Baastrup Syndrome: Difference between revisions

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== Introduction ==
== Introduction ==
[[File:Baastrup-disease-1.jpeg|thumb|Baastrup syndrome with active inflammation (e.g. bursitis)|alt=|400x400px]]
[[File:Baastrup-disease-1.jpeg|thumb|Baastrup syndrome with active inflammation (e.g. bursitis)|alt=|400x400px]]
Baastrup syndrome (also referred to as kissing spines) is a cause of low back pain characterized by interspinous bursitis and other degenerative changes of the bones and soft tissues where adjacent spinous processes in the lumbar spine rub against each other.
Baastrup syndrome (also referred to as kissing spines) is a cause of low back pain characterized by interspinous bursitis and other degenerative changes of the bones and soft tissues where adjacent spinous processes in the lumbar spine rub against each other.<ref name=":4">Radiopedia Basstrup Syndrome Available;https://radiopaedia.org/articles/baastrup-disease-1?lang=us (accessed 29.8.2022)</ref>


Kissing Spine mainly affects the lumbar area of the spine, with L4-L5 being the most frequently affected level <ref name=":3">Filippiadis D.K. et al., Baastrup’s disease (kissing spines syndrome): a pictorial review, Springer, 2015, 6(1): 123–128</ref>, but it has also been reported in the cervical spine.<ref name=":8">Rajasekaran S. et al., Baastrup’s Disease as a Cause of Neurogenic Claudication: a case report, Lippincott Williams &amp; Wilkins, 2003, 28(14): 273-275</ref>  
Kissing Spine mainly affects the lumbar area of the spine, with L4-L5 being the most frequently affected level <ref name=":3">Filippiadis D.K. et al., Baastrup’s disease (kissing spines syndrome): a pictorial review, Springer, 2015, 6(1): 123–128</ref>, but it has also been reported in the cervical spine.<ref name=":8">Rajasekaran S. et al., Baastrup’s Disease as a Cause of Neurogenic Claudication: a case report, Lippincott Williams &amp; Wilkins, 2003, 28(14): 273-275</ref>


Kissing Spine has numerous consequences such as the formation of hypertrophic spinous processes, which can lead to mechanical back pain in combination with degenerative disc disease.<ref name=":2">Singla A. et al., Baastrup’s disease: the kissing spine, World Journal of Clinical Cases, 2014, 2(2): 45-47.</ref> <ref name=":1">Kacki S. et al., Baastrup’s Sign (Kissing Spines): A neglected condition in paleopathology, International Journal of Paleopathology, 2011, 1(2): 104-110</ref><sup>&nbsp;</sup>In some cases, the syndrome can also evoke neuromuscular damage.<ref>Rajasekaran S. et al., Baastrup’s Disease as a Cause of Neurogenic Claudication: a case report, Lippincott Williams &amp; Wilkins, 2003, 28(14): 273-275</ref>
Clinically Relevant Anatomy: See [[Lumbar Anatomy]]  
 
Clinically Relevant Anatomy: See [[Lumbar Anatomy]]
[[File:Baastrup_2.png|alt=|thumb|463x463px|Lumbar Spine Anatomy]]
 
 
'''Figure 2: '''Vertebral Ligaments <ref name=":7">Masaracchio M. et al., Clinical Guide to Musculoskeletal Palpation, Human Kinetics, 2014, 203-208</ref>


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==


A few studies have investigated the influence of the age on Baastrup Syndrome. ''DePalma et al''. demonstrated that the average age of patients with Baastrup’s disease is 75.<ref>DePalma M.J. et al., What is the source of Chronic Low Back Pain and does age play a role?, Pain Medicine, 2011, 12: 224-233</ref> which was supported  by ''Maes R. et al.'' that Baastrup Syndrome is more common amongst elderly persons, but this does not preclude incidence in younger individuals. The effect of gender is still unknown, so further research is necessary.<ref name=":9">Maes R. et al., Lumbar Interspinous Bursitis (Baastrup Disease) in a Symptomatic Population: Prevalence on Magnetic Resonance Imaging, The Spine Journal, 2008, 33(7): 211-215</ref>
Baastrup Syndrome tends to be more common in the elderly. Other suggested risk factors are:<ref name=":1">Kacki S. et al., Baastrup’s Sign (Kissing Spines): A neglected condition in paleopathology, International Journal of Paleopathology, 2011, 1(2): 104-110</ref> <ref name=":3" />
 
