DISH, or Diffuse Idiopathic Skeletal Hyperostosis, is a condition that often goes overlooked or not treated adequately. In this article, we’ll explore the topic of DISH disease treatment, focusing on the most effective method to alleviate the symptoms and complications caused by Diffuse Idiopathic Skeletal Hyperostosis.
Brief Overview of DISH Disease
Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a form of enthesopathy characterized by the calcification and ossification of tendons and ligaments throughout the body but mostly along the anterior surface of the spine. This calcification eventually leads to the formation of bone spurs, also known as osteophytes, protruding out the spine.
Symptoms of DISH can include severe pain and stiffness, limited mobility, and other similar symptoms of significant spine conditions. The rigidity of the spine in DISH patients increases the risk and severity of fractures, even with minor trauma.
DISH is often overlooked as a normal age-related spinal condition and some clinicians do not consider it as a disease.
Mistaking DISH with Other Spine Conditions
Sometimes, due to its tendency toward ossification and causing spine pain, DISH can be misrepresented as other spine diseases like ankylosing spondylitis and degeneration. However, while degeneration, ankylosing spondylitis and DISH all result in significant discomfort, their underlying mechanisms differ. Ankylosing spondylitis and degeneration primarily affect the vertebral discs, whereas DISH involves calcification around the disc joints. Characteristic feature of DISH is the absence of inflammation in affected area which is opposite to all arthritis conditions. In some cases DISH and spinal degeneration may coexist and there is clinical data that DISH may worsen the course of spinal degeneration.
Misidentifying DISH can lead to inappropriate treatments and worsening of the condition, making it crucial to recognize DISH as a distinct disease with proper diagnosis and tests.
Misconception of DISH as Age-Related Condition that Can’t Be Treated
Many doctors in the medical community have historically viewed Diffuse Idiopathic Skeletal Hyperostosis merely as a part of the natural aging process rather than a distinct disease. While the risk for DISH increases with age, it is not solely an age-related condition. DISH falls under the category of enthesopathy, meaning its exact cause is unknown, and it should not be seen as a normal part of aging.
Unlike any other type of arthritis or age-related spine degeneration, DISH can lead not only to severe pain but also significant harm to internal organs, and even the need for intensive care in advanced and untreated cases.
As we will explore in the following sections, not taking DISH seriously can be dangerous, and the misconception that there are no effective treatments is equally harmful.
Understanding DISH Osteophytes
Historical Neglect of Osteophytes’ Role
For many years in medicine, the role of osteophytes in causing pain was overlooked. These bony growths can exert pressure on nearby structures, leading to severe symptoms. Historically, the medical community did not fully recognize the impact of these growths, resulting in a lack of a targeted DISH disease treatment.
“We were hearing from patients that they were increasingly frustrated by descriptions of the disease as asymptomatic, when that wasn’t at all their lived experience,” says Cheryle Séguin, professor and lead author of the recent study on DISH published in the journal Arthritis Research & Therapy. 1
Unmanaged DISH disease often progresses unchecked, exacerbating its symptoms. The progression of DISH leads to patients experiencing chronic back pain, mobility issues, and organ dysfunction, which could have been mitigated with proper recognition.
This neglect has long emphasized the need for a more proactive approach in the diagnosis and management of DISH disease.
Specific Issues Caused by DISH Osteophytes
When DISH is left untreated, the resulting osteophytes can cause a range of serious health problems. Here are some specific complications that can arise from untreated DISH disease.
Cervical Spine Osteophytes and Dysphagia
Cervical osteophytes, which form in the neck region, can press against the pharynx and esophagus, leading to dysphagia, or difficulty swallowing. 2 This compression in the cervical spine can severely affect a patient’s ability to eat and drink.
Studies show that dysphagia is observed in 0.6–1.0% of cervical DISH cases. 3 The cervical osteophytosis, or new bone formation in the cervical spine, also poses a risk of malnutrition and dehydration due to the difficulty in swallowing.
Thoracic Osteophytes and Sympathetic Nerves
Autonomous nervous system is part of our nervous systems and consist of sympathetic and parasympathetic parts. It is responsible for innervating internal organs and regulating their functions. Despite enormous clinical significance autonomous nervous system diseases didn’t receive much attention.
