Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

no fracture present

1st line – analgesia

Back
ACUTE
|
no fracture present
1st line – 

analgesia

Paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen is recommended for the medical management of pain in axial disease. Topical NSAIDs may be trialled in patients with peripheral joint disease.

NSAIDs should be used with caution in older people because of increased susceptibility to adverse effects such as gastrointestinal bleeding and cardiovascular events.[59][60]​​​​​​ Use the lowest effective dose for the shortest effective treatment duration.

Application of heat may also be effective in providing temporary relief of pain symptoms.[57]

Consider referral to a specialist in pain management if pain symptoms are not adequately controlled by simple analgesia.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND / OR --

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

or

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac topical: (1% gel) upper extremity joints: apply 2 g to the affected joint(s) four times daily, maximum 8 g/joint/day or 32 g/day total; lower extremity joints: apply 4 g to the affected joint(s) four times daily, maximum 16 g/joint/day or 32 g/day total

Plus – physiotherapy and patient education

Back
ACUTE
|
no fracture present
Plus – 

physiotherapy and patient education

Treatment recommended for ALL patients in selected patient group

Non-pharmacological approaches include patient education (with particular emphasis on joint protection and fracture prevention) and exercise/physiotherapy.

Literature on the use of exercise/physiotherapy in patients with DISH is sparse. One study on the effect of a 24-week exercise programme consisting of mobility, stretching, and strengthening exercises for the cervical, thoracic, and lumbar spine reported small improvements in physical measures, which achieved significance only for lumbosacral flexion.[58]

Orthotic insoles may also be considered as an option to improve posture.

Consider – surgical decompression

Back
ACUTE
|
no fracture present
|
with progressive neurological symptoms
Consider – 

surgical decompression

Additional treatment recommended for SOME patients in selected patient group

Specialist input for consideration of surgical decompression is recommended for progressive neurological symptoms, such as spinal stenosis, myelopathy, or radiculopathy.[1]​ Robust literature on the management of neurological symptoms in patients with DISH is lacking.

Consider – dietary changes and swallowing therapy

Back
ACUTE
|
no fracture present
|
with dysphagia or airway issues
Consider – 

dietary changes and swallowing therapy

Additional treatment recommended for SOME patients in selected patient group

For patients with dysphagia or airway issues, a multidisciplinary approach, including otolaryngologists and speech therapists, is recommended.[1]

If the dysphagia is mild, manage conservatively with dietary changes (modifying texture to soft, pureed foods), swallowing therapy, and medical management.[1]

Consider – surgical resection of anterior cervical osteophytes

Back
ACUTE
|
no fracture present
|
with dysphagia or airway issues
Consider – 

surgical resection of anterior cervical osteophytes

Additional treatment recommended for SOME patients in selected patient group

If there is airway impairment and/or severe dysphagia, obtain urgent orthopaedic input for consideration of surgical osteophyte removal.[1][61]​​​​

For surgical resection of anterior cervical osteophytes, trans-oral, posterolateral, and anterior cervical osteophyte exposures have been used. However, the left anterolateral technique is frequently employed because it is convenient for spinal surgeons and may reduce the risk of injury to the recurrent laryngeal nerve.[1] The anterolateral approach is particularly preferred given the ease of osteophyte removal and extended approach from C2-T1.[62]

Risks associated with surgery are usually related to frailty of patients and/or distorted anatomy.[1]

fracture present

1st line – orthopaedic referral and consideration for surgery

Back
ACUTE
|
fracture present
1st line – 

orthopaedic referral and consideration for surgery

Patients with DISH are at increased risk of vertebral body fractures. DISH increases the risk of unstable spine fractures, which can result from low-energy mechanisms such as ground-level falls, tenfold.[1][63]​​​​​ The most frequent fractures seen in individuals with DISH are hyperextension fractures through fused vertebral bodies; the most commonly affected segments of the spine are the cervical, thoracic, and lumbar, in that order.[1]

Seek orthopaedic assessment for patients with spinal fracture associated with DISH as these patients are typically managed with surgery. Non-surgical management of vertebral body fracture associated with DISH is typically reserved for individuals without neurological compromise who have medical conditions that make surgery unsuitable, because immobilisation with an orthosis alone is linked to problems such as fracture displacement with consequent neurological dysfunction and increasing deformity.[1] Patients with DISH frequently have fixed kyphotic deformities, making the bracing treatment of thoracolumbar fractures challenging.[1] Compared with non-surgical management, surgery is linked to lower mortality rates.[1]

If surgery is indicated, important factors to consider when choosing a technique include the patient's comorbidities, the presence of neurological deficits, any pre-existing deformities, and the requirement for fracture reduction.[1] Surgical techniques typically used in patients suitable for surgery are open pedicle screw fixation and percutaneous pedicle screw (if no neurological deficit is present). Studies show that, compared with open fixation, percutaneous stabilisation results in reduced blood loss, shorter operating times, fewer transfusion requirements, and lower perioperative complication rates.[62]

Corrective osteotomies are rarely advised as part of the surgical management of spinal fractures, even in the presence of significant baseline kyphotic abnormalities.[1] These procedures may increase spinal instability or increase the likelihood of pseudoarthrosis and implant failure.[1]

Management options in patients without neurological compromise who are unsuitable for surgical intervention include immobilisation, use of a cervical collar (c-collar), halo, and analgesia.[1][64]​​​ Serial neurological examination is recommended in those unsuitable for surgical management to assess for development of neurological deficit.