Age is not the only factor that is responsible for the evolution of Baastrup Syndrome. Other suggested risk factors are:<ref name=":1" /> <ref name=":3" />  
 
*Excessive lordosis which results in increased mechanical pressure  
*Excessive lordosis which results in increased mechanical pressure  
*Repetitive strains of the interspinous ligament with subsequent degeneration and collapse  
*Repetitive strains of the interspinous ligament with subsequent degeneration and collapse  
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*Stiffening of the thoracic spine or the thoracolumbar transition  
*Stiffening of the thoracic spine or the thoracolumbar transition  
*Obesity
*Obesity
The cause of pain is described as being mainly mechanical due to the neighbouring spinous processes coming into contact. Pain worsens with hyperextension or increased lordosis which can been seen in patients with obesity, limitation in hip movements and pro/elite swimmers.<ref name=":8" /><ref name=":9" />
Baastrup syndrome can occur independently or together with symptoms of other disorders, such as spondylolisthesis and spondylosis with osteophyte formation and a loss of disc height.<ref name=":3" />
The precise prevalence in the population remains still uncertain, but ''Kacki  et al''. suggest that this disease may be common, given the relatively frequent abnormal changes of the interspinous spaces.<ref name=":1" />
== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
[[File:Baastrup_3.png|alt=|thumb|400x400px|Basstrup or Kissing Spine]]
Patients with Baastrup syndrome typically show an excessive lordosis.<ref name=":3" /> <ref name=":19">Jang E-C. et al., Posterior epidural fibrotic mass associated with Baastrup’s disease, Springer, 2010; 19(2): 165-168</ref> Patients with Kissing Spine often complain about back pain, more specifically, midline pain that radiates distally and proximally, increasing on extension and reducing on flexion.<ref name=":2">Singla A. et al., Baastrup’s disease: the kissing spine, World Journal of Clinical Cases, 2014, 2(2): 45-47.</ref> <ref name=":3" />  This abnormal contact between adjacent spinous processes can lead to neoarthrosis and formation of an adventitious bursa. This can be seen pathologically on MRI. <ref name=":0">Kwong Y. et al., MDCT Findings in Baastrup Disease: Disease or Normal Feature of the Aging Spine?,American Journal of Roentgenology, 2011, 196(5):1156-9.</ref> <ref name=":9">Maes R. et al., Lumbar Interspinous Bursitis (Baastrup Disease) in a Symptomatic Population: Prevalence on Magnetic Resonance Imaging, The Spine Journal, 2008, 33(7): 211-215</ref> <ref>FarinhaF. et al., Baastrup’s disease: a poorly recognized cause of back pain, ActaReumatol Port, 2015, 40:302-303</ref>


Patients with Baastrup syndrome typically show an excessive lordosis. This results in mechanical pressure that can cause pain and repetitive strains combined with subsequent degeneration and collapse.<ref name=":3" /> <ref name=":19">Jang E-C. et al., Posterior epidural fibrotic mass associated with Baastrup’s disease, Springer, 2010; 19(2): 165-168</ref> Patients with Kissing Spine often complain about back pain, more specifically, midline pain that radiates distally and proximally, increasing on extension and reducing on flexion.<ref name=":2" /> <ref name=":3" />  This abnormal contact between adjacent spinous processes can lead to neoarthrosis and formation of an adventitious bursa. This can be seen pathologically on MRI. <ref name=":0">Kwong Y. et al., MDCT Findings in Baastrup Disease: Disease or Normal Feature of the Aging Spine?,American Journal of Roentgenology, 2011, 196(5):1156-9.</ref> <ref name=":9" /> <ref>FarinhaF. et al., Baastrup’s disease: a poorly recognized cause of back pain, ActaReumatol Port, 2015, 40:302-303</ref>
Rotation and lateral flexion are usually painful with flexion being the least painful of all lumbar movements.<ref name=":12">Hertling D. et al., Management of common musculoskeletal disorders: Physical Therapy Principles and Methods, Lippincott Williams &#x26; Wilkins, 2006, 4th edition</ref> Baastrup’s disease can result in intraspinal cysts secondary to an interspinous bursitis which may, in rare cases, cause symptomatic spinal stenosis and neurogenic claudation <ref name=":0" />
 
