Skip to main content
SpringerLink
Log in

Interobserver agreement using Schlapbach graded scale for diffuse idiopathic skeletal hyperostosis (DISH): can we reduce the cut-off point of vertebral affection?

  • Original Article
  • Published:
Clinical Rheumatology Aims and scope Submit manuscript

Abstract

Resnick-Niwayama criteria for diagnosing DISH depict an advanced stage, and a new reduced cut-off point with three contiguous vertebrae affected (two bone bridges) has been proposed. The aim has been to know the interobserver agreement by using a graded scale of DISH in which grade II matches with the new proposed cut-off point and grade III matches with the first criterion of Resnick-Niwayama. Males ≥ 50 years and postmenopausal women included in a population-based prospective study (the Camargo Cohort) were analyzed. Sample size was obtained according to an expected kappa of 0.95 and an accuracy of ± 8%. Three physicians applied independently Schlapbach graded scale (ranged from grade 0, no ossification, to grade III, ≥ 3 consecutive bone bridges) on the lateral radiographs of thoracic and lumbar spine of participants. We calculated inter- and intra-observer agreement and correlation. One hundred and fifty eight radiographs (79 patients, 68 ± 9 years) were assessed. Kappa values (95% confidence interval) for grades 0, I, II, and III were 0.63 (0.50–0.77), 0.49 (0.37–0.62), 0.32 (0.17–0.47), and 0.69 (0.60–0.77), respectively. Weighted kappa for the three pairs of raters were 0.87 (0.82–0.93), 0.84 (0.77–0.91), and 0.81 (0.72–0.90). Grade III was the image that generated greater agreement, while a significant decrease was noted in grade II, the new proposed criterion. The simultaneous presence of an incomplete DISH and osteoarthritis, in a thoracic spinal segment with peculiar anatomical characteristics (reduced disk spaces, kyphotic curve), is thought to be a major cause of variability in the results.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Mader R, Sarzi-Puttini P, Atzeni F, Olivieri I, Pappone N, Verlaan JJ, Buskila D (2009) Extraspinal manifestations of diffuse idiopathic skeletal hyperostosis. Rheumatology 48:1478–1481

    Article  PubMed  Google Scholar 

  2. Forestier J, Rotés-Querol J (1950) Senile ankylosing hyperostosis of the spine. Ann Rheum Dis 9:321–330

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Olivieri I, Trippi D, Gherardi S, Pdsero G (1987) Coexistence of ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis: another report. J Rheumatol 14:1058–1060

    CAS  PubMed  Google Scholar 

  4. Resnick D, Niwayama G (1976) Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 119:559–568

    Article  CAS  PubMed  Google Scholar 

  5. Mader R, Verlaan JJ, Buskila D (2013a) Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms. Nat Rev Rheumatol 9:741–750

    Article  PubMed  Google Scholar 

  6. Kim BS, Moon MS, Yoon M, Kim ST, Kim SJ, Kim MS et al (2018) Prevalence of diffuse idiopathic skeletal hyperostosis diagnosed by whole spine computed tomography: a preliminary study. Clin Orthop Surg 10:41–46

    Article  PubMed  PubMed Central  Google Scholar 

  7. Vaishya R, Vijay V, Nwagbara IC, Agarwal AK (2017) Diffuse idiopathic skeletal hyperostosis (DISH): a common but less known cause of back pain. J Clin Orthop Trauma 8:191–196

    Article  PubMed  Google Scholar 

  8. Mader R, Verlaan JJ, Eshed I, Jacome BA, Puttini PS, Atzeni F et al (2017) Diffuse idiopathic skeletal hyperostosis (DISH): where we are now and where to go next. RMD Open 3:e000472

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pillai S, Littlejohn G (2014) Metabolic factors in diffuse idiopathic skeletal hyperostosis: a review of clinical data. Open Rheumatol J 8:116–128

    Article  PubMed  PubMed Central  Google Scholar 

  10. Mader R, Novofastovski I, Schwartz N, Rosner E (2018) Serum adiponectin levels in patients with diffuse idiopathic skeletal hyperostosis (DISH). Clin Rheumatol 37:2839–2845

