Diffuse Idiopathic Skeletal Hyperostosis: The Evolution of a Disease Concept

Diffuse idiopathic skeletal hyperostosis (DISH) has traditionally been regarded as an age-related radiographic disorder characterized by flowing spinal ossification. Advances in epidemiology, imaging, and pathobiology have progressively challenged this restricted view, suggesting a broader systemic disorder of pathological bone formation involving axial and peripheral entheses. This narrative review examines the evolution of the DISH disease concept, integrating historical descriptions and diagnostic criteria with contemporary evidence from epidemiological, imaging, clinical, genetic, metabolic, and mechanistic studies. This review emphasizes developments that have changed our understanding of disease definition, heterogeneity, and pathogenesis. The Resnick and Niwayama criteria established a reproducible radiographic framework for DISH but predominantly identify established spinal disease and incompletely capture earlier or extraspinal manifestations. Modern computed tomography and magnetic resonance imaging have broadened recognition of the anatomical spectrum and highlighted overlap with degenerative and inflammatory spinal disorders. Epidemiological and mechanistic studies increasingly associate DISH with metabolic susceptibility, genetic factors, mechanical loading, and dysregulated osteogenic responses at the enthesis. These observations support a transition from viewing DISH as an isolated spinal radiographic abnormality toward a systemic osteoproliferative entheseal disorder with heterogeneous clinical and imaging phenotypes. Nevertheless, validated biomarkers, standardized criteria for early disease, and disease-modifying therapies remain lacking. The conceptual evolution of DISH has important implications for diagnosis, phenotyping, and future research. Integration of standardized imaging with clinical, metabolic, genetic, and molecular characterization may enable earlier recognition, biologically informed phenotyping, and ultimately more individualized approaches to disease management.