Other characteristics can be pain upon palpation at the level of pathologic interspinous ligament, oedema, cystic lesions, sclerosis, flattening and enlargement of the articulating surfaces and bursitis. Occasionally epidural cysts or midline epidural fibrotic masses can also occur <ref name=":3" />
 
Rotation and lateral flexion are usually painful with flexion being the least painful of all lumbar movements.<ref name=":12">Hertling D. et al., Management of common musculoskeletal disorders: Physical Therapy Principles and Methods, Lippincott Williams &#x26; Wilkins, 2006, 4th edition</ref> Baastrup’s disease can result in intraspinal cysts secondary to an interspinous bursitis which may, in rare cases, cause symptomatic spinal stenosis and neurogenic claudation <ref name=":0" />  
 
== Differential Diagnosis<ref name=":2" /><ref>Kaye A.D. et al., Pain Management, Cambridge University Press, 2015</ref>  ==
*[[Lumbar Spondylosis]]
*[[Muscle Strain]]
*[[Spondylolisthesis]]
*Fracture of the spinous process
*Vertebral (e.g. lumbar) compression fractures
*Infectious etiologies of the spine
*Proliferative hyperostosis of the lumbar spinous processes
*Degenerative disease of the spine
*Cysts
*Ossification of the posterior longitudinal ligament
*Sclerotic bone metastases to spine
 
== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
[[File:Baastrup_4.png|alt=|right|frameless|399x399px]]
Baastrup Syndrome cannot be diagnosed by simply assessing the lumbar spine (see [[Lumbar Assessment|clinical examination]]), imaging modalities are required to prevent misdiagnosis.  <ref name=":3" />


Baastrup Syndrome cannot be diagnosed by simply assessing the lumbar spine (see [[Lumbar Assessment|clinical examination]]), imaging modalities are required to prevent misdiagnosis. Numerous radiographic methods can be used to determine a diagnosis of Baastrup Syndrome. If necessary different methods can be combined for a more detailed picture of the degenerative and inflammatory signs at the level of interspinous ligament <ref name=":3" /><br>
# '''CT and Xrays:''' Often shows close approximation and contact of adjacent spinous processes (kissing spines). Resultant enlargement, flattening, and reactive sclerosis of apposing interspinous surfaces
 
# '''Magnetic Resonance Imaging MRI:''' May demonstrate interspinous bursal fluid and posterocentral epidural cyst(s). MRI can be very helpful in determining whether there is resulting posterior compression of the thecal sac.  
'''Computed Tomography (CT) scan'''  
 
Kissing Spine is diagnosed if 3 criteria appear on a CT scan:
* close approximation and contact between touching lumbar spinous processes
* flattening and enlargement of the articulating surfaces
* reactive sclerosis of the superior and inferior fragments of adjacent processes.<ref name=":0" /><ref name=":3" /><ref name=":10">DePalma M.J. et al., Interspinous Bursitis in an Athlete, The Journal of Bone and Joint Surgery, 2004, 86: 1062-1064</ref> 
CT scans can also report on detailed degenerative changes (e.g. facet joints hypertrophy, intervertebral disc herniation or spondylolisthesis).<ref name=":3" /><ref name=":10" />
 
However, this type of diagnostic procedure is limited in the assessment of disc degeneration and soft tissue imaging, which means that interspinous bursae cannot be seen.<ref name=":0" /> 
 
[[Image:Baastrup 3.png]]
 
'''Figure 3:''' CT scan of Baastrup Syndrome T12-L1-L2-L3 <ref name=":0" />
 
'''Radiography (X-rays)'''
 
X-rays are analogous to CT scans and show <ref name=":3" />
 
*Close approximation and contact of opposed spinous processes with sclerosis of the articulating surfaces;
*Expansion of the articulating surfaces or articulation of the two affected spinous processes;
*General degenerative changes in the spine.
 
X-rays have a lower cost, are more readily availability and give a relatively low ionising radiation dose. The disadvantage of radiographic imaging is poor imaging quality, in particular, at the lower lumbar fragments.
 
