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

Management of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

The management of DISH should focus on symptom control with NSAIDs/COX-2 inhibitors as first-line therapy, followed by intravenous bisphosphonates or TNF-α inhibitors for non-responders, with surgical intervention reserved only for cases with severe functional impairment or neurological complications. 1

Clinical Presentation and Assessment

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

Common presentations include:

• Spinal stiffness and pain
• Reduced range of motion
• Often asymptomatic or presenting with minor chronic symptoms 2
• Frequently coexists with metabolic disorders (diabetes, obesity, hyperlipidemia) 1

Less common but serious presentations:

• Dysphagia (when cervical spine is involved)
• Airway obstruction (rare but potentially life-threatening) 3, 4

Treatment Algorithm

First-Line Treatment

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

Second-Line Treatment (for non-responders)

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

Bridging Therapy (for acute symptom flares)

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

Surgical Management

• Reserved for:
  • Severe functional impairment
  • Neurological complications
  • Upper airway obstruction requiring osteophytectomy 3
  • Failure of conservative management 1

Management of Associated Conditions

• Control of associated metabolic disorders:

  • Hypertension
  • Hyperinsulinemia/hyperglycemia
  • Hyperlipidemia
  • Hyperuricemia 5

• Lifestyle modifications:

  • Weight management for obese patients
  • Physical therapy for general strengthening
  • Gait education and postural training 1

Monitoring and Follow-up

• Assess treatment success through:

  • Pain reduction and improved function
  • Radiological assessment (MRI or CT combined with nuclear imaging) to evaluate reduction in bone marrow edema or tracer uptake
  • Laboratory monitoring of inflammatory markers if previously elevated 1

• Regular follow-up to monitor:

  • Clinical response
  • Radiological changes
  • Potential complications 1

Special Considerations

• Airway management: In cases of respiratory compromise due to cervical osteophytes, careful airway assessment is crucial. Options include:

  • Conservative management with CPAP for mild cases
  • Surgical intervention for severe airway obstruction 4

• Pain management: A significant proportion of DISH patients (51%) may require opioid medications for pain control, highlighting the potential severity of symptoms 2

• Healthcare utilization: DISH is associated with substantial healthcare resource utilization, with many patients requiring spinal surgery (31%) and specialist consultations (57%) 2

Pitfalls and Caveats

• DISH is often underdiagnosed or misdiagnosed as asymptomatic, leading to inadequate management of symptoms 2
• Include DISH in the differential diagnosis of airway obstruction and dysphagia, especially in older males 3, 4
• Avoid confusing DISH with primary osteoarthritis, as they differ in prevalence, gender distribution, and anatomical sites of involvement 5
• Be vigilant for DISH-like changes in patients on long-term retinoid therapy 1
• Consider the risk of unstable spinal fractures in DISH patients, particularly with minor trauma 6