Post on 11-Feb-2022
transcript
Bombay Hospital Journal, Vol. 54, No. 2, 2012
Dept. of Nuclear Medicine and PET, Bombay Hospital and Medical Research Centre, 12, Marine Lines, Mumbai 400 020.
Unique Scintigraphic Features of Diffuse Idiopathic Skeletal Hyperostosis (DISH) on 99mTc-MDP Bone Scan
Pallavi Patil, Sunita Tarsarya Sonavane, Amrita Lahoti, Roshni Bhandary, Rajnath Jaiswar, Chanchala Kale
Introduction
ISH is diagnosed when ossification of Dthe anterolateral aspect of the
anterior longitudinal ligament is present
on at least four contiguous spinal levels
without involvement of the intervertebral
disk space and/or apophyseal (facet) 2joints. The disease can manifest itself also
at extraspinal locations leading to
peripheral entheseal ossification and bony 3,4spurs.
Case Report
A 61 years old gentleman, a known case of DISH
and recently diagnosed with adenocarcinoma of left
lung with mediastinal adenopathy complaining of
dull aching pain in the mid-dorsal region was referred
to our department for a bone scan to rule out skeletal
metastases. There is no history of trauma to the back.
Lateral view radiograph of the thoracic spine revealed
osteophytes present at the anterior margin of the D 6
to D vertebral bodies with normal intervertebral 10
discs and no evidence of lytic or sclerotic lesions in
the vertebrae. Ossification of the anterior
longitudinal ligament at multiple thoracic levels,
except for the part where the aorta is located,
confirmed the diagnosis DISH. In this individual the
CT scan of chest when performed for evaluation of
primary tumour left lung upper lobe mass, which
additionally revealed ossification of the ligamentum
flavum and partial ossification of the interspinal
ligament and supraspinal ligament. No other signs of
spinal degenerative changes such as intervertebral or
apophyseal joint space narrowing were observed. The
patient had no extraspinal manifestations of DISH.
Wholebody bone multiple planar static images were
obtained 3 hr after intravenous administration of 20 99mmCi (740 MBq) Tc-MDP. Images (preset counts of
700 Kcts) were made in the anterior and posterior
views with a Hawkeye GE millennium VG dual head
digital gamma camera equipped with a low-energy,
high-resolution collimator. The planar whole body
anterior and posterior views (fig. 1), static oblique
Fig. 1: Whole body planar anterior and posterior
images obtained 3 hrs after the injection of the
radioisotope reveals no definite scintigraphic
evidence of skeletal metastasis. Moderately increased
osteoblastic activity seen involving D6 and D7 right
paravertebral region, in view of the clinical history of
DISH is likely to represent benign degenerative
changes (osteophytes).
Abstract
Diffuse idiopathic skeletal hyperostosis (DISH) is a common but often unrecognised 1systemic disorder observed mainly in the elderly. All papers pertinent to DISH
5demonstrate a consistent and marked increase of the disease with advancing age .
341
Bombay Hospital Journal, Vol. 54, No. 2, 2012
chest images (fig. 2) revealed no definite scintigraphic
evidence of skeletal metastasis. Moderately increased
osteoblastic activity seen in the right paravertebral
region in view of the clinical history of DISH is likely to
represent ben ign degenerat i ve changes
(osteophytes).
In conclusion, DISH may actually be a clinically
relevant condition although presumably only so
when the more advanced stages of the disease have
been reached.
Fig. 2: Static oblique chest images revealed
moderately increased osteoblastic activity seen
involving the D6 and D7 right paravertebral region.
Discussion
D i f f u s e i d i o p a t h i c s k e l e t a l
h y p e r o s t o s i s ( D I S H ) i s a
spondyloarthropathy also known as
Forestier's disease and ankylosing
hyperostosis. It is a noninflammatory
disease, with the principal manifestation
being calcification and ossification of
spinal ligaments and the regions where
tendons and ligaments attach to bone
(entheses). The most common abnormality
is unilateral calcification seen on one side 6,7of the thoracic spine. The exact cause is
unknown. It can be present as a
radiological abnormality, without any
symptoms. The usual complaint is with
thoracic spine pain. This occurs in around
80% of patients. Morning stiffness is also 8,9noticed in almost two thirds of patients.
