What is the initial treatment for Baastrup disease?

Initial Treatment for Baastrup's Disease

The initial treatment for Baastrup's disease should focus on conservative management with analgesics, anti-inflammatory medications, and physical therapy before considering more invasive interventions. Based on the available evidence, a stepwise approach is recommended for managing this condition, which is characterized by close approximation of adjacent spinous processes leading to chronic low back pain.

Understanding Baastrup's Disease

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

• Close approximation and contact of adjacent spinous processes, most commonly at L4-L5 level 1
• Back pain with midline distribution that worsens during extension and is relieved during flexion
• Higher occurrence in individuals over 70 years of age
• No gender predilection
• Often associated with excessive lordosis

Initial Treatment Approach

First-Line Management:

1. Non-steroidal anti-inflammatory drugs (NSAIDs)

   • Similar to the approach for other inflammatory spinal conditions
   • Helps reduce pain and inflammation at the site of spinous process contact

2. Physical therapy

   • Focus on exercises that reduce lumbar lordosis
   • Core strengthening to improve posture and spinal alignment
   • Flexion-based exercises that open the posterior elements of the spine

3. Activity modification

   • Avoidance of activities that increase lumbar extension
   • Postural education to minimize excessive lordosis

This conservative approach is supported by evidence showing that 35.7% of reported cases were initially managed with anti-inflammatory drugs and physical therapy 2.

Second-Line Interventions

If conservative management fails to provide adequate relief after 4-6 weeks:

Interventional Procedures:

1. Fluoroscopically guided interspinous ligament steroid injections

   • Injection of corticosteroids (e.g., triamcinolone acetate 20mg) with local anesthetic
   • Targets the neoarthrosis between spinous processes
   • Can provide pain relief for up to 3 months 3

2. Percutaneous infiltrations

   • Used in approximately 28.9% of reported cases 2
   • Particularly effective when imaging shows evidence of inflammation or edema between spinous processes

Diagnostic Confirmation

Proper diagnosis requires:

• Clinical examination showing pain that worsens with extension and improves with flexion
• Imaging studies:
  • Standard and dynamic flexion-extension radiographs
  • MRI to identify edema, cystic lesions, or bursitis between spinous processes
  • CT scan to evaluate bony changes including sclerosis, flattening, and enlargement of articulating surfaces

When to Consider Surgical Management

Surgical intervention should be considered when:

• Conservative and interventional treatments fail to provide adequate pain relief
• Patient has significant functional limitations despite appropriate non-surgical management
• Imaging confirms advanced changes with significant impingement

Surgical options include:

• Excision of the affected spinous processes
• Osteotomy to reduce contact between adjacent spinous processes
• Removal of any associated bursa or cyst

Approximately 70.7% of patients in reported studies eventually underwent surgical decompression 2, suggesting that while conservative management is the appropriate initial approach, many patients with persistent symptoms may ultimately benefit from surgery.

Key Considerations and Pitfalls

1. Misdiagnosis is common

   • Baastrup's disease is often underdiagnosed or misattributed to other causes of low back pain
   • Careful clinical correlation with imaging findings is essential

2. Associated conditions

   • Consider the possibility of concurrent degenerative disk disease or spinal stenosis
   • Paraspinal muscle atrophy may play a role in pathogenesis 4

3. Age-related considerations

   • While more common in older adults, can occur in younger patients with excessive lordosis
   • A 31-year-old patient with persistent symptoms eventually required surgical management 5

By following this stepwise approach from conservative management to more invasive interventions, clinicians can effectively address the pain and functional limitations associated with Baastrup's disease while minimizing unnecessary procedures.