What is the treatment for Baastrup sign?

Treatment of Baastrup's Disease (Kissing Spine Syndrome)

The treatment of Baastrup's disease should follow a stepwise approach, beginning with conservative management and progressing to more invasive interventions only when conservative measures fail to provide adequate pain relief.

Understanding Baastrup's Disease

Baastrup's disease, also known as kissing spine syndrome, is characterized by:

• Close approximation of adjacent spinous processes, most commonly at L4-L5 level 1
• Pain that typically worsens with extension and is relieved with flexion 2
• Higher occurrence in individuals over 70 years of age 1
• Degenerative changes including oedema, sclerosis, flattening, and enlargement of articulating surfaces 1

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Anti-inflammatory medications and physical therapy

   • NSAIDs for pain management
   • Physical therapy focused on:
     • Core strengthening exercises
     • Posture correction to reduce excessive lordosis
     • Flexibility exercises
   • This approach is used in approximately 35.7% of cases 3

2. Activity modification

   • Avoid activities that exacerbate symptoms (particularly spinal extension)
   • Encourage positions that reduce pain (typically flexion)

Second-Line Treatment: Interventional Procedures

If conservative management fails after 4-6 weeks:

1. Fluoroscopically guided interspinous ligament steroid injections
   • Injection of corticosteroid (e.g., 20mg triamcinolone acetate) with local anesthetic 4
   • Target the neoarthrosis between spinous processes
   • Can provide pain relief for up to 3 months 4
   • Used in approximately 28.9% of cases 3

Third-Line Treatment: Surgical Intervention

Consider surgical options when conservative and interventional treatments fail:

1. Surgical decompression
   • Excision of the interspinous bursa
   • Osteotomy of the spinous processes
   • Used in approximately 70.7% of patients who require treatment 3
   • Allows for definitive diagnosis confirmation and potential return to normal social and professional life 5

Special Considerations

• Diagnostic confirmation: Diagnosis should be verified with both clinical examination and imaging studies (MRI, CT, or dynamic flexion-extension radiographs) 1, 3
• Pain characteristics: Pain is typically midline, worsens during extension, is relieved during flexion, and is exacerbated by finger pressure at the affected level 1
• Imaging findings: Look for close approximation of adjacent spinous processes, oedema, cystic lesions, sclerosis, and enlargement of articulating surfaces 1

Common Pitfalls

1. Underdiagnosis: Baastrup's disease is frequently underdiagnosed due to lack of knowledge or improper diagnostic techniques 2
2. Misattribution of pain: Pain may be incorrectly attributed solely to degenerative disk disease or spinal stenosis rather than the neoarthrosis between spinous processes 4
3. Inadequate imaging: Failure to obtain appropriate imaging studies, particularly dynamic flexion-extension radiographs, may lead to missed diagnosis 3

By following this structured approach to the management of Baastrup's disease, clinicians can provide effective treatment while minimizing unnecessary interventions and improving patient outcomes.