Diffuse idiopathic skeletal hyperostosis
(DISH) describes a phenomenon
characterised by a tendency toward
ossification of ligaments. It most 10characteristically affects the spine.
Ossification of the longitudinal ligaments
(especially the anterior ligaments) of the
spine produces a tortuous paravertebral
mass anterior to and distinct (at least 11radiologically) from the vertebral bodies.
Grossly, the appearance is that of candle
wax dripping down the spine. While the
thoracic anterior longitudinal ligament is
ossified, the areas of ossification often
meet without fusion. Pathophysiology of
diffuse idiopathic skeletal hyperostosis
(DISH) is characterised by a tendency
toward ossification of ligament, tendon, 12and joint capsule (enthesial) insertions.
DISH is a completely asymptomatic
phenomenon; no alterations are
detectable based on history or through
physical examination. The features used 1 3to diagnose DISH are f lowing
calcifications and ossifications along the
anterolateral aspect of at least 4
contiguous vertebral bodies, with or
without osteophytes. Preservation of disc
height in the involved areas and an
absence of excessive disc disease. Absence
of bony ankylosis of facet joints and
absence of sacroiliac erosion, sclerosis, or
bony fusion, although narrowing and 14sclerosis of facet joints are acceptable.
The hallmark of DISH is ossification
342
Bombay Hospital Journal, Vol. 54, No. 2, 2012
occurring along the anterior aspect of the
vertebral bodies but remaining separate
from the vertebrae. Osteophytes of
degenerative spinal disease usually occur
along the anterolateral aspect. The
location of the ossification distinguishes
DISH from ossification of the posterior 1 5l ong i tud ina l l i gament (OPLL ) .
Omnipresent degenerative osteophytes
represent the most common finding that
mimics DISH; however, DISH is defined by
the strict criteria of anterior location and
the bridging involvement of 4 contiguous
vertebral bodies (3 intervertebral disc
spaces). DISH and ankylosing spondylitis
differ in their age of onset. Unlike
ankylosing spondylitis, DISH does not
involve the sacroiliac joint. DISH is also
distinct from marginal osteophytes that
form in response to degenerative disc
disease. Lower thoracic spine involvement
is typical of DISH, but the lumbar and
cervical spine can also be affected. The left
side of the spine is typically spared or less
involved, which is probably attributable to
the pulsating aorta. Preferred examination
is radiography of the thoracic and lumbar
spine usually is sufficient for diagnosing
D I S H . O c c a s i o n a l l y , c o m p u t e d
tomography (CT) scanning may be
performed to evaluate complications, such
as fracture, or symptoms caused by
pressure effects on the trachea,
oesophagus, and veins. CT scanning of the
spine is helpful and especially is aided by
coronal and sagittal reconstructions. Bone
scanning and magnetic resonance
imaging (MRI) do not play a significant role 13in the diagnosis of DISH. The differential
diagnosis includes ankylosing spondylitis,
neuropathic arthropathy (Charcot joint),
primary osteoarthritis, and psoriatic
arthritis.
In conclusion, regarding the presently
known clinical symptoms, the diagnosis
DISH should be considered in patients of
m i d d l e o r a d v a n c e d a g e w i t h
unexplainable back pain or peripheral
arthralgia and/or restricted motion and
should alert the physician for the presence
of fracture dislocations in DISH patients
complaining of back pain after relatively 16minor trauma.
References
1. Belanger TA, Rowe DE. Diffuse idiopathic
skeletal hyperostosis: musculoskeletal
manifestations. J Am Acad Orthop Surg 2001;
9:258-267.
2. Resnick D. Diffuse idiopathic skeletal
hyperostosis. Am J Roentgenol 1978;130:588-
589.
3. Maat GJR, Mastwijk RW, Van der Velde EA.
Skeletal distribution of degenerative changes in
vertebral osteophytosis, vertebral osteoarthritis
and DISH. Int J Osteoarchaeol 1995; 5:289-298.
4. Resnick D, Niwayama G. Radiographic and
pathologic features of spinal involvement in
diffuse idiopathic skeletal hyperostosis (DISH).
Radiology 1976;119:559-568.
5. Weinfeld RM, Olson PN, Maki DD et al. The
prevalence of diffuse idiopathic skeletal
hyperostosis (DISH) in two large American
Midwest metropolitan hospital populations.