  11. Kuperus JS, de Gendt E, Oner FC, de Jong PA, Buckens S, van der Merwe A et al (2017) Classification criteria for diffuse idiopathic skeletal hyperostosis: a lack of consensus. Rheumatology 56:1123–1134

    Article  PubMed  Google Scholar 

  12. Kuperus JS, Buckens CF, Šprem J, Oner FC, de Jong PA, Verlaan JJ (2018) The natural course of diffuse idiopathic skeletal hyperostosis in the thoracic spine of adult males. J Rheumatol 45:1116–1123

    Article  PubMed  Google Scholar 

  13. Mader R, Buskila D, Verlaan JJ, Atzeni F, Olivieri I, Pappone N, di Girolamo C, Sarzi-Puttini P (2013b) Developing new classification criteria for diffuse idiopathic skeletal hyperostosis: back to square one. Rheumatology 52:326–330

    Article  PubMed  Google Scholar 

  14. Mata S, Chhem RK, Fortin PR, Joseph L, Esdaile JM (1998) Comprehensive radiographic evaluation of diffuse idiopathic skeletal hyperostosis: development and interrater reliability of a scoring system. Semin Arthritis Rheum 28:88–96

    Article  CAS  PubMed  Google Scholar 

  15. Hernández JL, Olmos JM, Pariente E, Martínez J, Valero C, García-Velasco P, Nan D, Llorca J, González-Macías J (2010) Metabolic syndrome and bone metabolism: the Camargo cohort study. Menopause 17:955–961

    Article  PubMed  Google Scholar 

  16. Schlapbach P, Beyeler C, Gerber NJ, Van der Linden SJ, Bürgi U, Fuchs WA et al (1989) Diffuse idiopathic skeletal hyperostosis (DISH) of the spine: a cause of back pain? A controlled study. Br J Rheumatol 28:299–303

    Article  CAS  PubMed  Google Scholar 

  17. Beyeler C, Thomann SR, Gerber NJ, Kunze C, Aeberli D (2015) Diffuse idiopathic skeletal hyperostosis (DISH) of the elbow: a controlled radiological study. BMC Musculoskelet Disord 16:119

    Article  PubMed  PubMed Central  Google Scholar 

  18. Utsinger PD (1985) Diffuse idiopathic skeletal hyperostosis. Clin Rheum Dis 11:325–351

    CAS  PubMed  Google Scholar 

  19. Julkunen H, Heinonen OP, Pyörälä K (1971) Hyperostosis of the spine in an adult population – Its relation to hyperglycaemia and obesity. Ann Rheum Dis 30:605–612

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Sim J, Wright C (2005) The kappa statistic in reliability studies: use, interpretation and sample size requirements. Phys Ther 85:257–268

    PubMed  Google Scholar 

  21. Bruton A, Conway JH, Holgate ST (2000) Reliability: what is it, and how is it measured? Physiotherapy 86:94–99

    Article  Google Scholar 

  22. Blasingame JP, Resnick D, Coutts RD, Danzig LA (1981) Extensive spinal osteophytosis as a risk factor for heterotopic bone formation after total hip arthroplasty. Clin Orthop 161:191–197

    Google Scholar 

  23. Bloom RA (1984) The prevalence of ankylosing hyperostosis in a Jerusalem population - with description of a method of grading the extent of the disease. Scand J Rheumatol 13:181–189

    Article  CAS  PubMed  Google Scholar 

  24. Fornasier VL, Littlejohn G, Urowitz MB (1983) Spinal entheseal new bone formation: the early changes of spinal diffuse idiopathic skeletal hyperostosis. J Rheumatol 10:939–947

    CAS  PubMed  Google Scholar 

  25. Haller J, Resnick D, Miller CW, Schils JP, Kerr R, Bielecki D, Sartoris DJ, Gundry CR (1989) Diffuse idiopathic skeletal hyperostosis: diagnostic significance of radiographic abnormalities of the pelvis. Radiology 172:835–839

    Article  CAS  PubMed  Google Scholar 

  26. Otsuki B, Fujibayashi S, Takemoto M, Kimura H, Shimizu T, Matsuda S (2015) Diffuse idiopathic skeletal hyperostosis (DISH) is a risk factor for further surgery in short-segment lumbar interbody fusion. Eur Spine J 24:2514–2519

