|Ahead of print
Swati Bhat1, Chandramukhi1, Pawan Kumar Bichal2, Harshapriya Jyotinagar3, KS R. S. Prasad4, Pankaj N Surange5
1 IPSC India Interventional Pain and Spine Center, New Delhi, India
2 Pain Clinic, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India
3 Department of Pain and Palliative Care, Cytecare Cancer Hospitals, Bengaluru, Karnataka, India
4 Vishakha Pain Spine Center, Vishakhapatnam, Andhra Pradesh, India
5 IPSC India Chain of Single Speciality Hospitals, New Delhi, India
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|Date of Submission||15-Jul-2021|
|Date of Decision||16-Jul-2021|
|Date of Acceptance||08-Oct-2021|
|Date of Web Publication||15-Nov-2021|
Baastrup's syndrome or “kissing spine” is a common pathology of the vertebral column among the various conditions of the degenerative spine disorders. This syndrome is generally missed by clinicians; therefore, it is underdiagnosed and subsequently mismanaged. We report the case of a 61-year-old female who presented with chronic, ongoing, low back pain of several years duration who had been managed conservatively by various specialities over the last few years with no improvement.
Keywords: Baastrup's disease, facetal cyst, fluoroscopic butterfly appearance, kissing spine, spinal stenosis
Baastrup's disease (Baastrup syndrome) or “kissing spine” syndrome is a common pathology of the vertebral column. In this disorder, there is close approximation and contact of the spinous processes of adjacent vertebrae in the setting of degenerative spine disease., The impingement of the hypertrophied spinous processes may lead to a reactive sclerosis, remodelling, and spinal degeneration. This syndrome is generally missed by clinicians; therefore, it is underdiagnosed and subsequently mistreated.
Here, we present a case that we came across as our outpatient. The patient is a 61-year-old female who presented with chronic, ongoing, low back pain of several years duration. The pain radiated to both legs and was associated with paresthesia and stiffness. Pain was associated with numbness after walking few steps. Her pain aggravated with extension of the back and relieved with flexion. She had been managed conservatively by various specialities over the last few years but with no improvement.
Clinical examination revealed paraspinal muscle and midline tenderness from L2 to L5, SLR Rt 40°, Lt 50°.
After history and clinical examination, we made a differential diagnosis of lumbar spondyolisthesis and lumbar canal stenosis and ordered magnetic resonance imaging (MRI) lumbosacral spine.
MRI revealed facetal arthropathy with facetal cyst compromising the lumbar canal.
With history, clinical findings and MRI images [Figure 1], [Figure 2], [Figure 3] we diagnosed this as a case of Baastrup's disease.
|Figure 1: Axial T2-weighted images of lumbar vertebrae depicting thickened fibers of ligamentum flavum with bilateral cyst (marked as arrows)|
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|Figure 2: STIR sagittal images of lumbar spine showing apposition of spinous processes with cystic changes (marked with arrow heads) at L3 L4 causing posterior compression of the thecal sac, buckling of ligamentum flavum leading to lumbar canal stenosis|
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|Figure 3: Coronal section of lumbar spine showing butterfly appearance of bilateral facet joint filled with fluid (marked with arrowhead)|
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This patient was managed by image-guided facetal aspiration and injection of local anesthetic and long-acting steroids under local anesthesia.
The procedural images are as follows [Figure 4] and [Figure 5]:
|Figure 4: Procedural image showing fluoroscopic dye in the butterfly appearance|
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|Figure 5: Comparison of two images procedural fluoroscopic image after radiographic dye and magnetic resonance imaging coronal section image, both showing the characteristic butterfly pattern|
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The patient was followed up monthly for pain relief telephonically. She remained pain free.
| Discussion|| |
Baastrup's disease mostly affects lumbar spine L4-5 and may be mostly single level. Chronic contact between the spinous processes results in osseous hypertrophy and eburnation at this level. Repetitive shear force results in distortion and sclerosis which ultimately forms interspinal bursae and cysts. When the inflammation extends through ligamentum flavum, it may cause central canal stenosis., Other associated changes are degenerative disc disease with loss pf disc height, spondylolisthesis, and spondyolisis. Trauma and poor posture may be an associated cause.
These changes are mostly seen in elderly patients due to repetitive strain and mechanical pressure because of excessive lordiosis. Persistent strain on interspinous ligament may yield to degeneration and collapse.,,, Furthermore, due to repetitive spinal flexion and extension, this syndrome has been seen in 6.3% of athletes and mostly gymnasts. Therefore, it is important to consider Baastrup's syndrome in populations lying outside the anticipated age for degenerative spine disease.
Initially, Baastrup's presents as low back pain in the midline lumbar region with radiation along the spine, relieved by flexion and aggravated by extension. Leg pain and weakness similar to neurogenic claudication are seen on standing and walking when central canal disease sets in.,,,,
The diagnosis on imaging studies on lateral plain X-ray film is seen as “kissing” of closely approximated spinous processes and sometimes with visible sclerosis of the articulating surfaces. Computed tomography although suitable for visualizing the degenerative bony changes but not suitable for demonstrating pathological changes in the soft tissues of spine. Frequently, Baastrup's disease is missed due to the lack of knowledge and overexposure of the spinous processes.
MRI is the most sensitive imaging modality for detecting Baastrup's disease and much earlier. It has been noted that interspinous bursitis may precede the more pronounced osseous changes of the spinous processes, which MRI is best suited for detecting. The bursae appear as bright, high-intensity areas on T2-weighted MRI, between posterior spinous processes. In addition, MRI may show reactive sclerosis and hypertrophy of the spinous processes which may have flattened and enlarged articulating surfaces, may show associated edema at the level of the interspinous ligament, and also provides insight into the degree to which the posterior thecal sac is compressed.,
The treatment of Baastrup's syndrome is an ongoing topic for debate. Conventionally, surgical techniques have been employed including excision of the bursae and osteotomy to shorten the offending spinous processes. The use of interlaminar stabilization devices has not been investigated in patients with Baastrup's disease. Alternatively, percutaneous injections of long-acting steroids and local anesthetics have been used to treat inflammation and pain.,,
The results have shown significant improvement in pain scores at over 1 year following treatment. Physical therapy also plays an important role in the long-term management and focuses on reducing interspinous strain and lordiosis.
| Conclusion|| |
Baastrup's syndrome although a common etiology for low back pain but is generally underdiagnosed due to the lack of knowledge or improper diagnostic technique. These patients are generally mistreated thus resulting in unnecessary procedures. MRI is apparently the most sensitive imaging tool and percutaneous facetal aspiration along with instillation of local anesthetics and long-acting steroids offer symptomatic pain relief.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Pankaj N Surange,
IPSC India Chain of Single Speciality Hospitals, Dwaraka, New Delhi
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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