DISH Disease Spine: When Spinal Ligaments Turn to Bone?

Diffuse idiopathic skeletal hyperostosis (DISH), also called Forestier disease, is a condition that turns spinal ligaments and tendons into bony tissue over time. As these tissues harden, you may develop spinal stiffness, pain, and limited motion. A stiff spinal column also absorbs less force, which raises your risk of spinal fractures after minor trauma.

At Total Orthopedics & Sports Medicine, our spine specialists provide personalized care to reduce discomfort and preserve your mobility. We assess your symptoms, spinal motion, and imaging to determine the extent of ligament hardening. Then, our team recommends treatment to improve pain relief and lower the risk of fractures or nerve problems. Call 855-321-6784 to schedule a DISH diagnosis and discuss the right care for your symptoms.

Why Does DISH Disease Turn Spinal Ligaments into Bone?

DISH disease turns spinal ligaments into bone due to abnormal cell activity that promotes excess calcium deposits and new bone growth. This process starts with calcification (calcium buildup) and progresses to ossification (bone formation). Over time, the ligaments harden and form new bone along the spine.

Here is the step-by-step process that explains how flexible spinal ligaments gradually develop into rigid bone:

1. Calcification Process

Calcium salts gradually collect within the ligaments and tendons attached to your spine. This calcification (calcium buildup in soft tissue) often affects the anterior longitudinal ligament, which runs along the front of the vertebrae. As these deposits increase, the ligament becomes thicker and less flexible. These tissue changes create the conditions for new bone to develop.

2. Stem Cell Activation

As tissue changes progress, metabolic and growth signals can activate mesenchymal stem cells within the affected area. These specialized cells can develop into several types of connective tissue cells, such as:

• Bone cells
• Cartilage cells
• Fat cells

In DISH, abnormal signals direct these cells toward a bone-forming pathway. This cellular shift promotes new bone development within the affected ligaments. A 2022 study in the Journal of Bone and Mineral Research also supports this cellular process. It found that stem cells from people with DISH showed a greater capacity to develop into bone-forming cells. Researchers linked this increased activity to higher levels of Galectin-3, a protein that can promote bone formation.

3. Ossification Process

Once cells become active, growth signals such as insulin-like growth factor and bone morphogenetic proteins can promote their conversion into osteoblasts (bone-forming cells). These cells begin forming new bone tissue in areas that once consisted of a flexible ligament. This process is called ossification (formation of new bone). As ossification progresses, the affected ligament becomes thicker and more rigid.

Moreover, research published in Applied Sciences examined growth factors and molecular signals in intervertebral disc cells from people with DISH. Researchers found significantly higher EGR2 and IL-6 activity compared with control cells. Insulin-like growth factor 1 (IGF-1) also showed an upward trend. However, this difference did not reach statistical significance.

4. Bone Bridge Formation

Over time, osteoblasts build enough new bone to create thick bone spurs along the spine. These large bone spurs can extend across several contiguous vertebrae (vertebrae located beside one another). As the new bone connects these areas, bridges replace part of the ligament’s normal flexibility. This change can restrict spinal motion and contribute to spinal stiffness.

What Happens When Spinal Ligaments Become Bone?

In DISH, hardened ligaments develop into solid bony tissue, which reduces the spine’s normal flexibility. As this process progresses, large bone spurs can extend along the sides of the vertebral bodies. These growths may eventually form bony bridges between nearby vertebrae.

Over time, these bridges can connect several spinal segments and cause partial spinal fusion. The fused areas lose some of their normal range of motion, which contributes to spinal stiffness. With less spinal movement, everyday activities such as bending or twisting may become difficult.

Where Does Abnormal Bone Growth Develop in the DISH Spine?

DISH commonly affects the thoracic spine in the middle back. From there, bone growth can extend into the cervical or lumbar spine. This new bone typically develops along the anterior longitudinal ligament, which runs down the front of the vertebral bodies.

Moreover, research published in RMD Open found that DISH-related bone growth often develops prominently along the right side of the thoracic spine. Researchers link this pattern to the location of the descending aorta. The descending aorta (the large artery that carries blood downward from the heart) lies on the left side of the spine, and its repeated pulsations may limit bone growth in this area.

What Are the Symptoms of DISH Disease in Your Spine?

DISH disease can cause persistent back or neck pain and spinal stiffness, especially in the morning. When symptoms occur, you may also notice limited back movement and difficulty turning your neck. These changes can gradually restrict your normal range of motion. However, many people with DISH have no symptoms and may not know they have the condition.

Here are some other symptoms you may notice as DISH affects nearby tissues and nerves:

• Spinal tenderness: Pressure along your spine may cause discomfort.
• Trouble swallowing: Neck bone growth can press on your esophagus.
• Hoarseness: Cervical bone growth may affect your voice.
• Numbness or tingling: Nerve pressure can cause unusual sensations.
• Muscle weakness: Nerve or spinal cord pressure can reduce strength.

