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 non-pharmacological interventions (e.g., patient education, self-management, physiotherapy), pharmacological therapies, and surgery.[1]​​​[4][57]​ Therapy must be individualised; 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, neurological compromise, or airway obstruction.[1]

Non-pharmacological approaches

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

Literature on the use of exercise/physiotherapy 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 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.

Pain management

Paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID) 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]

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.[57]

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, hypertriglyceridaemia, low high-density lipoprotein cholesterol level, hypertension, hyperuricaemia, and hyperglycaemia.[1][57]​ See Metabolic syndrome, Hypertriglyceridaemia, Hypercholesterolaemia, Essential hypertension, Gout, and Type 2 diabetes in adults.

Dysphagia and airway impairment

Exuberant bone formation over the cervical spine anterior to the vertebral bodies can cause the oesophagus or trachea to be displaced, potentially leading to dysphagia or airway obstruction. This may subsequently contribute to the development of obstructive sleep apnoea 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 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 patient frailty or distorted anatomy.[1]

Neurological symptoms

As a consequence of the ankylosed spine and subsequent impingement on the spinal canal, patients with DISH have a higher likelihood of neurological deficit, particularly after trauma.[62] 

Seek specialist input for consideration of surgical decompression for progressive neurological symptoms, such as with spinal stenosis, myelopathy, or radiculopathy.[1] Robust literature on the management of neurological 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][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 a fracture associated with DISH as these patients are usually managed with surgery. Non-surgical management 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][63] Patients with DISH frequently have fixed kyphotic deformities, making the bracing treatment of thoracolumbar fractures challenging.[1] Compared with non-surgical 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 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:[1][64]

  • immobilisation

  • cervical collar (c-collar)

  • halo

  • analgesia.

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

Analgesia for patients with fractures should begin with non-opioid drugs such as paracetamol 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.[65][66]

If stronger analgesia is required, opioids 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.

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 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.

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