What is the initial treatment for Baastrup disease?

Initial Treatment for Baastrup's Disease

The initial treatment for Baastrup's disease should consist of conservative management with non-steroidal anti-inflammatory drugs (NSAIDs) and physical therapy, with fluoroscopically-guided interspinous ligament steroid injections reserved for patients who fail to respond to initial conservative measures. 1, 2, 3

Understanding Baastrup's Disease

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

• Close approximation of adjacent spinous processes, typically in the lumbar spine (most commonly at L4-L5)
• Degenerative changes leading to contact between spinous processes
• Midline low back pain that worsens during extension and is relieved during flexion
• Pain that can be exacerbated by finger pressure at the affected level
• Higher occurrence in patients over 70 years of age with no gender predilection 2

Diagnostic Approach

Diagnosis is based on:

1. Clinical examination:

   • Midline back pain that worsens with extension and improves with flexion
   • Pain reproduction with direct pressure over the affected spinous processes

2. Imaging studies:

   • X-rays (including dynamic flexion-extension views) to demonstrate close approximation of spinous processes
   • MRI to identify edema, cystic lesions, and inflammation
   • CT scan to visualize bony changes including sclerosis, flattening, and enlargement of articulating surfaces 2, 3

3. Diagnostic injection:

   • Local anesthetic injection into the interspinous region can serve as both diagnostic and potentially therapeutic 4

Treatment Algorithm

First-Line Treatment

1. Conservative management:
   • NSAIDs for pain control and to reduce inflammation
   • Physical therapy focused on core strengthening and posture correction
   • Activity modification to avoid excessive lumbar extension 2, 3

Second-Line Treatment

1. Interventional procedures (if conservative management fails after 4-6 weeks):
   • Fluoroscopically-guided interspinous ligament steroid injections (20mg triamcinolone acetate with local anesthetic)
   • These injections can provide pain relief for up to 3 months 5

Third-Line Treatment

1. Surgical intervention (for refractory cases):
   • Interspinous plasty: Endoscopic resection of marginal osteophytes to restore physiological gap between adjacent spinous processes
   • Removal of inflamed tissue and reduction of inflammation via intraoperative saline irrigation
   • Excision of bursa or osteotomy in severe cases 4

Efficacy of Treatments

• Conservative treatment: Effective for mild to moderate cases, but may not provide long-term relief in advanced disease
• Interspinous injections: Case reports show significant pain relief lasting up to 3 months 5
• Surgical treatment: Endoscopic interspinous plasty has shown promising results with improvements in Visual Analog Scale (VAS) scores (from 7-8 to 1-2) and Oswestry Disability Index (ODI) (from 68-78% to 28-33%) at 12-month follow-up 4

Important Considerations and Pitfalls

• Baastrup's disease is often underdiagnosed or misdiagnosed due to poor knowledge about the condition
• The condition may coexist with other spinal pathologies such as degenerative disc disease or spinal stenosis
• Failure to identify the neoarthrosis between spinous processes as the primary pain generator may lead to ineffective treatment
• Surgical intervention should be considered only after failure of conservative and interventional treatments
• Patients should be carefully selected for surgical intervention, with confirmation of diagnosis through clinical examination, imaging, and positive response to diagnostic injection 1, 3