What is the management plan for a patient with Diffuse Idiopathic Skeletal Hyperostosis (DISH) noted on a Computed Tomography (CT) scan?

Management of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Noted on CT Scan

For patients with DISH incidentally found on CT scan, symptomatic management is recommended with NSAIDs for pain relief, physical therapy for mobility, and monitoring for complications, as DISH typically does not require specific intervention unless complications develop.

Understanding DISH

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by:

• Calcification and ossification of soft tissues, primarily ligaments and entheses
• Flowing ossifications along the anterior spine spanning ≥4 vertebral bodies
• Common in men over 50 years of age
• Often asymptomatic but may cause pain, stiffness, and reduced range of motion

Clinical Assessment

When DISH is identified on CT scan, evaluate for:

1. Symptoms:

   • Back or neck pain
   • Stiffness and reduced range of motion
   • Dysphagia (if cervical involvement)
   • Respiratory symptoms (less common but potentially serious)
   • Neurological symptoms (rare but concerning)

2. Associated conditions:

   • Diabetes mellitus
   • Hypertension
   • Hyperlipidemia
   • Hyperuricemia
   • Obesity

Management Approach

1. Asymptomatic DISH

For incidental findings without symptoms:

• No specific treatment required
• Monitor periodically for symptom development
• Educate patient about potential complications
• Address associated metabolic disorders if present

2. Symptomatic Management

For patients with pain and stiffness:

• NSAIDs for short-term pain relief 1
• Physical therapy to maintain mobility and function
• Weight loss if overweight/obese
• Heat therapy for stiffness
• Lifestyle modifications including regular exercise within tolerance

3. Management of Associated Conditions

• Control of metabolic disorders that may be associated with DISH 2:
  • Diabetes management
  • Hypertension treatment
  • Lipid-lowering therapy if indicated
  • Management of hyperuricemia

4. Monitoring for Complications

Spine Fracture Risk

• Patients with DISH have increased risk of unstable spine fractures from low-energy trauma 3, 4
• Educate patients about this risk
• Consider bone density testing if other risk factors for osteoporosis exist

Airway/Esophageal Compression

• Monitor for dysphagia or respiratory symptoms, especially with cervical involvement 5
• If dysphagia or respiratory symptoms develop, refer for ENT evaluation
• In severe cases with airway obstruction, surgical intervention may be necessary

Special Considerations

Imaging Follow-up

• Routine radiographic follow-up is not recommended for asymptomatic DISH 1
• Targeted imaging for atypical musculoskeletal pain may be informative

Surgical Intervention

• Reserved for cases with:
  • Severe neurological compromise
  • Significant dysphagia or airway obstruction
  • Unstable fractures through ankylosed segments

Pitfalls to Avoid

1. Misdiagnosis: DISH can be confused with ankylosing spondylitis or spondyloarthropathies. Ensure correct diagnosis by confirming:

   • Flowing ossifications along anterolateral spine
   • Preservation of disc height
   • Absence of sacroiliac joint erosions

2. Overlooking fractures: Due to ankylosed spine, even minor trauma can cause unstable fractures. Maintain high suspicion for fractures in DISH patients with new-onset pain after trauma.

3. Unnecessary interventions: Most cases of DISH do not require specific treatment beyond symptomatic management and addressing associated metabolic conditions.

4. Ignoring respiratory symptoms: While less common than dysphagia, respiratory manifestations can be life-threatening and require prompt evaluation 5.

By following this management approach, patients with DISH can be appropriately monitored and treated to minimize complications and maintain quality of life.