Skeletal Radiol 1997; 26:222-225.
6. Resnick D; Niwayama G. Radiographic and
pathologic features of spinal involvement in
diffuse idiopathic skeletal hyperostosis (DISH).
Radiology Jun 1976; 119(3):559-68.
7. Utsinger PD, Resnick D, Shapiro R. .Diffuse
skeletal abnormalities in Forestier disease. Arch
Intern Med Jul 1976; 136(7):763-8.
8. Utsinger, PD. Diffuse idiopathic skeletal
hyperostosis. Clin Rheum Dis 1985; 11:325.
9. Mata S; Fortin PR; Fitzcharles MA; Starr MR;
Joseph L; Watts CS; Gore B; Rosenberg E;
Chhem RK; Esdaile JM. A controlled study of
diffuse idiopathic skeletal hyperostosis. Clinical
343
Bombay Hospital Journal, Vol. 54, No. 2, 2012
features and functional status. Medicine
(Baltimore) Mar 1997; 76(2):104-17.
10. Miyazawa N, Akiyama I. Ossification of the
ligamentum flavum of the cervical spine. J
Neurosurg Sci. Sep 2007; 51(3):139-44.
11. Westerveld LA, Verlaan JJ, Oner FC. Spinal
fractures in patients with ankylosing spinal
disorders: a systematic review of the literature
on treatment, neurological status and
complications. Eur Spine J. Sep 13 2008.
12. Fornasier VL, Littlejohn G, Urowitz MB, et al.
Spinal entheseal new bone formation: the early
changes of spinal diffuse idiopathic skeletal
hyperostosis. J Rheumatol. Dec 1983;
10(6):939-47.
13. Cammisa M, De Serio A, Guglielmi G. Diffuse
idiopathic skeletal hyperostosis. Eur J Radiol.
May 1998;27 Suppl 1:S7-11.
14. Dar G, Peleg S, Masharawi Y, et al. The
association of sacroiliac joint bridging with
other enthesopathies in the human body. Spine.
May 1 2007;32(10):E303-8.
15. Resnick D, Guerra J Jr, Robinson CA, et al.
Association of diffuse idiopathic skeletal
hyperostosis (DISH) and calcification and
ossification of the posterior longitudinal
ligament. Am J Roentgenol. Dec 1978;
131(6):1049-53.
16. Belanger TA, Rowe DE. Diffuse idiopathic
skeletal hyperostosis: musculoskeletal
manifestations. J Am Acad Orthop Surg. 2001;
9:258-267.
Dalcetrapib: turning the tide for CETP inhibition?
In the search for additional cardiovascular-risk lowering strategies on top of statins, raising highdensity lipoprotein cholesterol (HDL-C) is an attractive target.
Despite controversial data on the role of cholesteryl ester transfer protein (CETP) in atherosclerosis, the impressive increase in concentrations of HDL-C after CETP inhibition has raised expectations for drugs of the CETP inhibitor class. But the ILLUMINATE study was prematurely terminated in 2006 because of an increased cardiovascular event rate in patients receiving the CETP inhibitor torcetrapib, which led to a fall in the popularity of CETP inhibition as a therapeutic target, while also casting a broader shadow on the attractiveness of raising HDL-C concentrations.
In The Lancet, Zahi Fayad and colleagues report a randomised, placebo-controlled, phase 2b study in which the CETP inhibitor dalcetrapib was used to increase HDL-C concentrations in 130 patients with coronary heart disease or an equivalent cardiovascular risk.
Dalcetrapib given for 2 years increased HDL-C concentrations by 26.9%, (90% Cl 20.0-33.9%) without affecting those of low density lipoprotein cholesterol (LDL-C) and triglycerides,. No adverse effects on the arterial wall or blood pressure were recorded. In fact, dalcetrapib was associated with a reduction in carotid vessel wall inflammation at 6 months.
Notwithstanding the absence of harmful effects, the jury is still out on the clinical value of cardiovascular protection by dalcetrapib.
As we await the final verdict on dalcetrapib in 2013, when the DAL-OUTCOME study will provide data on cardiovascular endpoints in 15600 patients, the findings of Fayad and colleagues bring us one step higher on the ladder of CETP research, after its free fall since 2006.
E Stroes, D Wijk, The Lancet, 2011; 1529-1530Vol. 378,
344