Who Is at Risk for Idiopathic Skeletal Hyperostosis (DISH)?

People older than 50 and biological males have the highest risk of DISH. In fact, a study published in Seminars in Arthritis and Rheumatism found DISH in 42% of men over 65 years. Your risk can also rise with obesity, diabetes mellitus, and high blood sugar, especially when several metabolic problems occur together. Certain medications and other biological risk factors may further increase your risk of abnormal bone growth, such as:

1. Long-Term Acne Medication Use

Long-term use of certain acne medications may increase the risk of DISH-like bone changes. Retinoids such as isotretinoin are derived from compounds related to natural vitamin A. These medicines can affect the activity of cells that regulate bone formation. Prolonged exposure may therefore promote excess bone growth along ligaments and tendon attachments.

2. High Uric Acid Levels

High uric acid levels have also been associated with DISH. Doctors call this condition hyperuricemia (excess uric acid in the blood). It often occurs alongside obesity, diabetes, and other metabolic syndrome features. This association suggests that metabolic abnormalities may contribute to the development of DISH.

3. Genetic Factors

A 2026 review published in Frontiers in Endocrinology found that DISH prevalence differs across countries and ethnic groups, and the condition can cluster within families. Some research cited in the review suggests an autosomal dominant inheritance pattern (a trait that can be passed from an affected parent to a child). In the families studied, about 50% of children with an affected parent also had DISH.

4. Endocrine Disorders

Some endocrine disorders may also raise the risk of abnormal bone formation. For example, excess growth hormone can alter normal bone metabolism and promote new bone growth. Similarly, other hormonal changes can affect the way bone and connective tissues respond to growth signals. These changes may contribute to excess bone formation along spinal ligaments in DISH.

How Common Is Spinal Ligament Ossification in Older Adults?

According to the National Library of Medicine, DISH becomes more common as you age. Among adults aged 50 or older, it affects about 25% of men and 15% of women. At age 80 or older, the rates rise to 28% of men and 26% of women.

Similarly, an autopsy study published in Spine examined 75 spinal specimens. Researchers found DISH in 21 specimens (28%), with an average age of 65 years. The youngest affected person was 50, which further supports the strong link between DISH and older age.

Another study published in The Journal of Rheumatology examined the prevalence of DISH in a large Asian population. Researchers evaluated 3,595 Korean adults over age 50 and diagnosed DISH in 104 people using the Resnick criteria. They found that DISH incidence is 2.9% in Asian populations.

They also found that DISH prevalence increased with age, and men were about 7 times more likely to have DISH than women. Moreover, a 2020 study published in Bone Research reports an estimated prevalence of DISH of 15%–25% in North America among people over age 50. It also identifies Caucasian ethnicity as a risk factor.

What Does DISH Disease Look Like on a Spine X-Ray?

On a spine X-ray, DISH often appears as thick, flowing bone along the front and sides of the vertebrae, sometimes described as “flowing candle wax.” Under the classic Resnick-Niwayama criteria, this flowing ossification extends across at least four contiguous vertebrae (vertebrae located beside one another). These diffuse skeletal abnormalities are often most noticeable in the thoracic spine.

Doctors also look for other X-ray findings that support the classic Resnick-Niwayama criteria:

• Preserved disc spaces: The intervertebral disc spaces usually show minimal narrowing.
• No sacroiliac joint fusion: The sacroiliac joints typically lack erosions or fusion.
• No facet joint fusion: The small thoracic and cervical spine joints generally lack bony fusion.
• Thoracic predominance: Flowing bone growth appears most prominently in the middle back.

When Do You Need a CT or MRI for Spinal Ossification?

A computed tomography scan (CT) may be needed to confirm the location, size, and pattern of abnormal bone growth along the spine. In contrast, magnetic resonance imaging (MRI) helps assess the spinal cord, discs, and nerve roots for compression or injury.

MRI can also assess your neurological status, such as nerve function and spinal cord health. These imaging tests can clarify unusual spine anatomy that may not appear clearly on standard X-rays. Moreover, a PubMed study evaluated 558 people who received both CT scans and X-rays to identify DISH. In this study, researchers found the following differences between the two imaging methods:

• DISH detection: CT identified DISH in 27.2% of participants, compared with 17.6% on X-ray.
• Men: CT detected DISH in 38.7%, compared with 23.3% on X-ray.
• Women: CT detected DISH in 14.0%, compared with 10.9% on X-ray.
• Reliability: CT showed higher agreement within and between reviewers than X-ray.

How Is DISH Different From Ankylosing Spondylitis?

