What is the next step in managing a patient with moderate degenerative changes of the thoracic spine and diffuse idiopathic skeletal hyperostosis (DISH)?

Management of Thoracic Spine Degenerative Changes with DISH

For patients with moderate degenerative changes of the thoracic spine and diffuse idiopathic skeletal hyperostosis (DISH), the next step should be conservative management with NSAIDs/COXIBs at maximum tolerated dosage, along with physical therapy focused on thoracic spine mobility. 1, 2

Initial Assessment and Monitoring

• Evaluate for neurological symptoms:

  • Check for myelopathy signs (spasticity, hyperreflexia, Babinski sign)
  • Assess for radiculopathy (motor/sensory deficits, pain radiation)
  • Screen for bladder dysfunction (present in 24% of symptomatic thoracic disc cases) 1

• Determine pain severity and functional limitations:

  • Document baseline pain levels
  • Assess impact on activities of daily living
  • Evaluate postural abnormalities (DISH can mimic advanced ankylosing spondylitis) 3

First-Line Treatment

1. NSAIDs/COXIBs at maximum tolerated dosage

   • Start with maximum approved dosage for 2-4 weeks
   • Consider cardiovascular, gastrointestinal, and renal risks when prescribing 1
   • If insufficient response after 2-4 weeks, consider NSAID rotation 1

2. Physical therapy focused on thoracic spine mobility

   • Evidence supports increasing thoracic spine mobility for improved outcomes 4
   • Include exercises to maintain spinal flexibility and prevent further stiffening
   • Focus on posture correction and ergonomic training

3. External bracing (if needed for pain control)

   • Consider thoracolumbosacral orthosis for immobilization if pain is severe
   • Use as a temporary measure during acute pain episodes 1

Monitoring Response

• Evaluate treatment response at 2-4 weeks:
  • If sufficient response, continue and re-evaluate at 12 weeks
  • Consider tapering or on-demand NSAID treatment with sustained improvement 1
  • If insufficient response, proceed to second-line options

Second-Line Options

If first-line treatment fails after 4-12 weeks:

1. Consider short courses of oral prednisolone

   • Use as bridging therapy while awaiting effects of other treatments
   • Avoid long-term glucocorticoid use 1

2. Image-guided interventions

   • Consider facet joint injections for localized pain
   • Diagnostic medial branch blocks may be required before considering rhizotomy 2

When to Consider Advanced Imaging and Surgical Consultation

• Immediate surgical consultation if:

  • Signs of myelopathy develop (spasticity, hyperreflexia, Babinski sign)
  • Progressive neurological deficits occur
  • Spinal cord compression is evident on imaging 1, 5

• Consider MRI thoracic spine without contrast if:

  • Pain persists despite 6 weeks of conservative management
  • Neurological symptoms develop
  • Significant functional decline occurs 1

Important Considerations

• DISH is often viewed as asymptomatic but can cause significant morbidity:

  • 63-81% of patients report chronic back pain 6
  • 31% may eventually require spinal surgery 6
  • 51% need opioid medications for pain control 6

• Avoid repeated spinal radiographs:

  • Do not repeat more frequently than every 2 years unless clinically indicated 1
  • Remember that morphologic imaging changes of osteoarthritis do not correlate well with pain 1

Pitfalls to Avoid

1. Overlooking neurological symptoms: DISH can cause spinal stenosis and cord compression requiring prompt surgical intervention 5

2. Misdiagnosing as ankylosing spondylitis: DISH can mimic the postural abnormalities of advanced AS 3

3. Premature invasive interventions: Thoracic facet rhizotomy should only be considered after failed conservative management and positive diagnostic blocks 2

4. Inadequate pain management: DISH patients often require multimodal pain management approaches due to significant pain burden 6