi-
of
forty-six
cases. Brain Nerve 22 : 909-921 , 1970 Palacios E, Brackett CE, Leany DJ: Ossification of the posterior longitudinal ligament associated with a herniated intervertebral disc. Radiology 1 00 : 31 3-31 4 , 1971
18.
19.
POSTERIOR
LIGAMENT
1053
Anlet PJ, Pujol M, Buc A, Genaud G, Gaynand M, Latorzeff S: Role de l’hyperostose vertebrale dans es myelopathies cervicales. Rev Rhum Mal Osteoartic 43 : 167-175, 1976 Ono K, Ota H, Tada K, Hamada H, Takaoka K: Ossified posterior longitudinal ligament. A clinicopathologic study. Spine
Nakanishi
15.
Mannen
myelopathy ligament.
the
Japanese.
OSSIFICATION
13.
ment.
T,
AND
2:126-138,
1977
AF, Wiesner KB, Niwayama G, Utsingen PD, Shaul SA: Diffuse idiopathic skeletal hyperostosis (DISH). Ankylosing hyperostosis of Fonestien and RotesQuerol. Semin Arthritis Rheum 7 : i53-i87, 1978 Hyman RA, Merten CW, Liebeskind AL, Naidich JB, Stein HL: Computed tomography in ossification of the posterior longitudinal spinal ligament. Neuroradiology 13 : 227-228, Aesnick
1977
D, Shapiro