DISH is a non-inflammatory condition that causes abnormal bone growth along spinal ligaments and tendons. In contrast,ankylosing spondylitis (AS) is an inflammatory autoimmune disease that primarily affects the spine and SI joints (joints that connect the spine to the pelvis). Although both ankylosing spinal disorders can cause spinal stiffness, here are the key differences:

Key Difference	DISH	Ankylosing Spondylitis (AS)
Age of Onset	More common after age 50	Often starts before age 30
Underlying Process	Abnormal ligament ossification without primary inflammation	Chronic inflammation drives spinal changes
Genetic Link	No established HLA-B27 association	Strongly associated with HLA-B27
Health Associations	Linked with metabolic factors such as obesity and diabetes	Linked with uveitis and inflammatory bowel disease

Is DISH Disease the Same as Arthritis or Bone Spurs?

No, DISH is not the same as typical arthritis or bone spurs. It is a form of degenerative arthritis that mainly affects ligaments and tendons rather than joint cartilage. These tissues can calcify (harden from calcium deposits) and gradually turn into bone. As bone spurs develop, they can form bony bridges along the spine and affect peripheral joints. Therefore, bone spurs are a feature of DISH rather than a separate disease.

Can Bony Overgrowth in Your Neck Affect Swallowing?

Yes, large bone growths in the cervical spine can affect your ability to swallow. These bone spurs can press against the esophagus (the tube that carries food to your stomach). This pressure can narrow the passage and prevent food from moving through smoothly.

Large growths can also restrict the movement of the epiglottis (a flap that directs food away from your airway). This restricted movement, along with repeated pressure from the bone growth, can irritate nearby throat tissues and cause swelling. In severe cases, these changes can lead to persistent swallowing difficulty and airway obstruction.

In fact, a report published in the Korean Journal of Neurotrauma found that dysphagia (difficulty swallowing) occurs in about 17% to 28% of people with cervical ossification. Researchers linked this problem to direct pressure from the bone growth and scar-like tissue attachments. Reduced epiglottic movement may also interfere with normal swallowing.

Moreover, DISH can cause other serious complications, such as:

• Acute spinal fractures: A rigid spine can break after minor trauma.
• Spinal cord compression: Pressure on the spinal cord can cause weakness or balance problems.
• Nerve root compression: Bone growth can press on nerve roots, causing radiating pain.
• Sleep apnea: Cervical bone growth can contribute to airway obstruction during sleep.

Can DISH Disease Cause Spinal Cord Compression?

Yes, DISH can cause spinal cord compression in some cases. This often happens when ossified spinal ligaments narrow the spinal canal and reduce the space around the spinal cord. For example, a 2025 case report published in the Journal of International Medical Research found severe spinal cord compression linked to DISH in a woman in her 70s. She developed progressive lower-limb numbness and weakness and eventually could not walk without assistance. Imaging identified several spinal changes, such as:

• Narrowed intervertebral space at T10–T11
• Severe spinal canal stenosis (narrowing)
• Ligamentum flavum ossification at T10–T11
• Significant spinal cord compression

Due to these spinal changes, the patient underwent surgical decompression to create more space around the spinal cord. After surgery, imaging showed a significant reduction in spinal cord compression. Her lower-limb symptoms also improved after treatment.

Can Spinal Ligament Ossification Be Treated Without Surgery?

Yes, spinal ligament ossification can often be treated without surgery when symptoms are mild and do not worsen. Your doctor may recommend anti-inflammatory drugs, muscle relaxants, or pain relievers to control discomfort. Guided rehabilitation, activity changes, and supportive devices can also reduce stiffness and limit excess stress on your spine.

Here is how these conservative treatment options can support your recovery:

• Medications: NSAIDs and pain relievers can reduce discomfort.
• Guided rehabilitation: Gentle exercises can improve strength and mobility.
• Activity changes: Do not lift heavy objects or perform movements that strain your spine.
• Supportive devices: A neck brace may provide short-term support.

When Does Bony Overgrowth in the Spine Need Surgery?

Surgeons may recommend spine surgery if conservative treatments fail to control severe symptoms or neurological problems continue to worsen. They may also recommend surgery when bone growth causes significant pressure on the spinal nerves or spinal cord. Beyond this, unstable fractures and cervical bone growth that affects swallowing or breathing may require surgical treatment.

Consult Our Spine Specialists at Total Orthopedics & Sports Medicine for DISH Disease!

DISH disease can limit your movement and turn simple daily activities into a struggle. Spinal stiffness and persistent back or neck pain may interfere with walking, sleep, work, or activities you enjoy. As symptoms progress, you may need specialist care to protect your mobility and address problems from excess bone growth.

At Total Orthopedics & Sports Medicine, our spine specialists perform a detailed physical examination and review your imaging to understand the extent of your condition. From nonsurgical care to spine surgery, we recommend treatment according to your symptoms and spinal changes. We also monitor your progress through regular follow-up visits. Call 855-321-6784 or visit our clinics in Syosset, Massapequa, East Meadow, or Deer Park todiscuss the right treatment.

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