Plus – analgesia

Back
ACUTE
|
fracture present
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Analgesia should begin with non-opioid drugs such as paracetamol and a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen. Data from animal studies on the impairment of fracture healing by NSAIDs are inconclusive, and these agents are regularly used clinically for this indication.[65][66]​​​​ NSAIDs should be used with caution in older people because of increased susceptibility to adverse effects such as gastrointestinal bleeding and cardiovascular events.[59][60]​ Use the lowest effective dose for the shortest effective treatment duration.

If stronger analgesia is required, opioids (e.g., oxycodone) can be used in combination with paracetamol. If opioids are used, a laxative should also be prescribed and fluid intake encouraged to prevent constipation. If used chronically, opioids may lose potency, induce dependence, raise risk for addiction, and lead to falls and central sensitisation.[67]​ Opioids are recommended only for very short-term use with acute fractures. Use the lowest effective dose for the shortest effective treatment duration.

For persistent severe pain, use of centrally-acting therapies including tricyclic antidepressants (e.g., amitriptyline) and gabapentin should be considered after discussion about the potential risks and benefits.

Amitriptyline should be used with caution in older patients, due to the risk of anticholinergic and sedating effects, and in patients with a history of cardiovascular disease.

Gabapentin should be used with caution in older patients due to the increased risk of respiratory depression and neurocognitive changes; start at the lowest dose and increase dose gradually while monitoring for symptoms. Also use with caution in patients with a history of substance misuse.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

or

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

Secondary options

oxycodone/paracetamol: 2.5 to 10 mg orally every 6 hours when required

More

Tertiary options

amitriptyline: 10-25 mg orally once daily at bedtime initially, increase gradually according to response, maximum 150 mg/day

OR

gabapentin: 300 mg orally once daily for 1 day, followed by 300 mg twice daily for 1 day, then 300 mg three times daily thereafter, increase gradually according to response, maximum 3600 mg/day

Plus – physiotherapy and patient education

Back
ACUTE
|
fracture present
Plus – 

physiotherapy and patient education

Treatment recommended for ALL patients in selected patient group

A period of immobilisation or rest is recommended post fracture while the patient continues to be in acute pain. Physiotherapy and exercise programmes can be initiated when the degree of pain starts to diminish; prolonged immobilisation is not recommended.

Literature on the use of exercise/physiotherapy in patients with DISH is sparse. One study on the effect of a 24-week exercise programme consisting of mobility, stretching, and strengthening exercises for the cervical, thoracic, and lumbar spine reported small improvements in physical measures, which achieved significance only for lumbosacral flexion.[58]

Patient education, with particular emphasis on joint protection and fracture prevention, is recommended.

Consider – surgical decompression

Back
ACUTE
|
fracture present
|
with progressive neurological symptoms
Consider – 

surgical decompression

Additional treatment recommended for SOME patients in selected patient group

Specialist input for consideration of surgical decompression is recommended for progressive neurological symptoms, such as spinal stenosis, myelopathy, or radiculopathy.[1]​ Robust literature on the management of neurological symptoms in patients with DISH is lacking.

Consider – dietary changes and swallowing therapy

Back
ACUTE
|
fracture present
|
with dysphagia or airway issues
Consider – 

dietary changes and swallowing therapy

Additional treatment recommended for SOME patients in selected patient group

For patients with dysphagia or airway issues, a multidisciplinary approach, including otolaryngologists and speech therapists, is recommended.[1]

If the dysphagia is mild, manage conservatively with dietary changes (modifying texture to soft, pureed foods), swallowing therapy, and medical management.[1]

Consider – surgical resection of anterior cervical osteophytes

Back
ACUTE
|
fracture present
|
with dysphagia or airway issues
Consider – 

surgical resection of anterior cervical osteophytes

Additional treatment recommended for SOME patients in selected patient group

If there is airway impairment and/or severe dysphagia, obtain urgent orthopaedic input for consideration of surgical osteophyte removal.[1][61]​ Surgical intervention is typically reserved for cases of cervical DISH leading to airway impairment or severe dysphagia, as well as spinal fractures.

For surgical resection of anterior cervical osteophytes, trans-oral, posterolateral, and anterior cervical osteophyte exposures have been used. However, the left anterolateral technique is frequently employed because it is convenient for spinal surgeons and may reduce the risk of injury to the recurrent laryngeal nerve.[1] The anterolateral approach is particularly preferred given the ease of osteophyte removal and extended approach from C2-T1.[62]

Risks associated with surgery are usually related to frailty of patients and/or distorted anatomy.[1]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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