What is the management of Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

Management of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Treatment for DISH should focus on symptom management with NSAIDs/COX-2 inhibitors as first-line therapy, with surgical intervention reserved only for cases with severe functional impairment or neurological complications. 1

Clinical Features and Diagnosis

DISH is a systemic condition characterized by:

• Ossification and calcification of ligaments and entheses (tendon/ligament insertion sites)
• Most commonly affects men over 50 years of age 2
• Predominantly involves the thoracic spine, but can affect any spinal region
• Often coexists with metabolic disorders including diabetes, obesity, and hyperlipidemia 3

Diagnosis is typically made through imaging findings:

• Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae
• Preservation of intervertebral disc height
• Absence of apophyseal joint ankylosis or sacroiliac joint erosion

Clinical Manifestations

While DISH is often asymptomatic, it can present with:

1. Spinal symptoms:

   • Pain and stiffness
   • Reduced range of motion
   • Increased risk of spinal fractures (even with minor trauma) 4

2. Extraspinal manifestations:

   • Peripheral joint involvement
   • Enthesopathies

3. Specific complications:

   • Dysphagia (when cervical spine is involved) - seen in 0.6-1.0% of cases 5
   • Airway obstruction (rare)
   • Neurological symptoms from cord compression

Treatment Algorithm

First-line Treatment:

• NSAIDs/COX-2 inhibitors at maximum tolerated dosage 1
  • Options include naproxen, indomethacin, ibuprofen, celecoxib
  • Evaluate response after 2-4 weeks
  • Goal: Pain relief and improved function

Physical Therapy:

• Range of motion exercises
• Strengthening exercises
• Postural training
• Heat therapy

Management of Associated Metabolic Disorders:

• Control of hypertension
• Management of hyperinsulinemia/hyperglycemia
• Treatment of hyperlipidemia
• Management of hyperuricemia 3

Surgical Intervention:

• Reserved for cases with:
  • Severe dysphagia (anterior cervical osteophyte resection) 5
  • Neurological compromise
  • Respiratory compromise
  • Failure of conservative management 1

Monitoring and Follow-up

• Regular clinical assessment of symptoms
• Evaluation of functional status
• Radiological monitoring when clinically indicated
• Assessment of treatment response based on pain reduction and improved function

Special Considerations

1. Spinal Fracture Risk: Patients with DISH have increased risk of unstable spinal fractures even with minor trauma. This risk should be discussed with patients, particularly those with cervical involvement 4.

2. Medication Side Effects: Monitor for gastrointestinal, renal, and cardiovascular adverse effects with long-term NSAID use, especially in elderly patients.

3. Dysphagia Management: For patients with dysphagia due to cervical DISH, surgical intervention with anterior cervical osteophyte resection can provide significant symptom improvement 5.

4. Retinoid Association: DISH-like skeletal hyperostosis has been reported as a rare side effect of systemic retinoid therapy (e.g., acitretin). Patients on long-term retinoid therapy should be monitored for development of hyperostosis 6.

Prognosis

The condition is typically slowly progressive. With proper symptom management, most patients maintain good quality of life despite the radiographic abnormalities. However, patients should be educated about potential complications, particularly the increased risk of spinal fractures with even minor trauma.