DISH-ing out the details: An interesting incidental finding of Diffuse Idiopathic Skeletal Hyperostosis on SPECT-CT

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Introduction:We present an unexpected but clinically important incidental finding of diffuse idiopathic skeletal hyperostosis (DISH) with a discrete ligamentous fracture in a patient with suspected prostate cancer. DISH, characterised by ossification along the antero-lateral aspect of at least 4 contiguous vertebral bodies (Kawabata et al, 2020), is common in asymptomatic older adults and predisposes individuals to fractures even with minor trauma, potentially causing spinal instability (Westerveld et al. 2014).Methods:80-year-old male presented with pelvic pain and a PSA of 17. A suspicious digital rectal exam prompted referral for a bone scan and MRI to assess for bony metastases. Following administration of 600MBq of Technetium-99m HDP, planar imaging was acquired using a Siemens Intevo Bold scanner. Intense non-specific uptake at T12-L1 and arthritic patterns in multiple joints led to the acquisition of localized SPECT-CT of T11-L2.Summary of Results:SPECT CT shows flowing anterior ossification with lateral osteophyte formation and associated ossification of the posterior longitudinal and supraspinous ligaments. A discoligamentous fracture at T12-L1 is demonstrated with lucency and increased activity through the osteophytes, ossified ligaments and posterior elements at the level of the disc space.No osteoblastic metastases visualised.Conclusion:This case underscores the importance of recognizing DISH, particularly its potential for fractures, which can mimic metastatic disease on bone scan. Accurate diagnosis is critical to avoid misdiagnosis and unnecessary oncological interventions, while ensuring timely management of DISH-related complications. Multidisciplinary care is essential for optimal patient outcomes.Reference:Kawabata, A et al. (2020). Surgical stabalisation of spinal metastasis in diffuse skeletal hyperostosis (“Mets-on-DISH”). Medicine [online]. 99(22), pp. 220397. Available from: DOI: 10.1097/MD.0000000000020397Westerveld, L., Bemmel, J., Dhert, W., Oner, F. & Verlaan, J. (2014). Clinical outcome after traumatic spinal fractures in patients with anklyosing spinal disorders compared with control patients. The Spine Journal [online]. 14(5), pp. 729-740. Available from: https://doi.org/10.1016/j.spinee.2013.06.038.

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