What is the treatment for idiopathic skeletal hyperostosis?

Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

The primary treatment for diffuse idiopathic skeletal hyperostosis (DISH) is symptom management with NSAIDs or COX-2 inhibitors as first-line therapy, with evaluation of response after 2-4 weeks, and consideration of more advanced interventions for non-responders. 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

DISH commonly coexists with metabolic disorders including diabetes, obesity, and hyperlipidemia 1. Despite being relatively common in middle-aged and elderly populations, it often remains undiagnosed 2.

Clinical Presentation

DISH can present with various symptoms:

• Back and neck pain
• Restriction of spinal mobility
• Peripheral joint involvement
• Dysphagia (most common complaint when cervical spine is affected)
• Stridor (rare but documented complication)
• Breathing problems (particularly when C3-C4 level is involved)
• Neurological manifestations due to spinal cord compression

A recent study found that chronic back pain was common in DISH patients (63-81%), with many requiring opioid medications (51%), spinal surgery (31%), and specialist consultations (57%) 3.

Treatment Algorithm

First-line Treatment:

• NSAIDs/COX-2 inhibitors at maximum tolerated dosage
  • Options include: naproxen, indomethacin, ibuprofen, celecoxib, etoricoxib, piroxicam, meloxicam
  • Evaluate response at 2-4 weeks
  • Monitor for gastrointestinal, renal, and cardiovascular adverse effects, especially in elderly patients 1

Second-line Treatment (for non-responders):

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

Bridging Therapy:

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

Surgical Intervention:

• Reserved for cases with:
  • Severe functional impairment
  • Neurological complications
  • Failure of conservative management 1

Specific surgical approaches may include:

• Endoscopic spine surgery through an interlaminar approach for thoracic spinal stenosis 4
• Hip arthroscopy using a capsulotomy-first approach for hip involvement 5
• Osteophysectomy for relief of airway symptoms (after tracheostomy for airway stabilization if needed) 6

Monitoring and Assessment

Treatment success should be assessed through:

• Pain reduction and improved function
• Radiological assessment using MRI or CT combined with nuclear imaging
• Laboratory monitoring of inflammatory markers if previously elevated 1

Special Considerations

• Airway Management: When DISH affects the upper cervical spine (particularly C3-C4), airway compromise may occur, potentially requiring tracheostomy before definitive treatment 6
• Metabolic Comorbidities: Address associated conditions such as diabetes, obesity, and hyperlipidemia 1, 2
• Retinoid Therapy: Patients on long-term retinoid therapy should be monitored for development of DISH-like hyperostosis 1

Treatment Categories

Patients can be categorized into four groups based on clinical symptoms and radiological findings:

1. Active disease
2. Inactive disease
3. Probable inactive disease
4. No clinically relevant activity 1

This categorization can help guide treatment intensity and follow-up frequency.

Despite being commonly viewed as asymptomatic, DISH is associated with significant morbidity and healthcare utilization 3, highlighting the importance of appropriate diagnosis and management.