Sympathetic part of the autonomous nervous system originates at T1 – L3 spinal segments. Nerves originating in the thoracic and lumbar segments make sympathetic trunk of the left and right sides of the spine starting from the skull base and ending in the coccyx. The trunk maybe affected by DISH osteophytes in the lower thoracic and lumbar area where the bony spurs tend to develop in the vicinity of the chain. In thoracic spine the sympathetic trunk is usually posterior to osteophytes and not directly affected. Yet it gives off many branches which join together and constitute splanchnic nerves which travel on the anterior surface of the spine. These splanchnic nerves and their branches are usually compressed by thoracic DISH osteophytes. This idea was first proposed by Nathan in 1987 4
The anatomical impact of DISH osteophytes once again highlights the critical need for targeted intervention for this disease.
Osteophytes’ Impact on the Heart and Gastrointestinal System
Osteophytes formed due to DISH can compress various internal organs and structures, leading to a range of symptoms.
Imagine the spine as a central column with nerves radiating out to different parts of the body. When bone growths, or osteophytes, form along this column, they press on the sympathetic nerves that are crucial for the autonomic regulation of the heart. This can lead to arrhythmias, disrupting the normal rhythm and causing irregular heartbeats. Research from 2019 published in the Atherosclerosis Journal also indicates that people with DISH have an increased burden of coronary artery disease. 5
Furthermore, osteophytes can affect the gastrointestinal system by compressing the nerves that innervate the stomach and intestines. This can lead to a variety of gastrointestinal issues, such as dyspepsia, bloating, and altered bowel habits. Patients with DISH often experience significant discomfort and disruption in their digestive processes, which can contribute to a decline in their overall health. Research from 2014 by Rabia Terzi goes as far as to say that “rare, life-threatening gastrointestinal events may develop due to bone compression” in patients with DISH. 6
How DISH Disease Increases Susceptibility to Spinal Fractures
The increased rigidity of the spine due to DISH can also make patients more susceptible to fractures. Typically a DISH patient develops fused segment of the spine spanning several vertebral segments which serves as a long cantilever arm. As a result, even minor trauma or fall can lead to severe fractures in the spine with catastrophic neurological consequences like spinal cord injury. For example, a 2015 research paper from Japan shows that “DISH can make the spine prone to fracture after even trivial trauma”. 7
DISH and respiratory functions compromise
Non-surgical DISH Treatment Options: Are they Effective?
Non-surgical treatments for Diffuse Idiopathic Skeletal Hyperostosis primarily focus on managing symptoms rather than addressing the root cause. These treatments can provide temporary relief but often fall short of offering a permanent solution.
Physiotherapy for DISH
Physiotherapy is commonly recommended to improve mobility and reduce stiffness and pain in patients with DISH. Techniques include exercises and manual therapy aimed at enhancing flexibility and strength. While physiotherapy can help manage symptoms, it does not address the underlying osteophyte formations.
DISH Medications: Painkillers, Anti-Inflammatory Drugs, Corticosteroid Injections
Medications such as painkillers, anti-inflammatory drugs, and corticosteroid injections are frequently used to manage the pain and inflammation associated with Diffuse Idiopathic Skeletal Hyperostosis. Pain relievers like acetaminophen and prescription opioids can provide temporary relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) help reduce inflammation and pain. Corticosteroid injections can be administered to target specific areas of inflammation, providing more localized and potent relief.
However, corticosteroid injections, painkillers and NSAIDs, again, only offer symptomatic relief and do not stop the progression of the disease.
Percutaneous Kyphoplasty for DISH Disease Treatment
Percutaneous kyphoplasty is a minimally invasive surgical procedure used to manage spinal fractures in DISH patients. The procedure involves making a small incision and inserting a balloon into the fractured vertebra. After inflating the balloon to create space, bone cement is injected to stabilize the vertebra. While kyphoplasty is effective for treating fractures, it is not suitable for addressing problems caused by advanced osteophytes in DISH.
Please keep in mind that if a patient’s problems are caused by osteophytes, percutaneous kyphoplasty will not be sufficient. In such cases, other surgical interventions, such as the removal of bone spurs, will be required to alleviate symptoms caused by advanced osteophytes.
Why Isn’t Surgery More Commonly Used for DISH?
