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

Management and Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Treatment of DISH should focus on symptom management with NSAIDs/COX-2 inhibitors as first-line therapy, with consideration of intravenous bisphosphonates and TNF-α inhibitors for non-responders, while reserving surgical intervention for cases with severe functional impairment or neurological complications. 1

Understanding DISH

DISH is a systemic condition characterized by:

• Ossification and calcification of ligaments and entheses
• 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 1

DISH frequently coexists with metabolic disorders including:

• Diabetes mellitus
• Obesity
• Hyperlipidemia 1, 2

Clinical Presentation

DISH is often asymptomatic but can present with:

• Chronic back pain (reported in 63-81% of patients) 2
• Spinal stiffness
• Dysphagia (rare, occurring in only 0.6-1.0% of cases, typically with cervical involvement) 3
• Functional decline
• Neurological deficits 4

Treatment Algorithm

First-Line Treatment

• NSAIDs/COX-2 inhibitors at maximum tolerated dosage:
  • Options include naproxen, indomethacin, ibuprofen, celecoxib, etoricoxib, piroxicam, and meloxicam
  • Evaluate response after 2-4 weeks 1
  • Caution: Long-term NSAID use can cause gastrointestinal, renal, and cardiovascular adverse effects, especially in elderly patients 1

Second-Line Treatment (for non-responders)

• Intravenous bisphosphonates
• TNF-α inhibitors
• Evaluate response after 3-6 months 1

Bridging Therapy

• Short courses of oral prednisolone
• Intra-articular glucocorticoid injections for localized symptoms 1

Surgical Intervention

• Reserved for:
  • Severe functional impairment
  • Neurological complications
  • Dysphagia due to cervical osteophytes 1, 3
• Surgical approaches include:
  • Anterior cervical osteophyte resection for dysphagia 3
  • Spinal decompression for neurological symptoms 2

Management of Associated Conditions

Control of associated metabolic disorders is essential:

• Hypertension
• Hyperinsulinemia with or without hyperglycemia
• Hyperlipidemia
• Hyperuricemia 5

Addressing these conditions may:

• Reduce associated morbidities
• Potentially prevent further progression of DISH 5

Monitoring and Assessment

Treatment success should be evaluated through:

• Pain reduction
• Improved function
• Radiological assessment using MRI or CT combined with nuclear imaging
• Monitoring of inflammatory markers if previously elevated 1

Special Considerations

Risk of Spinal Fractures

• Spinal ankylosis in DISH predisposes patients to unstable spine fractures from low-energy trauma 4, 6
• These fractures can lead to catastrophic neurological outcomes, including tetraplegia 6
• Patients should be educated about this risk and advised to seek immediate medical attention after any trauma

Healthcare Utilization

• DISH is associated with significant healthcare utilization:
  • 51% of patients require opioid medications for pain control
  • 31% undergo spinal surgery
  • 57% require consultations with various specialists for regional pain 2

Lifestyle Modifications

• Physical therapy for general strengthening and gait education
• Weight management for patients with obesity
• Nutritional counseling
• Activity modification to reduce mechanical stress on affected areas 1, 5

DISH, while often considered asymptomatic, can significantly impact quality of life and requires a structured approach to management focused on symptom control, prevention of complications, and addressing associated metabolic conditions.