Diffuse Idiopathic Skeletal Hyperostosis Causes Artificially Elevated Lumbar Bone Mineral Density Measured by Dual X-ray Absorptiometry

doi:10.1385/JCD:4:4:385

Journal of Clinical Densitometry

Volume 4, Issue 4, Winter 2001, Pages 385-388

https://doi.org/10.1385/JCD:4:4:385 Get rights and content

Abstract

A 76-yr-old man with bilateral total hip arthroplasties was referred for a baseline bone mineral density (BMD) measurement. The L1–L4 lumbar bone density revealed a density above the upper expected value for a young individual (i.e., T-score > 2.5) with large intervertebral variation, while the forearm study revealed an osteoporotic measurement. Lumbar spine radiographs demonstrated abundant, flowing ossification of the anterior spinal ligament, predominately at L3, consistent with diffuse idiopathic skeletal hyperostosis, which accounted for the increased BMD.

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Cited by (9)

Diffuse idiopathic skeletal hyperostosis (DISH) and trabecular bone score (TBS) in postmenopausal women: The Camargo cohort
2023, Seminars in Arthritis and Rheumatism
The potential relationship between diffuse idiopathic skeletal hyperostosis (DISH) and bone microstructure has not been studied in women. We aimed to assess the association between the trabecular bone score (TBS) and DISH in postmenopausal women, as well as the role of other parameters related to bone metabolism, such as bone mineral density (BMD), calciotropic hormones, and bone remodeling markers.
Cross-sectional study, nested in a prospective population-based cohort (Camargo cohort). Clinical covariates, DISH, TBS, vitamin D, parathormone, BMD and serum bone turnover markers, were analyzed.
We have included 1545 postmenopausal women (mean age, 62±9 years). Those with DISH (n = 152; 8.2%) were older and had a significantly higher prevalence of obesity, metabolic syndrome, hypertension, and type 2 diabetes mellitus (p<0.05). Moreover, they had lower TBS values (p = 0.0001) despite having a higher lumbar spine BMD (p<0.0001) and a higher prevalence of vertebral fractures than women without DISH (28.6% vs. 15.1%; p = 0.002). When analyzing DISH through Schlapbach grades, women without DISH had a median TBS value consistent with a normal trabecular structure while the values for women with DISH from grades 1 to 3 were consistent with a partially degraded trabecular structure. Women with vertebral fractures and DISH had a mean TBS corresponding to a degraded trabecular structure (1.219±0.1). After adjusting for confounders, the estimated TBS means were 1.272 (1.253–1.290) in the DISH group, and 1.334 (1.328–1.339) in the NDISH group (p<0.0001).
An association between DISH and TBS has been shown in postmenopausal women, in which hyperostosis has been significantly and consistently related to trabecular degradation and, therefore, to deterioration in bone quality after adjusting for confounding variables.
Artifacts and incidental findings encountered on dual-energy x-ray absorptiometry: Atlas and analysis
2015, Seminars in Nuclear Medicine
Citation Excerpt :
Diffuse idiopathic skeletal hyperostosis (DISH) is a spondyloarthropathy of the spine characterized by ossification of the anterior and posterior longitudinal ligaments and paraspinal connective tissues. These changes can lead to overestimation of lumbar BMD by 24%-39% as compared with quantitative CT, which assays only the unaffected “true” trabecular bone.26-31 In spite of an increase in the apparent BMD, it has been suggested that fracture risk is actually increased in patients with DISH.27
Bone mineral densitometry (BMD) using dual-energy x-ray absorptiometry (DEXA) has been widely adopted as the standard method of assessing bone density. Although not intended to be a primary imaging modality, the technique generates attenuation map images that are used to guide region-of-interest placement. Artifacts and incidental findings are frequently encountered on the DEXA images, some of which directly affect BMD values and others that are only of incidental importance to clinical practice. We systematically review a variety of artifacts and incidental findings that may be encountered on DEXA, illustrated by a collection of findings from our own practice. Being cognizant of these unexpected abnormalities, and understanding their etiology, will prepare the reader to more readily appreciate significance of these findings when seen in clinical practice.