If nonsurgical treatment doesn’t help much with DISH, the next logical step would be surgery. However, despite the potential benefits of treating DISH with surgery, it remains a relatively uncommon approach compared to other spine treatments.
One might wonder, “Why is it so hard to find a doctor to treat DISH surgically?” This is mainly because the complex spine anatomy and the specialized skills required for spine surgery make this option much more complicated. Here are some key reasons for this challenge:
Expertise Gap
One of the reasons surgery is not commonly offered as standard treatment for DISH is the gap in expertise between thoracic surgeons, who typically handle chest and lung issues, and neurosurgeons, who specialize in spine conditions. This gap has resulted in a lack of comprehensive management and treatment approaches for Diffuse Idiopathic Skeletal Hyperostosis.
Thoracic surgeons historically focus on lung and tumor surgeries and may not be familiar with the sympathetic nervous system’s role in pain or the specific needs for treating DISH. Because of this, Diffuse Idiopathic Skeletal Hyperostosis effectively falls into a gray area between specialties, leading to further neglect.
The Lack of Precedent
Another significant challenge is the lack of precedent for the surgical treatment of DISH. Medical practices often rely on established cases and published studies to guide treatment decisions and surgical procedures. With few documented cases of successful surgeries for DISH, many doctors are hesitant to recommend this option.
The lack of awareness and precedent means that many patients who could benefit from surgery are not offered this option.
Treatment of Diffuse Idiopathic Skeletal Hyperostosis: Why Open Surgery?
Due to the involvement of multiple spinal levels, open surgery often becomes necessary for treating DISH. While endoscopic methods can be effective for removing osteophytes at a single level, they fall short when dealing with extensive cases that span several levels of the spine.
For instance, Dr. Kamran Aghayev performed open surgeries for patients with osteophytes from levels T-3 to T-12. This technique allows the surgeon to access and remove multiple osteophytes precisely, providing comprehensive relief for the patient.
DISH Surgery Technique by Dr. Kamran Aghayev
Dr. Kamran Aghayev has developed a specialized technique for the surgical removal of osteophytes in DISH patients. The procedure involves accessing the spine through a lateral approach, either from the right or left side, depending on the area with the most osteophytes. Typically, the approach is from the right side. The lung is deflated to provide better access to the thoracic cavity, allowing the surgeon to work effectively in this space.
Once the spine is exposed, the osteophytes are visible and can be removed using various bone instruments. The precise removal of these bone growths alleviates pressure on the nerves and other affected structures. This meticulous approach ensures that the spine’s integrity and the patient’s overall health are maintained.
Efficacy and Safety of Dr. Aghayev’s Approach for DISH
Dr. Kamran Aghayev’s surgical approach for treating DISH has shown excellent results in terms of both efficacy and safety. The procedure, though intricate, is relatively straightforward and does not result in complications. Since the surgery is performed away from the primary nerves and spinal cord, the risks of complications are exceptionally low.
Based on the outcomes of Dr. Aghayev’s patients, there is considerable hope that DISH can be effectively managed through this surgical approach. This method offers a degree of improvement not seen with other current DISH disease treatments.
Dr. Aghayev’s technique provides a much-needed solution for patients suffering from the severe effects of DISH, presenting a viable option where non-surgical treatments have failed.
DISH Surgical Treatment Review: Frequently Asked Questions
Is Surgery a Permanent Solution to Cure DISH?
While the exact cause of DISH is unknown and the disease itself cannot technically be cured, surgical removal of osteophytes can still be considered a permanent solution for DISH. This is because the osteophytes grow very slowly, and it may take around 30 years for them to cause significant issues again after removal.
What are the Benefits of Removing Osteophytes?
Surgical removal of osteophytes alleviates pressure on nerves and organs. This approach directly addresses the cause of the symptoms rather than merely managing them. As a result, patients experience long-term relief from the pain and complications associated with DISH, making surgery an effective and lasting option for managing the condition.
Will the Osteophytes Come Back After Surgery?
There is a possibility that osteophytes may recur after surgery, but this process is typically very, very slow. It may take several decades for new osteophytes to form to the extent that they cause symptoms again. In many cases, the long-term relief provided by surgery outweighs the potential for recurrence.
What’s the Long-Term Prognosis After DISH Surgery?
The long-term prognosis for patients who undergo surgery for DISH is generally positive. Most patients experience significant and lasting relief from symptoms. While there is a chance of osteophyte recurrence, it typically takes many years for new growths to become problematic.
