Approach

The goal of treatment is to:

  • alleviate symptoms

  • manage cardiometabolic comorbid disease

  • maintain functional status

  • prevent fractures.

Management of DISH requires a multidisciplinary approach and may include nonpharmacologic interventions (e.g., patient education, self-management, physical therapy), pharmacologic therapies, and surgery.[1]​​​[4][59]​ Therapy must be individualized; different treatments can be combined as required. Management strategies are largely extrapolated from the treatment of osteoarthritis.[4] Patients with DISH are often frail and have comorbidities; therefore, conservative treatment may be more appropriate.[1]

Surgical management may be required in patients with severe symptomatic cervical DISH or in those experiencing serious complications such as unstable spinal fractures, neurologic compromise, or airway obstruction.[1]

Nonpharmacologic approaches

Nonpharmacologic approaches include patient education (with particular emphasis on joint protection and falls/fracture prevention) and exercise/physical therapy.

Literature on the use of exercise/physical therapy in patients with DISH is sparse but may be effective in improving balance, stiffness, range of motion, and muscle strength. One study on the effect of a 24-week exercise program - 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.[60]

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

Pain management

Acetaminophen and/or a nonsteroidal anti-inflammatory drug (NSAID) is recommended for the medical management of pain in axial disease. Topical NSAIDs may be trialed 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.[61][62]

Literature on the use of other analgesics, including opioids, is sparse and no definitive recommendations can be made regarding their use. Intra-articular corticosteroid injections are used in practice in some patients with peripheral joint disease, although there are no robust data to support their use in this setting.

Application of heat may be effective in providing temporary relief of pain symptoms.[59]

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

Metabolic derangements

DISH may be associated with underlying metabolic conditions that are treatable. Manage metabolic derangements, such as obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol level, hypertension, hyperuricemia, and hyperglycemia.[1][59]​ See Metabolic syndrome, Hypertriglyceridemia, Hypercholesterolemia, Essential hypertension, Gout, and Type 2 diabetes mellitus in adults.

Dysphagia and airway impairment

Exuberant bone formation over the cervical spine anterior to the vertebral bodies can cause the esophagus or trachea to be displaced, potentially leading to dysphagia or airway obstruction. This may subsequently contribute to the development of obstructive sleep apnea and post-obstructive pneumonia.[2]

For patients with dysphagia or airway issues, always involve an otolaryngologist and/or speech therapist.[1]

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

If there is airway impairment and/or severe dysphagia, obtain urgent orthopedic input for consideration of surgical osteophyte removal.[1][63]​ For surgical resection of anterior cervical osteophytes, transoral, 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.[64]

Risks associated with surgery are usually related to patient frailty or distorted anatomy.[1]

Neurologic symptoms

As a consequence of the ankylosed spine and subsequent impingement on the spinal canal, patients with DISH have a higher likelihood of neurologic deficit, particularly after trauma.[64] 

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

Fractures

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][65]​ 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 orthopedic assessment for patients with a fracture associated with DISH as these patients are usually managed with surgery. Nonsurgical management is typically reserved for individuals without neurologic compromise who have medical conditions that make surgery unsuitable, because immobilization with an orthosis alone is linked to problems such as fracture displacement with consequent neurologic dysfunction and increasing deformity.[1][65] Patients with DISH frequently have fixed kyphotic deformities, making the bracing treatment of thoracolumbar fractures challenging.[1] Compared with nonsurgical treatment of fractures, surgical management 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 neurologic deficits, any preexisting 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 neurologic deficit is present).

  • Studies show that, compared with open fixation, percutaneous stabilization results in reduced blood loss, shorter operating times, fewer transfusion requirements, and lower perioperative complication rates.[64]

  • 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 neurologic compromise who are unsuitable for surgical intervention include:[1][66]

  • immobilization

  • cervical collar (c-collar)

  • halo

  • analgesia.

Serial neurologic examination is recommended in those who are unsuitable for surgical intervention to assess for development of neurologic deficit.

Analgesia for patients with fractures should begin with nonopioid drugs such as acetaminophen and NSAIDs. Data from animal studies on the impairment of fracture healing by NSAIDs are inconclusive, and these agents are regularly used clinically for this indication.[67][68]

If stronger analgesia is required, opioids can be used in combination with acetaminophen. 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 sensitization.[69] Opioids are recommended only for very short-term use with acute fractures.

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

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

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