'''Magnetic Resonance Imaging MRI'''
 
In contrast to CT scans, an MRI may pick up on interspinous bursal fluid and a postero-central epidural cyst(s) at the opposing spinous processes.<ref name=":14">Chen C.K.H. et al., Intraspinal Posterior Epidural Cysts Associated with Baastrup's Disease: Report of 10 patients, American Journal of Roentgenology, 2004, 182(1): 191-194</ref> lumbar interspinous bursitis is diagnosed where bursal fluid is present between 2 opposing affected spinous processes' (illustrated as a bright and/or high signal intensity areas on imaging) <ref name=":9" /><ref name=":11">Clifford P.D. et al., Baastrup Disease: Imaging Series, The American Journal of Orthopedics, 2007, 36(10): 560-561</ref>
 
Similar to a CT scan MRI shows any flattening, sclerosis, enlargement, cystic lesions and bone oedema at the articulating surfaces of the spinous processes. This type of diagnostic procedure is extremely beneficial in determining whether there is a compression of the posterior thecal sac as an outcome of this contact of the interspinous processes.<ref name=":11" />
 
Further advantages of MRI imaging also include no ionising radiation and a highly detailed image at various levels (axial, coronal and sagittal).<ref name=":3" />[[Image:Baastrup 4.png]]
 
'''Figure 4:''' MRI scan of Baastrup Syndrome L3-L4 <ref name=":0" />
 
Baastrup’s Syndrome is regularly misdiagnosed and often incorrectly treated. A thorough clinically assessment and scrutinising of radiographic imaging are vital for an accurate diagnosis and to prevent mismanagement.<ref name=":2" />


== Outcome Measures  ==
== Outcome Measures  ==
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*[[Quebec Back Pain Disability Scale]]  
*[[Quebec Back Pain Disability Scale]]  
*[[Visual Analogue Scale]]  
*[[Visual Analogue Scale]]  
*[[Oswestry Disability Index|Oswestry]]
*[[Fingertips to Floor Distance - Special Test|Fingertip-to-Floor]] (FTF) Test
*[[Roland‐Morris Disability Questionnaire]]
*Measurements of spinal mobility:
*Fingertip-to-Floor (FTF) Test
*Modified [[Schober Test|Schober Test]]
== Examination  ==
== Examination  ==
[[File:Baastrup_5.png|alt=|thumb|Stork Test]]Diagnosis of Baastrup’s disease is verified with clinical examination as well as imaging studies.<ref name=":3" /> Symptoms include low back pain with midline distribution that exacerbates when performing extension, relieved during flexion and is exaggerated upon finger pressure at the level of the pathologic interspinous ligament. Rotation and lateral flexion are also very painful. <ref name=":3" /> The pain can be described as a sharp or deep ache, often worse during physical activities that increase lumbar lordosis or compression of these structures.<ref name=":6">DePalma M.J., iSPINE Evidence Based Interventional Spine Care, Demos Medical, 2011, 4-8</ref>


Diagnosis of Baastrup’s disease is verified with clinical examination as well as imaging studies.<ref name=":3" /> Symptoms include low back pain with midline distribution that exacerbates when performing extension, relieved during flexion and is exaggerated upon finger pressure at the level of the pathologic interspinous ligament. Rotation and lateral flexion are also very painful. <ref name=":3" /> The pain can be described as a sharp or deep ache, often worse during physical activities that increase lumbar lordosis or compression of these structures.<ref name=":6">DePalma M.J., iSPINE Evidence Based Interventional Spine Care, Demos Medical, 2011, 4-8</ref>
Throughout the physical examination, the physiotherapist uses active and passive techniques with the intention of evoking complaints. Active spinal extension can reproduce the symptoms. The stork test  is very beneficial in the examination of this disease.<ref name=":6" /> When the patient bends forward, relief is also gained.<ref name=":12" />
 
Throughout the physical examination, the physiotherapist uses active and passive techniques with the intention of evoking complaints. Active spinal extension can reproduce the symptoms. The stork test  is very beneficial in the examination of this disease.<ref name=":6" /> When the patient bends forward, relief is also gained.<ref name=":12" />    
[[File:Baastrup_5.png|center]]
'''Figure 5:''' [[Stork test|Stork Test]] <br>
 