What are the Case Studies for Dr. Aghayev’s Technique?
Dr. Kamran Aghayev has successfully treated several patients with DISH using his surgical techniques. These case studies include individuals who experienced immediate and long-term relief from chronic pain and other symptoms following surgery. For example, one case report includes a patient who experienced a complete resolution of pain from DISH and arrhythmia after the removal of thoracic osteophytes.
What’s the Success Rate of DISH Surgery?
Surgery for DISH has shown high success rates in relieving pain and improving function. Case studies have demonstrated significant symptom relief and improved quality of life for patients who have undergone the procedure.
Conclusion: What is the Best Treatment for DISH?
Comparing surgical treatment to other options reveals that surgery is often the most effective way to achieve long-term relief from DISH symptoms. While non-surgical treatments can manage symptoms temporarily, surgery addresses the root cause by removing the osteophytes.
Surgery offers a more permanent solution for pain relief in people with DISH. By removing the osteophytes that cause nerve compression and organ dysfunction, patients can experience lasting relief from DISH pain and other symptoms, significantly improving their quality of life.
Previous Chapter: A Closer Look at DISH — Idiopathic Skeletal Hyperostosis Explained
References
- D E Fournier, M A Veras, C R Brooks, Stiffness and axial pain are associated with the progression of calcification in a mouse model of diffuse idiopathic skeletal hyperostosis, Arthritis Research and Therapy, 2023, https://doi.org/10.1186/s13075-023-03053-3[↩]
- J H Lee, S H Paeng, S Y Pyo, S Tae Kim, W Hee Lee, Swallowing Difficulty in Diffuse Idiopathic Skeletal Hyperostosis with Metabolic Syndrome, Korean J Neurotrauma, 2020, https://doi.org/10.13004/kjnt.2020.16.e4[↩]
- N Karaarslan, M S Gürbüz, T Çalışkan, A T Simsek, Forestier syndrome presenting with dysphagia: case report of a rare presentation, J Spine Surg, 2017, https://doi.org/10.21037/jss.2017.11.05[↩]
- Nathan H. Osteophytes of the spine compressing the sympathetic trunk and splanchnic nerves in the thorax. Spine (Phila Pa 1976). 1987;12(6): 527-532. https://doi.org/10.1097/00007632-198707000-00003)) based on extensive cadaveric observations. The clinical features sympathetic trunk and/or splanchnic nerve compression hasn’t been investigated much. There are few speculations about the possibility on either paresis or irritation of internal organs but there is substantial gap in our knowledge regarding clinical symptoms that might be related to sympathetic nervous system compression. In addition to that we do not have reliable test to diagnose sympathetic dysfunction due to osteophyte compression. This area is in medical science is pretty much unexplored.
Compression of sympathetic nerves by the extra bone in the thoracic spine can lead to severe, chronic pain and dysfunction of internal organs such as the heart and gastrointestinal tract. A notable study published in 2021 by J Jankowski documented cases where thoracic osteophytes caused symptomatic compression of the greater splanchnic nerve which was cured by surgical resection. ((J Jankowski, A Pawełczyk, M Radek, Thoracic osteophyte as a cause of symptomatic greater splanchnic nerve compression, Case report, Neurochirurgie, 2022, https://doi.org/10.1016/j.neuchi.2021.02.017[↩]
- S F Oudkerk, F A A Mohamed Hoesein, E K Silverman, M J Budoff, E A Regan, Subjects with diffuse idiopathic skeletal hyperostosis have an increased burden of coronary artery disease: An evaluation in the COPDGene cohort, Atherosclerosis, 2019, https://doi.org/10.1016/j.atherosclerosis.2019.05.030[↩]
- Rabia Terzi, Extraskeletal symptoms and comorbidities of diffuse idiopathic skeletal hyperostosis, World J Clin Cases, 2014, https://doi.org/10.12998/wjcc.v2.i9.422[↩]
- Murakami Y, Mashima N, Morino T, et al. Association Between Vertebral Fracture and Diffuse Idiopathic Skeletal Hyperostosis. Spine (Phila Pa 1976). 2019;44(18): E1068-E1074. https://doi.org/10.1097/BRS.0000000000003151[↩]