    Article  PubMed  Google Scholar 

  27. Holton KF, Denard PJ, Yoo JU, Kado DM, Barrett-Connor E, Marshall LM, Osteoporotic Fractures in Men (MrOS) Study Group (2011) Diffuse idiopathic skeletal hyperostosis (DISH) and its relation to back pain among older men: the MrOS study. Semin Arthritis Rheum 41:131–138

    Article  PubMed  PubMed Central  Google Scholar 

  28. Pariente E, Olmos JM, Landeras R, Nan D, González-Macías J, Hernández JL (2017) Relationship between spinal osteoarthritis and vertebral fractures in men older than 50 years: data from the Camargo cohort study. J Bone Miner Metab 35:114–121

    Article  PubMed  Google Scholar 

  29. Oudkerk SF, de Jong PA, Attrach M, Luijkx T, Buckens CF, Mali WP et al (2017) Diagnosis of diffuse idiopathic skeletal hyperostosis with chest computed tomography: inter-observer agreement. Eur Radiol 27:188–194

    Article  CAS  PubMed  Google Scholar 

  30. Slonimsky E, Lidar M, Stern M, Eshed I (2018) Degenerative changes of the thoracic spine do exist in patients with diffuse idiopathic skeletal hyperostosis: a detailed thoracic spine CT analysis. Acta Radiol 59:1343–1350

    Article  PubMed  Google Scholar 

  31. Hirasawa A, Wakao N, Kamiya M, Takeuchi M, Kawanami K, Murotani K, Matsuo T, Deie M (2016) The prevalence of diffuse idiopathic skeletal hyperostosis in Japan The first report of measurement by CT and review of the literature. J Orthop Sci 21:287–290

    Article  PubMed  Google Scholar 

  32. Verlaan JJ, Westerveld LA, van Keulen JW, Bleys RL, Dhert WJ, van Herwaarden JA et al (2011) Quantitative analysis of the anterolateral ossification mass in diffuse idiopathic skeletal hyperostosis of the thoracic spine. Eur Spine J 20:1474–1479

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Sade R, Ulusoy OL, Sirvanci M, Bayraktutan U, Kantarci M (2016) Cord compression and myelopathy due to stress fracture in a patient with diffuse idiopathic skeletal hyperostosis (DISH). Spine J 16:e503–e504

    Article  PubMed  Google Scholar 

Download references

Funding

The study has been funded in part by the Health Institute Carlos III (PI15/00521), Ministerio de Economía y Competitividad, Spain, which includes FEDER funds from the European Union.

Author information

Authors and Affiliations

  1. Camargo Primary Health Care Centre, Avda Bilbao, s/n 39600, Muriedas, Cantabria, Spain

    Stefanie Francesca Pini, Valentina Acosta-Ramón & Marian Tobalina-Segura

  2. Camargo Primary Health Care Centre and University of Cantabria, Avda Bilbao, s/n 39600, Muriedas, Cantabria, Spain

    Emilio Pariente-Rodrigo

  3. Musculoskeletal Unit. Department of Rheumatology, University Hospital Marqués de Valdecilla, 39008, Santander, Spain

    Javier Rueda-Gotor

  4. Bone Metabolism Unit. Department of Internal Medicine, University Hospital Marqués de Valdecilla-IDIVAL and University of Cantabria, 39008, Santander, Spain

    José Manuel Olmos-Martínez & José Luis Hernández-Hernández

Authors
  1. Stefanie Francesca Pini
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Valentina Acosta-Ramón
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marian Tobalina-Segura
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emilio Pariente-Rodrigo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Javier Rueda-Gotor
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. José Manuel Olmos-Martínez
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. José Luis Hernández-Hernández
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to José Luis Hernández-Hernández.

Ethics declarations

Disclosures

None.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pini, S.F., Acosta-Ramón, V., Tobalina-Segura, M. et al. Interobserver agreement using Schlapbach graded scale for diffuse idiopathic skeletal hyperostosis (DISH): can we reduce the cut-off point of vertebral affection?. Clin Rheumatol 38, 1155–1162 (2019). https://doi.org/10.1007/s10067-018-4398-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10067-018-4398-2

Keywords

Search

Navigation