== Medical Management  ==
== Medical Management  ==


The main goal of any therapy is to reduce the lower back pain as well as a return to normal ADLs. Medical treatment can be conservative or surgical and an accurate diagnosis of the disease is necessary for determining appropriate treatment. Where an MRI shows active inflammatory changes or oedema, localised injections can be tried. If injections do not improve the patient's symptoms,  surgical treatment is then recommended. <ref name=":13">Lamer T.J. et al., Fluoroscopically-Guided Injections to Treat “Kissing Spine” Disease, Pain Physician, 2008; 11: 549-554</ref>
The main goal of any therapy is to reduce the lower back pain as well as a return to normal ADLs. Medical treatment can be conservative or surgical and an accurate diagnosis of the disease is necessary for determining appropriate treatment. Local steroid injection into the interspinous processes/ligament region may often ease the back pain 8. Surgical options include interspinous process decompression devices.<ref name=":4" /><ref name=":13">Lamer T.J. et al., Fluoroscopically-Guided Injections to Treat “Kissing Spine” Disease, Pain Physician, 2008; 11: 549-554</ref>
 
Non-surgical treatment consists of localised injections of analgesics or NSAIDs.<ref name=":3" />  which can be given bi-weekly.  During this treatment period, extension movements of the lumbar spine should be avoided. <ref name=":13" /> <ref name=":15">Okada K. et al., Interspinous Ligament Lidocaine and Steroid Injections for the Management of Baastrup’s Disease&nbsp;: A case Series, Asian Spine Journal, 2014&nbsp;; 8(3)&nbsp;: 260-266</ref> After local anesthesia of the skin and subcutaneous tissues, the injection is given the painful interspinous ligaments between the affected spinous processes' under fluoroscopic control.<ref name=":15" /> ''Okada et al''. study suggested a positive result in the long term effects of injections of steroid and local anesthetics into the interspinous ligaments for the treatment of Baastrup's disease <ref name=":15" /> 
 
Suggested surgical therapies include: excision of the bursa, partial or total removal of the spinous process, or an osteotomy.<ref name=":3" /> Average hospital stay is up to 31 days, however, such invasive therapies occasionally have unsatisfactory outcomes and is has been reported that numerous patients have developed pain post-surgery.<ref name=":3" /> It is also unclear whether surgery produces better results as an effective outcome has been reported in only  15 to 40&nbsp;% of cases.<ref name=":16">Cohen S.T. et al., Management of Low Back Pain, British Medical Journal, 2008, 338: 100-106</ref> 
 
Alternative techniques are interspinous spacer devices such as a X-STOP. <ref>Yue J.J. et al., Motion Preservation Surgery of the Spine, Elsevier - Health Sciences Division, 2008, 816 pagina’s</ref>  ''Zhou et al''. describes it as, 'a floating device inserted into the interspinous process to increase the distance between the spinous processes and the intervertebral foramen'.  This procedure is more straight forward and is less invasive than the alternatives.<ref name=":17">Zhou D. et al., Effects of Interspinous Spacers on Lumbar Degenerative Disease, Experimental and Therapeutic Medicine, 2013, 5: 952-956</ref> 
 
Outcomes for use of the spacers showed post-operative improvements in the initial, short term follow up, <ref name=":17" />  but the long-term outcomes regarding the durability of symptomatic relief and complications specific to the implanted device are currently lacking and need further investigation. <ref>Chao S. et al., Interspinous Process Spacer Technology, Techniques in Orthopaedics, 2011, 26(3): 141-145</ref>  


An interspinous processes spacer (also known as a decompression spacer or interspinous posterior device) is a device implanted between spinous processes to open narrowed exiting foraminal nerve channels to treat lumbar radiculopathy caused by spinal stenosis. The process of implantation is usually minimally invasive, performed under local anesthesia. <ref>Radiopedia Interspinous processes spacer Available:https://radiopaedia.org/articles/interspinous-processes-spacer?lang=us (accessed 29.8.2022)</ref>
== Physical Therapy Management  ==
== Physical Therapy Management  ==


As alluded to, the main goal is the reduction of pain as well as hyperlordosis and to improve spinal function. Once the pain is managed, physical therapy management can begin, involving education, strengthening and stretching of the abdominal and spinal muscles.<ref name=":0" /> <ref name=":16" />
As alluded to, the main goal is the reduction of pain as well as hyperlordosis and to improve spinal function. Once the pain is managed, physical therapy management can begin, involving education, strengthening and stretching of the abdominal and spinal muscles.<ref name=":0" /> <ref name=":16">Cohen S.T. et al., Management of Low Back Pain, British Medical Journal, 2008, 338: 100-106</ref>


