What is the treatment for Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

The treatment of DISH should focus primarily on symptom management through conservative measures including pain control, physical therapy, and lifestyle modifications, as there is no specific therapy that can reverse the ossification process.

Clinical Presentation and Diagnosis

DISH is characterized by:

• Ossification of ligaments and entheses (where tendons/ligaments attach to bone)
• Most commonly affects the spine, particularly thoracic spine
• Can cause stiffness, pain, and limited range of motion
• May lead to complications including:
  • Dysphagia (when cervical osteophytes compress the esophagus)
  • Airway obstruction (in severe cervical cases) 1, 2
  • Decreased mobility and quality of life

Treatment Approach

First-Line Conservative Management

1. Pain Management

   • NSAIDs for acute pain episodes
   • Acetaminophen for chronic pain management
   • Muscle relaxants for associated muscle spasms
   • Opioids may be required in severe cases (used by 51% of DISH patients in one study) 3

2. Physical Therapy

   • Regular exercise to maintain mobility and range of motion
   • Stretching exercises to reduce stiffness
   • Strengthening exercises for supporting muscles
   • Heat therapy for pain relief

3. Lifestyle Modifications

   • Weight management (DISH is associated with metabolic disorders)
   • Balanced diet
   • Regular physical activity
   • Ergonomic adjustments to reduce strain on affected areas

4. Management of Associated Metabolic Conditions 4

   • Control of hypertension
   • Management of hyperinsulinemia/diabetes
   • Treatment of hyperlipidemia
   • Management of hyperuricemia

Interventional Approaches

For patients with inadequate response to conservative measures:

1. Corticosteroid Injections

   • Local injections at sites of significant pain
   • Provides temporary relief for inflammation around ossified areas

2. Surgical Management

   • Reserved for specific complications or severe symptoms
   • Indications include:
     • Airway obstruction requiring osteophytectomy 1, 2
     • Severe dysphagia
     • Neurological compromise
     • Intractable pain unresponsive to conservative measures
   • Surgical approaches may include:
     • Osteophytectomy (removal of bony outgrowths)
     • Arthroscopic procedures for peripheral joint involvement 5
     • In emergency airway obstruction cases, tracheostomy may be required

Special Considerations

1. Respiratory Complications

   • CPAP may be used for mild airway obstruction 2
   • Emergency intubation and surgical intervention may be necessary in severe cases

2. Peripheral Joint Involvement

   • Hip involvement may benefit from arthroscopic intervention using specialized techniques 5

3. Monitoring

   • Regular follow-up to assess progression
   • Targeted imaging for new or worsening symptoms

Pitfalls and Caveats

1. DISH is often underdiagnosed or misdiagnosed as ankylosing spondylitis or degenerative joint disease.

2. Routine radiographic assessments are not required for long-term monitoring unless symptoms change significantly 6.

3. DISH patients have higher healthcare utilization than commonly recognized, with 31% requiring spinal surgery in one study 3.

4. The condition is often viewed as asymptomatic but can cause significant morbidity and decreased quality of life.

5. Surgical intervention carries risks of complications, particularly in cervical spine procedures, and should be reserved for specific indications.

Conclusion

Treatment of DISH focuses on symptom management rather than disease modification. A comprehensive approach addressing pain, mobility, and associated metabolic conditions can improve quality of life for patients with this condition. Surgical intervention should be reserved for specific complications or cases unresponsive to conservative management.