What is the management and treatment of Baastrup's (kissing spines syndrome) disease?

Management and Treatment of Baastrup's Syndrome (Kissing Spine Syndrome)

Begin with conservative management including NSAIDs and physical therapy for 3-6 months; if symptoms persist despite conservative treatment, proceed to percutaneous steroid infiltration at the interspinous level; reserve surgical excision of the spinous processes for cases refractory to both conservative and interventional treatments. 1, 2

Clinical Presentation and Diagnosis

Baastrup's disease presents with characteristic midline low back pain that worsens with spinal extension, improves with flexion, and is exacerbated by direct finger pressure over the affected spinous processes (most commonly L4-L5). 3, 4 The condition results from close approximation or contact of adjacent posterior spinous processes, typically due to excessive lumbar lordosis causing repetitive mechanical strain and subsequent degenerative changes. 3

Diagnostic Imaging Approach

• Standard anteroposterior and lateral radiographs should be obtained first to identify close approximation of spinous processes 2
• Dynamic flexion-extension radiographs are essential to demonstrate the mechanical nature of the contact and should be performed in all suspected cases 2
• MRI is the gold standard for comprehensive evaluation, revealing not only spinous process contact but also associated findings including bone marrow edema, interspinous bursitis, sclerosis, flattening/enlargement of articulating surfaces, and potential epidural cysts 3, 2
• CT scan can demonstrate bony changes and sclerosis in 43.9% of cases when MRI is contraindicated 2

Treatment Algorithm

First-Line: Conservative Management (3-6 months)

All patients should initially receive conservative treatment combining pharmacological and non-pharmacological approaches. 2, 4

Pharmacological Treatment

• NSAIDs as first-line medication for pain and inflammation control 2, 4
• Consider COX-2 selective inhibitors or non-selective NSAIDs with gastroprotection in patients with gastrointestinal risk factors 5
• Analgesics (acetaminophen, opioid-like drugs) may be added for residual pain if NSAIDs are insufficient, contraindicated, or poorly tolerated 5

Non-Pharmacological Treatment

• Physical therapy focusing on flexion-based exercises to reduce spinous process contact 2
• Gentle isometric strengthening exercises that minimize extension movements 5
• Patient education regarding posture modification and activity modification to avoid excessive lumbar extension 5, 3
• Avoidance of activities that exacerbate extension-related pain 4

Second-Line: Percutaneous Interventional Treatment

If conservative management fails after 3-6 months, proceed to image-guided percutaneous steroid infiltration at the interspinous bursa. 1, 2, 4

• Subcutaneous or interspinous corticosteroid injections directed to the site of inflammation 4
• This approach was used successfully in 28.9% of treated patients in systematic review 2
• The injection serves both diagnostic (confirms pain source) and therapeutic purposes 1
• May require repeat injections if initial response is partial 4

Third-Line: Surgical Management

Surgical intervention should be reserved for patients with persistent, disabling pain despite adequate conservative treatment (minimum 6 months) and failed percutaneous interventions. 1, 2

Surgical Options

• Excision of the interspinous bursa with or without partial spinous process resection 3, 2
• Osteotomy (resection) of the involved spinous processes to eliminate mechanical contact 3
• Surgical decompression was performed in 70.7% of surgically treated patients with generally favorable outcomes 2
• Surgery allows definitive diagnostic confirmation through histopathological examination 1

Surgical Indications

• Failure of conservative management for at least 6 months 1
• Failure of percutaneous steroid infiltration 1
• Severe, disabling pain significantly impacting quality of life 1
• Radiographic confirmation of kissing spines with clinical correlation 1, 3

Common Pitfalls and Caveats

Baastrup's disease is frequently underdiagnosed and misdiagnosed due to lack of clinical awareness, leading to prolonged inappropriate treatment. 4 The condition shows a decade-on-decade increase in incidence, particularly affecting patients over 70 years, though it can occur in younger patients (mean age 59.6 years). 2

Critical diagnostic error: Relying solely on static radiographs without dynamic flexion-extension views may miss the mechanical nature of the condition. 2

Treatment error: Proceeding directly to surgery without adequate trial of conservative management and percutaneous interventions. The stepwise approach is essential, as 35.7% of patients respond to conservative treatment alone. 2

Imaging pitfall: Even when imaging findings are unclear or show minimal inflammation, strong clinical suspicion based on characteristic pain patterns (extension-aggravated, flexion-relieved, midline tenderness) should guide further diagnostic and therapeutic interventions. 1