Treating the hyperlordosis is a key aspect, hence strengthening of the trunk muscles is recommended, along with postural education and hip flexor stretches. <ref>Scannell J.P. et al., Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living, 2003, 83(10): 907-917</ref>
Treating the hyperlordosis is a key aspect, hence strengthening of the trunk muscles is recommended, along with postural education and hip flexor stretches. <ref>Scannell J.P. et al., Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living, 2003, 83(10): 907-917</ref>
Line 151: Line 71:
== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


Kissing spines is characterised by the close approximation and contact of adjoining spinous processes'. It is often treated with injections as pain relief in the first instance. Physical therapy should include stretching and strengthening exercises to reduce the mechanical pressure on the spine and any hyperlordosis. Baastrup’s syndrome is still relatively unknown and is often misdiagnosed and consequently treated incorrectly. <ref name=":14" /><br><br>Baastrup syndrome is more common in the lumbar spine with L4-L5 being the most affected region.<ref name=":3" /> People who are most likely to suffer from Kissing Spine are particularly elderly patients with a degenerative disc disease or hyperlordosis. Both of these conditions may lead to chronic contact between adjacent spinous processes. <ref>Pinto P.S. et al., Spinous Process Fractures associated with Baastrup disease, Clinical Imaging, 2004, 28(3): 219-222</ref>
Kissing spines is characterised by the close approximation and contact of adjoining spinous processes'. It is often treated with injections as pain relief in the first instance. Physical therapy should include stretching and strengthening exercises to reduce the mechanical pressure on the spine and any hyperlordosis. Baastrup’s syndrome is still relatively unknown and is often misdiagnosed and consequently treated incorrectly. <ref name=":14">Chen C.K.H. et al., Intraspinal Posterior Epidural Cysts Associated with Baastrup's Disease: Report of 10 patients, American Journal of Roentgenology, 2004, 182(1): 191-194</ref><br><br>Baastrup syndrome is more common in the lumbar spine with L4-L5 being the most affected region.<ref name=":3" /> People who are most likely to suffer from Kissing Spine are particularly elderly patients with a degenerative disc disease or hyperlordosis. Both of these conditions may lead to chronic contact between adjacent spinous processes. <ref>Pinto P.S. et al., Spinous Process Fractures associated with Baastrup disease, Clinical Imaging, 2004, 28(3): 219-222</ref>
== References  ==
== References  ==
<references />
<references />

Revision as of 06:43, 29 August 2022

Original Editors - Fien Selderslaghs, Mirabella Smolders, Matthias Steenwerckx, Wout Theys as part of the Vrije Universiteit Brussel Evidence-Based Practice Project

Top Contributors - Sofie Bourdinon, Scott Cornish, Nikki Rommers, Admin, Arno Vrambout, Kim Jackson, Lucinda hampton, Fien Selderslaghs, Uchechukwu Chukwuemeka, Vidya Acharya, Ceulemans Lisa, Aarti Sareen, 127.0.0.1 and WikiSysop  

Introduction[edit | edit source]

Baastrup syndrome with active inflammation (e.g. bursitis)

Baastrup syndrome (also referred to as kissing spines) is a cause of low back pain characterized by interspinous bursitis and other degenerative changes of the bones and soft tissues where adjacent spinous processes in the lumbar spine rub against each other.[1]

Kissing Spine mainly affects the lumbar area of the spine, with L4-L5 being the most frequently affected level [2], but it has also been reported in the cervical spine.[3]

Clinically Relevant Anatomy: See Lumbar Anatomy

Epidemiology /Etiology[edit | edit source]

Baastrup Syndrome tends to be more common in the elderly. Other suggested risk factors are:[4] [2]

  • Excessive lordosis which results in increased mechanical pressure
  • Repetitive strains of the interspinous ligament with subsequent degeneration and collapse
  • Incorrect posture
  • Traumatic injuries
  • Tuberculous spondylitis
  • Bilateral forms of congenital hip dislocation
  • Stiffening of the thoracic spine or the thoracolumbar transition
  • Obesity

