Diffuse Idiopathic Skeletal Hyperostosis Treatment Guidelines

What is diffuse idiopathic skeletal hyperostosis (DISH)?

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory condition marked by abnormal calcification and ossification of ligaments and tendons, especially at their attachment points to bones. While it mainly affects the spine, DISH can also impact the pelvis, elbows, knees, and heels.

Unlike other forms of degenerative arthritis, DISH primarily affects ligaments and entheses rather than joint spaces, including the posterior longitudinal ligament in the spine. It often leads to the formation of large bony bridges, particularly in the thoracic spine, which involve structures like the anterior longitudinal ligament. However, intervertebral disc spaces are usually preserved, distinguishing DISH from other spinal disorders.

Symptoms of diffuse idiopathic skeletal hyperostosis (DISH)

The symptoms of DISH can vary widely, ranging from mild to severe. The condition is often asymptomatic and is discovered incidentally during imaging for unrelated issues. However, when symptoms do occur, they may include:

• Spinal stiffness and pain: The most common symptoms are stiffness and pain, particularly in the thoracic spine. In cases with more severe symptoms, patients might experience significant difficulty with movement or chronic pain.
• Reduced range of motion: As the condition progresses and bone spurs begin to form, the formation of bony growths can limit the range of motion, especially in the spine. This can lead to difficulty bending or twisting the torso.
• Difficulty swallowing (dysphagia): In severe cases, particularly when the cervical spine or spinal fractures are involved, bony growths can impinge on the esophagus, leading to difficulty swallowing or sleep apnea.

Causes of this disease

The exact cause of DISH is unknown, which is why it is termed "idiopathic." However, several factors have been associated with the development of the condition:

• Aging: DISH is more common in older adults, particularly those over the age of 50. The likelihood of developing DISH increases with age.
• Metabolic factors: Conditions such as obesity, diabetes mellitus, and metabolic syndrome are strongly associated with DISH. These metabolic disturbances are thought to play a role in the abnormal bone growth seen in DISH.
• Genetic predisposition: DISH may have a genetic component, as it sometimes occurs in families, suggesting that genetic factors may influence susceptibility.
• Mechanical stress: Chronic mechanical stress on certain ligaments and tendons, particularly in areas subjected to repetitive movements or strain, may contribute to the development of DISH.

How is DISH diagnosed?

Diffuse idiopathic skeletal hyperostosis (DISH) is typically diagnosed through a combination of clinical evaluation and imaging studies. The diagnosis is based on the characteristic features seen in the spine and, occasionally, in other areas of the body. Here are the key steps involved in diagnosing DISH:

• Clinical evaluation: The initial step in diagnosing DISH involves a thorough medical history and physical examination. The healthcare provider will assess symptoms such as back stiffness, pain, and reduced range of motion.
• Advanced imaging techniques: In some cases, additional imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI) may be used to provide more detailed views of the spine and other affected areas. These modalities can help assess the extent of bony growths and their impact on surrounding structures, such as nerves, the esophagus, or the spinal cord.
• Laboratory tests: While there are no specific blood tests for DISH, laboratory tests may be conducted to rule out other inflammatory or metabolic conditions. For example, tests for rheumatoid factor, anti-nuclear antibodies, or markers of inflammation may be performed to exclude autoimmune diseases.

How to use our DISH Treatment Guidelines template

The DISH Treatment Guidelines template is designed to help healthcare professionals efficiently navigate and apply the treatment strategies. Here’s how you can effectively use this template:

Step 1: Familiarize yourself with the handout

Take time to thoroughly read and understand the handout. It provides a comprehensive overview of DISH treatment, including general approaches, specific modalities, and special considerations.

Step 2: Use as a quick reference during patient consultations

Keep the handout readily accessible during patient visits. It can serve as a quick reference to guide your treatment decisions, ensure you cover all potential management strategies, and remind you of important considerations specific to DISH patients.

Step 3: Integrate into your treatment planning

Use the handout to create a structured treatment plan for each DISH patient. Start with the conservative measures outlined in the "general treatment approach" section. Refer to "medication considerations" when prescribing, noting the caution against certain drugs that might enhance insulin secretion.

Step 4: Patient education tool

The handout can also be a valuable patient education resource. Use it to explain the condition and various treatment options to your patients. Highlight relevant sections to help patients understand their treatment plan.

How do healthcare professionals treat DISH?

The treatment of diffuse idiopathic skeletal hyperostosis (DISH) focuses primarily on managing symptoms and maintaining mobility, as there is no cure for the condition. The approach to treatment typically involves a combination of physical therapy, medication, and lifestyle modifications. Here is how healthcare professionals commonly treat DISH:

Physical therapy

Physical therapy is a cornerstone of treatment for DISH. Its goal is to improve flexibility, maintain range of motion, and reduce stiffness, particularly in the spine. A physical therapist may design a personalized exercise program that includes stretching and strengthening exercises tailored to the patient's specific needs. Regular physical activity can help prevent further loss of mobility and manage pain associated with DISH.

Analgesics

Analgesics, or pain relievers, are commonly used to manage the discomfort associated with DISH. Over-the-counter medications such as acetaminophen (Tylenol) are often the first line of treatment for mild to moderate pain. These medications help reduce pain without the anti-inflammatory effects of other drugs, making them suitable for patients who need relief without additional medication effects.

Sedation

Sedation is not typically used as a primary treatment for DISH but may be considered in cases where pain or discomfort leads to significant sleep disturbances or anxiety. In such cases, short-term use of sedative medications may be prescribed to help the patient rest and recover. However, sedation is usually a secondary consideration, used only when necessary and under close supervision by a healthcare provider.

Anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve) are commonly prescribed to reduce both pain and inflammation associated with DISH. These medications can help alleviate symptoms, particularly during flare-ups or periods of increased discomfort.

How healthcare professionals will benefit from this handout

Healthcare professionals will benefit from the DISH Treatment Guidelines handout by gaining quick and comprehensive access to evidence-based recommendations for managing diffuse idiopathic skeletal hyperostosis. The handout provides clear guidelines, including medication options, physical therapy strategies, and lifestyle modifications, enabling efficient and effective patient care. Additionally, it helps clinicians stay informed about the latest best practices, ensuring consistent and up-to-date patient management across different healthcare settings.