Treatment Options for Hyperostosis
Treatment of hyperostosis should be tailored to the specific type of hyperostosis and primarily focus on symptom management, with surgical intervention reserved for cases with severe functional impairment or neurological complications.
Types of Hyperostosis and Their Management
1. Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Conservative Management:
- NSAIDs/COX-2 inhibitors: First-line treatment at maximum tolerated dosage (naproxen, indomethacin, ibuprofen, celecoxib) 1
- Physical therapy and exercise: Daily program consisting of mobility, stretching, and strengthening exercises for the spine 2
- Pain management: Short courses of oral prednisolone may be considered as bridging therapy 1
Surgical Management (for refractory cases):
- Osteophytectomy: Indicated when dysphagia, dysphonia, or respiratory compromise is present and refractory to conservative treatment 3, 4
- Surgical approach: Anterior cervical approach with possible fusion using polyether ether ketone cage and/or plate system 4
- Outcomes: Significant improvement in dysphagia and respiratory complaints typically seen within 6 weeks post-surgery 4
2. Chronic Non-Bacterial Osteitis (CNO)
First-line Treatment:
- NSAIDs/COX-2 inhibitors: Maximum tolerated dosage with evaluation of response at 2-4 weeks 5
Second-line Treatment:
- Intravenous bisphosphonates: Pamidronate or zoledronate 5
- TNF-α inhibitors: Infliximab, etanercept, adalimumab, golimumab, or certolizumab 5
- Response evaluation: Should be performed at 3-6 months 5
3. Hyperostosis in X-linked Hypophosphatemia (XLH)
Medical Management:
- Phosphate supplements: Dosage based on elemental phosphorus 5
- Active vitamin D: Calcitriol (0.50–0.75 μg daily) or alfacalcidol (0.75–1.5 μg daily) 5
- Burosumab: Consider for adults with persistent bone/joint pain, pseudofractures, or osteomalacia-related fractures 5
Orthopedic Management:
- Osteotomies: For severe deformities, with timing based on skeletal maturity 5
- Physical therapy: General strengthening and gait education programs, especially post-surgery 5
Special Considerations
Medication-Related Osteonecrosis of the Jaw (MRONJ)
- Conservative approach: Antimicrobial mouth rinses and systemic antibiotics for stage 2 MRONJ 5
- Surgical intervention: Minor procedures (sequestration or removal of dead bone) for stage 1 MRONJ to reduce soft tissue trauma 5
- Follow-up: Every 8 weeks by a dental specialist with communication to the oncologist 5
Fractures in Hyperostotic Spine
- Conservative treatment: May be appropriate in select cases using cervical orthosis, Jewett hyperextension brace, or thoraco-lumbo-sacral orthosis 6
- Surgical stabilization: Standard of care for most unstable fractures in the setting of DISH 6
Monitoring and Follow-up
- Clinical assessment: Pain reduction and improved function are primary measures of treatment success 1
- Radiological assessment: MRI or CT combined with nuclear imaging to evaluate reduction in bone marrow edema or tracer uptake 5, 1
- Laboratory monitoring: Follow inflammatory markers if previously elevated 1
Complications to Monitor
- Progressive structural damage
- Functional limitations
- Skeletal deformities
- Neurovascular entrapment
- Vertebral fractures
Treatment Algorithm
- Diagnosis confirmation: MRI or CT combined with nuclear imaging
- Initial treatment: NSAIDs/COX-2 inhibitors at maximum tolerated dose for 2-4 weeks
- If inadequate response:
- For CNO: Proceed to IV bisphosphonates or TNF-α inhibitors
- For DISH with dysphagia: Consider surgical osteophytectomy
- For XLH: Optimize phosphate and vitamin D supplementation
- Regular monitoring: Assess clinical response, radiological changes, and potential complications
- Surgical intervention: Reserved for cases with neurological compromise, severe functional impairment, or failure of conservative management
By following this structured approach to hyperostosis treatment, clinicians can effectively manage symptoms and minimize complications while improving patients' quality of life.