What is the initial management for diffuse idiopathic skeletal hyperostosis (DISH)?

Initial Management of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

The initial management of diffuse idiopathic skeletal hyperostosis should focus on symptomatic pain relief through NSAIDs, physical therapy, and lifestyle modifications, while monitoring for potential complications. 1, 2

Understanding DISH

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory entheses disease characterized by:

• Calcification and ossification of soft tissues, mainly ligaments and entheses 2
• Flowing anterior osteophytes affecting at least 3 adjacent vertebrae, most commonly in the thoracic spine 1
• Potential for spinal stiffness, pain, and reduced range of motion 3
• Association with metabolic disorders including obesity, diabetes, hyperlipidemia, and hyperuricemia 2

First-Line Management Approach

Pain Management

• NSAIDs/COXIBs at maximum tolerated doses for 2-4 weeks as first-line treatment 1
  • Options include naproxen (375-1100 mg/day), diclofenac (75-150 mg/day), or celecoxib (200-400 mg/day) 1
  • Evaluate response after 2-4 weeks and consider switching to another NSAID if ineffective 1
• Short courses of oral prednisolone may be considered as a bridging option in severe cases, but avoid long-term use of glucocorticoids 1

Physical Therapy

• Implement a structured exercise program focusing on mobility, stretching, and strengthening exercises for the affected spine regions 3
• Include supervised sessions initially, followed by a home exercise program 3
• Focus on improving spinal range of motion, particularly lumbosacral flexion, which has shown significant improvement in studies 3

Lifestyle Modifications

• Weight management for patients with obesity 2
• Control of associated metabolic disorders (diabetes, hyperlipidemia, hyperuricemia) 2
• Ergonomic adjustments to reduce strain on affected areas 1

Monitoring and Special Considerations

Imaging Assessment

• Initial radiographs to confirm diagnosis and assess extent of ossification 1
• CT scan provides superior spatial resolution for evaluating DISH-related complications such as spinal canal narrowing 1
• MRI may be indicated if neurological symptoms are present to assess for cord compression 1
• Avoid routine follow-up radiographs unless new symptoms develop 1

Fracture Risk Management

• Patients with DISH have increased risk of spinal fractures, even from minor trauma 4, 5
• Fractures in DISH patients may have worse outcomes with conservative treatment compared to typical osteoporotic fractures 4
• For stable fractures in non-fused segments, close monitoring is essential as bony union rates may be lower than in patients without DISH 4

Airway Considerations

• Monitor for symptoms of dysphagia or airway obstruction, particularly with cervical DISH 6
• In cases of airway compromise, careful airway management and possible surgical osteophytectomy may be required 6

When to Consider Advanced Therapies

• For patients with insufficient response to NSAIDs after 2-4 weeks 1
• For spinal bone lesions with risk of vertebral collapse 1
• For patients with significant accumulated skeletal damage 1
• For patients with neurological symptoms or airway compromise 6

Treatment Efficacy Evaluation

• Assess pain, stiffness, and function at 2-4 weeks after initiating treatment 1
• If response is sufficient, continue treatment; consider on-demand treatment or dose tapering with sustained response at 12 weeks 1
• If response is insufficient, consider advancing to second-line treatments 1

Remember that while DISH is often asymptomatic or causes minor chronic symptoms, it can lead to significant morbidity in some patients, requiring personalized management strategies based on symptom severity and affected areas 6, 2.