Diagnosis and Management of Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Introduction to DISH

DISH is a systemic condition characterized by ossification and calcification of ligaments and entheses, often coexisting with metabolic disorders including diabetes, obesity, and hyperlipidemia, as noted by the American College of Rheumatology, with similar findings in the context of retinoid therapy 1
The European League Against Rheumatism recommends considering the diagnosis of DISH through imaging findings, including flowing ossification along the anterolateral aspect of at least four contiguous vertebrae, preservation of intervertebral disc height, and absence of apophyseal joint ankylosis or sacroiliac joint erosion 2

Long-term NSAID use can cause gastrointestinal, renal, and cardiovascular adverse effects, especially in elderly patients, as advised by the National Institute for Health and Care Excellence, with similar concerns in retinoid therapy 1
Systemic retinoid therapy is associated with DISH-like skeletal hyperostosis, and patients on long-term retinoid therapy should be monitored for development of hyperostosis, as reported by the American Academy of Dermatology and the Journal of the American Academy of Dermatology 1, 2

The American College of Physicians recommends symptom management with NSAIDs/COX-2 inhibitors as first-line therapy, with evaluation of response at 2-4 weeks, and consideration of intravenous bisphosphonates and TNF-α inhibitors for non-responders, as supported by the American College of Rheumatology and the European League Against Rheumatism 3
Surgical intervention should be reserved for cases with severe functional impairment or neurological complications, as suggested by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis and the European League Against Rheumatism 3, 2
Treatment options include:
The National Kidney Foundation suggests phosphate supplements, active vitamin D, and consideration of burosumab for adults with persistent bone or joint pain, pseudofractures, or osteomalacia-related fractures, as well as osteotomies for severe deformities and physical therapy for general strengthening and gait education, especially post-surgery 4

Treatment success should be assessed through pain reduction and improved function, with radiological assessment using MRI or CT combined with nuclear imaging to evaluate reduction in bone marrow edema or tracer uptake, and laboratory monitoring of inflammatory markers if previously elevated, as recommended by the European League Against Rheumatism 3
Patients can be categorized into four groups based on clinical symptoms and radiological findings: active disease, inactive disease, probable inactive disease, and no clinically relevant activity 3
Regular monitoring should include assessment of clinical response, radiological changes, and potential complications, with consideration of surgical intervention for cases with neurological compromise, severe functional impairment, or failure of conservative management 3
Infection should be ruled out through appropriate cultures if fever or significantly raised inflammatory parameters are present, and bone biopsy is not routinely recommended unless there is suspicion of malignancy or infectious osteomyelitis 3