What is the best treatment approach for a patient with DISH (Diffuse Idiopathic Skeletal Hyperostosis) and cervical spine osteophytes?

Management of Cervical Spine DISH with Osteophytes

The optimal treatment approach for a 60-year-old female with cervical spine DISH and osteophytes should begin with conservative management, including physical therapy, NSAIDs, and lifestyle modifications, progressing to surgical intervention only if symptoms are severe or neurological complications develop. 1

Initial Assessment and Conservative Management

Assessment Priorities

• Evaluate for neurological symptoms (radiculopathy, myelopathy)
• Assess for respiratory compromise or dysphagia
• Determine impact on range of motion and daily activities

First-Line Treatment

1. NSAIDs/COXIBs at maximum tolerated dosage 2

   • Options include naproxen 375-1100 mg/day, diclofenac 75-150 mg/day, or celecoxib 200-400 mg/day
   • Evaluate response after 2-4 weeks
   • Use lowest effective dose for shortest duration to minimize adverse effects

2. Physical Therapy

   • Focus on mobility, stretching, and strengthening exercises for the cervical spine 3
   • Studies show improvements in spinal range of motion and reduced stiffness with consistent exercise therapy
   • Schedule 2-3 sessions weekly for 8 weeks, then transition to home program

3. Heat Therapy and Massage

   • Apply heat to reduce stiffness and improve mobility
   • Consider massage therapy to relieve muscle tension

Monitoring and Follow-up

• Re-evaluate after 4-6 weeks of conservative management 1
• Monitor for:
  • Progressive neurological deficits
  • Development of dysphagia or respiratory symptoms
  • Impact on activities of daily living
  • Response to conservative treatment

Advanced Treatment Options

For Persistent Pain Without Neurological Symptoms

• Short-course oral prednisolone (consider as bridging therapy) 2

  • 10-20 mg daily for 1-2 weeks with tapering
  • Avoid long-term use due to side effects

• Intra-articular glucocorticoid injections for focal pain 2

  • Can provide temporary relief while awaiting effect of other treatments

For Progressive Neurological Symptoms or Airway/Esophageal Compression

• Surgical intervention is indicated for: 1, 4, 5

  1. Progressive neurological deficits
  2. Significant respiratory distress or dysphagia
  3. Persistent severe symptoms despite 6-8 weeks of conservative management

• Surgical approach options:

  • Anterior approach for osteophyte removal is preferred for dysphagia or respiratory symptoms 4
  • Combined approach (anterior osteophyte removal + posterior stabilization) may be necessary when DISH is associated with OPLL to prevent postoperative instability and neurological complications 5

Important Considerations and Cautions

• Risk of complications: Surgical excision of osteophytes in patients with concurrent OPLL carries risk of spinal cord injury due to increased intervertebral mobility 5
• Respiratory distress: DISH should be included in differential diagnosis of respiratory distress and obstructive sleep apnea 6
• Bone health: Patients requiring corticosteroid treatment should have DEXA bone mineral density scan and calcium supplementation; consider bisphosphonates for those with osteopenia/osteoporosis 2
• Recurrence: Osteophytes may recur after surgical excision, requiring long-term monitoring

Lifestyle Modifications

• Maintain proper posture
• Regular exercise focusing on neck and upper back strength
• Stress management techniques
• Adequate hydration
• Moderate alcohol consumption 1

Prognosis

With appropriate management, most patients with cervical DISH can maintain adequate function and quality of life. However, the condition is typically progressive, requiring ongoing monitoring and adjustment of treatment strategies over time.