Objective To analyse the risk of incident vertebral and non-vertebral fracture in men with DISH. Methods In 782 men ages 50–85 years, DISH was diagnosed using Resnick’s criteria. In men followed prospectively for 7.5 years, a radiographic incident vertebral fracture was defined by a decrease of ≥20% or ≥4mm in any vertebral height vs baseline. Self-reported incident non-vertebral fractures were confirmed by medical records. Results Men with DISH had higher BMD at the lumbar spine (P < 0.05), but not at other skeletal sites. After adjustment for confounders including disc space narrowing (DSN) and endplate irregularity, the risk of vertebral fracture was higher in men with DISH vs men without DISH [10/164 (6.1%) vs 16/597 (2.7%), P < 0.05; odds ratio (OR) 2.89 (95% CI 1.15, 7.28), P < 0.05]. DISH and low spine BMD were each associated with a higher vertebral fracture risk. The vertebral fracture risk was higher in men who had both DISH and severe DSN. DISH and endplate irregularities (EIs) were each associated with higher vertebral fracture risk. DISH, DSN and EIs define the intervertebral space dysfunction, which was associated with higher vertebral fracture risk [OR 3.99 (95% CI 1.45, 10.98), P < 0.01]. Intervertebral space dysfunction improved the vertebral fracture prediction (ΔAUC = +0.111, P < 0.05), mainly in men with higher spine BMD (>0.9 g/cm2; ΔAUC = +0.189, P < 0.001). DISH was not associated with the risk of non-vertebral fracture. Conclusion DISH is associated with higher vertebral fracture risk, independently of other risk factors. Assessment of the intervertebral space dysfunction components may improve the vertebral fracture prediction in older men.

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BackgroundDiffuse idiopathic skeletal hyperostosis (DISH) is a common disorder of unknown cause characterized by ossifications of entheses with spinal and extraspinal manifestations(1). The prevalence ranges from 4% to 35%, depending on the diagnostic criteria (2). An increased risk of vertebral fracture in DISH has been suggested, due to the loss of flexibility of the fused spine, reminiscent of what is observed in ankylosing spondylitis(3–6).ObjectivesThe aim of this study was to prospectively analyze the risk of vertebral fracture in men with DISH, compared with men without DISH.MethodsMen older than 50 (n = 782) had coronal and lateral spine radiographs along with DXA and were monitored prospectively. We analyzed the risk of incident vertebral fractures (over 7.5 years) in men with DISH defined by flowing ossification alongside the anterolateral aspect of at least four contiguous vertebral bodies, relative intervertebral disc preservation and the absence of apophyseal ankylosis and inflammatory changes of the SI joints, according to Resnick’criteria (7). Incident vertebral fracture was defined by a decrease of at least 20% or 4 mm in any vertebral height (anterior, central or posterior) between the follow-up and the baseline radiographs.ResultsDISH was present in 21,7% (170/782) of men (mean age= ). Among the 782 examined at baseline, 761 had at least one spine X-ray after baseline and 164/170 men with DISH had enough available data to be analyzed. Vertebral fracture incidence was higher in men with DISH compared with those without DISH (mean 10/164 (6.1%) vs. 16/597 (2.7%); p<0.05). DISH was also associated with the risk of vertebral fracture after adjustment for age, BMI, lumbar spine bone mineral density (BMD), prevalent vertebral fractures (Grade 2&3), disc space narrowing and endplate irregularity (OR = 2.89, [95%CI : 1.15 – 7.28]; p<0.05). 6.3% (10/149) of men with DISH had both normal BMD (≥0.912 g/cm2) and increased risk of vertebral fracture (OR 6.54 [95%CI : 2.13 - 20.26]; p<0.05).ConclusionDISH is associated with higher risk of vertebral fracture, independently of BMD. The risk of vertebral fracture of men with DISH but normal BMD may be underestimated.References[1] Mader R, Verlaan J-J, Buskila D. Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms. Nat Rev Rheumatol. 2013;9(12):741–50.[2] Diederichs G, Engelken F, Marshall LM, Peters K, Black DM, Issever AS, et al. Diffuse idiopathic skeletal hyperostosis (DISH): relation to vertebral fractures and bone density. Osteoporos Int. juin 2011;22(6):1789–97.[3] Ghozlani I, Ghazi M, Nouijai A, Mounach A, Rezqi A, Achemlal L, et al. Prevalence and risk factors of osteoporosis and vertebral fractures in patients with ankylosing spondylitis. Bone. mai 2009;44(5):772–6.[4] Davey-Ranasinghe N, Deodhar A. Osteoporosis and vertebral fractures in ankylosing spondylitis. Curr Opin Rheumatol. juill 2013;25(4):509–16.[5] Leone A, Marino M, Dell’Atti C, Zecchi V, Magarelli N, Colosimo C. Spinal fractures in patients with ankylosing ...

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