What is the treatment for Baastrup's disease?

Treatment of Baastrup's Disease (Kissing Spine Syndrome)

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

Diagnosis Confirmation

Before initiating treatment, proper diagnosis is essential:

• Clinical presentation: Midline low back pain that worsens with extension and improves with flexion
• Imaging findings: Close approximation of adjacent spinous processes (typically at L4-L5), with potential findings of:
  • Edema
  • Cystic lesions
  • Sclerosis
  • Flattening and enlargement of articulating surfaces
  • Bursitis
  • Occasional epidural cysts or midline fibrotic masses 1

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Anti-inflammatory medications and physical therapy (35.7% of reported cases) 2

   • NSAIDs to reduce inflammation and pain
   • Physical therapy focusing on:
     • Core strengthening
     • Posture correction to reduce excessive lordosis
     • Flexion-based exercises (avoiding extension)

2. Activity modification

   • Avoid activities that exacerbate symptoms (especially those involving lumbar extension)
   • Maintain proper ergonomics

Second-Line Treatment: Interventional Procedures

If conservative management fails after 4-6 weeks:

1. Fluoroscopically guided interspinous ligament steroid injections 3
   • Injection of corticosteroid (e.g., 20mg triamcinolone acetate) with local anesthetic
   • Target: Interspinous space at the affected level
   • Can provide pain relief for up to 3 months
   • May need to be repeated for sustained benefit

Third-Line Treatment: Surgical Interventions

For patients with persistent symptoms despite conservative and interventional treatments:

1. Interspinous Plasty (Full-Endoscopic Approach) 4

   • Minimally invasive endoscopic resection of marginal osteophytes
   • Aims to recover physiological gap between adjacent spinous processes
   • Can be performed under local anesthesia
   • Advantages:
     • Removal of inflamed tissue
     • Reduction of inflammation via intraoperative saline irrigation
     • Low incidence of complications
     • Significant improvement in pain scores and function

2. Traditional Surgical Options 5, 2

   • Excision of the bursa
   • Partial or complete osteotomy of the spinous processes
   • Decompression procedures

Monitoring and Follow-up

• Regular assessment of pain using Visual Analog Scale (VAS)
• Functional assessment using Oswestry Disability Index (ODI)
• Follow-up imaging (CT) to assess:
  • Distance between adjacent spinous processes
  • Potential recrudescent osteoproliferation

Treatment Outcomes

Studies have reported significant improvements following surgical intervention:

• VAS scores for low back pain decreased from 7-8 to 1-2
• ODI scores improved from 68.9-77.8% to 28.9-33.3% at 12-month follow-up
• CT imaging showed enlargement of interspinous distance from 1 to 4 mm post-surgery 4

Important Considerations

• Baastrup's disease is often underdiagnosed and misdiagnosed 5, 2
• The incidence increases with age, with higher occurrence in patients over 70 years 1
• Dynamic flexion-extension radiographs are important for proper diagnosis 2
• The neoarthrosis between spinous processes may be the primary pain generator in cases without significant central canal stenosis 3

While there are no specific guidelines for Baastrup's disease treatment, this stepwise approach from conservative to interventional to surgical management represents the current best practice based on available evidence.