Characteristics/Clinical Presentation[edit | edit source]

Basstrup or Kissing Spine

Patients with Baastrup syndrome typically show an excessive lordosis.[2] [5] Patients with Kissing Spine often complain about back pain, more specifically, midline pain that radiates distally and proximally, increasing on extension and reducing on flexion.[6] [2] This abnormal contact between adjacent spinous processes can lead to neoarthrosis and formation of an adventitious bursa. This can be seen pathologically on MRI. [7] [8] [9]

Rotation and lateral flexion are usually painful with flexion being the least painful of all lumbar movements.[10] Baastrup’s disease can result in intraspinal cysts secondary to an interspinous bursitis which may, in rare cases, cause symptomatic spinal stenosis and neurogenic claudation [7]

Diagnostic Procedures[edit | edit source]

Baastrup Syndrome cannot be diagnosed by simply assessing the lumbar spine (see clinical examination), imaging modalities are required to prevent misdiagnosis. [2]

  1. CT and Xrays: Often shows close approximation and contact of adjacent spinous processes (kissing spines). Resultant enlargement, flattening, and reactive sclerosis of apposing interspinous surfaces
  2. Magnetic Resonance Imaging MRI: May demonstrate interspinous bursal fluid and posterocentral epidural cyst(s). MRI can be very helpful in determining whether there is resulting posterior compression of the thecal sac.

Outcome Measures[edit | edit source]

The following tests can be used to objectively determine the progress and efficacy of treatment:

Examination[edit | edit source]

Stork Test

Diagnosis of Baastrup’s disease is verified with clinical examination as well as imaging studies.[2] Symptoms include low back pain with midline distribution that exacerbates when performing extension, relieved during flexion and is exaggerated upon finger pressure at the level of the pathologic interspinous ligament. Rotation and lateral flexion are also very painful. [2] The pain can be described as a sharp or deep ache, often worse during physical activities that increase lumbar lordosis or compression of these structures.[11]

Throughout the physical examination, the physiotherapist uses active and passive techniques with the intention of evoking complaints. Active spinal extension can reproduce the symptoms. The stork test is very beneficial in the examination of this disease.[11] When the patient bends forward, relief is also gained.[10]

Medical Management[edit | edit source]

The main goal of any therapy is to reduce the lower back pain as well as a return to normal ADLs. Medical treatment can be conservative or surgical and an accurate diagnosis of the disease is necessary for determining appropriate treatment. Local steroid injection into the interspinous processes/ligament region may often ease the back pain 8. Surgical options include interspinous process decompression devices.[1][12]

An interspinous processes spacer (also known as a decompression spacer or interspinous posterior device) is a device implanted between spinous processes to open narrowed exiting foraminal nerve channels to treat lumbar radiculopathy caused by spinal stenosis. The process of implantation is usually minimally invasive, performed under local anesthesia. [13]

Physical Therapy Management[edit | edit source]

As alluded to, the main goal is the reduction of pain as well as hyperlordosis and to improve spinal function. Once the pain is managed, physical therapy management can begin, involving education, strengthening and stretching of the abdominal and spinal muscles.[7] [14]

Treating the hyperlordosis is a key aspect, hence strengthening of the trunk muscles is recommended, along with postural education and hip flexor stretches. [15]

When the abdominal muscles are weak, the hip flexors are mainly responsible in shaping the lumbar spine.[16] Furthermore the rectus femoris muscle is a continuation of the hip flexor complex so it is important to stretch these muscles. The hip flexors can become shorter through long-term sitting or resting. When these muscles shorten, it can affect the function of the gluteal and the spinal muscles.[17]

The stretch below is one example of how to lengthen these muscles. Resting the weight on the knee and the front foot, push the hips forward until a stretch is felt, keeping the trunk upright. Maintain this position for at least 20 seconds, and repeat this 3-5 times on each side.[16]

Baastrup 6.pngBaastrup 7.png

Figure 6: Stretching the hip flexors [16]

Motion of the gluteus maximus muscle during the flexion-extension cycle is decreased in patients with chronic low back pain, which is why strengthening of this muscle should be part of the physical management program [18]

Physical therapy is also suggested to be helpful for reducing the neuromuscular damage that is provoked by the disease and other treatments such as, heat therapy, ergotherapy and muscle relaxation techniques can be helpful [7]