Distribution of Z-Scores in a university cohort with an emphasis on "high" bone mineral density
2010, Journal of Clinical Densitometry
Citation Excerpt :
There are a variety of explanations for finding high BMD on a DXA scan, either globally or in isolated regions of interest (3,5,7). Careful inspection of the image may suggest artifacts, fractures, and degenerative changes (4), such as vertebroplasty/kyphoplasty, compression fractures, patients with ossification of the posterior longitudinal ligament (8), diffuse idiopathic skeletal hyperostosis (9,10), aortic calcification overlying the spine, and osteoarthritis (11). Other causes of high BMD include dysplasia and dystoses (such as autosomal dominant osteosclerosis, osteopetrosis, and osteopoikilosis); metabolic disorders (such as fluorosis) (12–15); and other disorders (including leukemia, lymphoma, multiple myeloma, Paget's disease) (3).
High bone mineral density (BMD) is currently not defined by the International Society for Clinical Densitometry with a specific Z-score cutoff; however, it has been suggested that a Z-score greater than or equal to 2.5 is not normal. Institutional Review Board approval was obtained. We evaluated a University dual-energy X-ray absorptiometry database over the previous 24 mo to define Z-score distributions. A Z-score greater than or equal to 2.5 was selected as the outcome event of interest in a logistic regression for adjusted odds ratio. The covariates were height; weight; body mass index (BMI); gender; menopausal status; use of female hormones; presence of insufficiency fractures after 50 yr of age; previous fractures; previous surgeries (back surgeries, vertebroplasty, or kyphoplasty); transplant history; presence of long-term chronic conditions (asthma, lupus, rheumatoid arthritis, or cystic fibrosis); eating disorder; current use of glucocorticoids; smoking status; and current and past use of osteoporosis pharmacological therapies. The study included a total of 8216 patients; 7212 (87.8%) were females, and 1044 (12.2%) were males. In the total population, 13.6% had a Z-score greater than or equal to 2.5 at the lumbar spine, femoral neck, or total hip. Only 0.2% of the males and 0.8% of the females had a Z-score greater than or equal to 2.5 at all 3 sites. The 97.5th percentiles for Z-scores in our population for men and women, respectively, were 3.4 and 3.9 at the lumbar spine, 1.5 and 2.1 at the femoral neck, and 1.6 and 2.2 at the total hip. The 99th percentile for Z-scores for men and women, respectively, were 4.9 and 4.7 at the lumbar spine, 2.4 and 2.7 at the femoral neck, and 2.2 and 2.7 at the total hip. At the lumbar spine, female gender and weight were found to be risk factors for a high Z-score (≥2.5). The use of glucocorticoids, bone-active medications, BMI, and smoking were significantly less likely to predict a lumbar spine Z-score greater than or equal to 2.5. A high total-hip Z-score is predicted by increasing weight, whereas those patients using bone-active medications were less likely to have high BMD at the total hip. At the femoral neck, there were no significant risk factors related to a Z-score greater than or equal to 2.5; those taking bone-active medications were significantly less likely to have a high Z-score. These data suggest that a high Z-score is common at 1 or more sites. Further research about the criteria for the diagnosis of high BMD is warranted.
Diffuse idiopathic skeletal hyperostosis (DISH): Relation to vertebral fractures and bone density
2011, Osteoporosis International
The influence of diffuse idiopathic skeletal hyperostosis on bone mineral density measurements of the spine
2009, Rheumatology
Prevalence of primary osteoporosis and osteoarthrosis in 203 middle-aged and elderly women
2005, Chinese Journal of Clinical Rehabilitation

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CaseDiffuse Idiopathic Skeletal Hyperostosis Causes Artificially Elevated Lumbar Bone Mineral Density Measured by Dual X-ray Absorptiometry

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations

Radiology

Radiographic and pathologic features of spinal involvement of diffuse idiopathic hyperostosis (DISH)

Radiology

Case
Diffuse Idiopathic Skeletal Hyperostosis Causes Artificially Elevated Lumbar Bone Mineral Density Measured by Dual X-ray Absorptiometry