Clinical Bottom Line[edit | edit source]

Kissing spines is characterised by the close approximation and contact of adjoining spinous processes'. It is often treated with injections as pain relief in the first instance. Physical therapy should include stretching and strengthening exercises to reduce the mechanical pressure on the spine and any hyperlordosis. Baastrup’s syndrome is still relatively unknown and is often misdiagnosed and consequently treated incorrectly. [19]

Baastrup syndrome is more common in the lumbar spine with L4-L5 being the most affected region.[2] People who are most likely to suffer from Kissing Spine are particularly elderly patients with a degenerative disc disease or hyperlordosis. Both of these conditions may lead to chronic contact between adjacent spinous processes. [20]

References[edit | edit source]

  1. ↑ 1.0 1.1 Radiopedia Basstrup Syndrome Available;https://radiopaedia.org/articles/baastrup-disease-1?lang=us (accessed 29.8.2022)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Filippiadis D.K. et al., Baastrup’s disease (kissing spines syndrome): a pictorial review, Springer, 2015, 6(1): 123–128
  3. ↑ Rajasekaran S. et al., Baastrup’s Disease as a Cause of Neurogenic Claudication: a case report, Lippincott Williams & Wilkins, 2003, 28(14): 273-275
  4. ↑ Kacki S. et al., Baastrup’s Sign (Kissing Spines): A neglected condition in paleopathology, International Journal of Paleopathology, 2011, 1(2): 104-110
  5. ↑ Jang E-C. et al., Posterior epidural fibrotic mass associated with Baastrup’s disease, Springer, 2010; 19(2): 165-168
  6. ↑ Singla A. et al., Baastrup’s disease: the kissing spine, World Journal of Clinical Cases, 2014, 2(2): 45-47.
  7. ↑ 7.0 7.1 7.2 7.3 Kwong Y. et al., MDCT Findings in Baastrup Disease: Disease or Normal Feature of the Aging Spine?,American Journal of Roentgenology, 2011, 196(5):1156-9.
  8. ↑ Maes R. et al., Lumbar Interspinous Bursitis (Baastrup Disease) in a Symptomatic Population: Prevalence on Magnetic Resonance Imaging, The Spine Journal, 2008, 33(7): 211-215
  9. ↑ FarinhaF. et al., Baastrup’s disease: a poorly recognized cause of back pain, ActaReumatol Port, 2015, 40:302-303
  10. ↑ 10.0 10.1 Hertling D. et al., Management of common musculoskeletal disorders: Physical Therapy Principles and Methods, Lippincott Williams & Wilkins, 2006, 4th edition
  11. ↑ 11.0 11.1 DePalma M.J., iSPINE Evidence Based Interventional Spine Care, Demos Medical, 2011, 4-8
  12. ↑ Lamer T.J. et al., Fluoroscopically-Guided Injections to Treat “Kissing Spine” Disease, Pain Physician, 2008; 11: 549-554
  13. ↑ Radiopedia Interspinous processes spacer Available:https://radiopaedia.org/articles/interspinous-processes-spacer?lang=us (accessed 29.8.2022)
  14. ↑ Cohen S.T. et al., Management of Low Back Pain, British Medical Journal, 2008, 338: 100-106
  15. ↑ Scannell J.P. et al., Lumbar posture--should it, and can it, be modified? A study of passive tissue stiffness and lumbar position during activities of daily living, 2003, 83(10): 907-917
  16. ↑ 16.0 16.1 16.2 Laughlin K., Overcome Neck and Back Pain, Simon & Schuster, 1998, 58-61
  17. ↑ Ross M., Stretching the Hip Flexors, National Strength & Conditioning Association, 1999, 21(3): 71-72
  18. ↑ Leinonen V. et al., Back an Hip Extensor Activities During Trunk Flexion/Extension: Effects of Low Back Pain and Rehabilitation, American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation, 200, 81: 32-37
  19. ↑ Chen C.K.H. et al., Intraspinal Posterior Epidural Cysts Associated with Baastrup's Disease: Report of 10 patients, American Journal of Roentgenology, 2004, 182(1): 191-194
  20. ↑ Pinto P.S. et al., Spinous Process Fractures associated with Baastrup disease, Clinical Imaging, 2004, 28(3): 219-222
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