Baastrup disease: a commonly overlooked cause of low back pain

Transcription

1 Baastrup disease: a commonly overlooked cause of low back pain Poster No.: C-0857 Congress: ECR 2014 Type: Educational Exhibit Authors: D. K. Filippiadis, A. Mazioti, E. Alexopoulou, K. Malagari, E. Brountzos, N. L. Kelekis, A. D. Kelekis; Athens/GR Keywords: DOI: Pathology, Inflammation, Diagnostic procedure, MR, CT, Musculoskeletal spine, Interventional non-vascular /ecr2014/C-0857 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Learning objectives To emphasize upon the inclusion of Baastrup disease in the list of potential causes of low back pain To illustrate the findings of Baastrup disease in CT and MR scans To describe potential therapeutic techniques for Baastrup disease Images for this section: Fig. 5: Fluoroscopy-guided infiltration (A: A-P and B: lateral view) at the level of L4-L5 interspinous ligament in a patient with Baastrup disease suffering from low back pain Page 2 of 23

3 Background Baastrup disease (kissing spine) is a term referring to pathologic changes at adjacent spinous processes and the surrounding soft tissues. Pathophysiology involves excessive lordosis with a resultant mechanical pressure process. This causes repetitive strains on the interspinous ligament leading in degeneration and collapse which allows contact between adjacent spinous processes. These repetitive shearing movements between the adjacent spinous processes result in further inflammation of an adventitious bursa present in the interspinous space along with enlargement, flattening, sclerosis and cyst formation in the opposing surfaces. Page 3 of 23

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5 Fig. 1: MR scan, T1-weighted sequence, sagittal reconstruction. Low signal intensity due to edema and sclerosis at the opposing surfaces of L4 and L5 spinous processes References: 2nd Radiology Dpt, University General Hospital" ATTIKON", Athens/GR Patients complain of back pain with midline distribution that worsens during extension and is relieved during flexion. Patients with Baastrup disease complain of pain exaggeration upon finger pressure at the level of interest. Diagnosis is verified with clinical examination and imaging studies (x-rays of the spine, Computed Tomography, Magnetic Resonance and PET-CT). Page 5 of 23

6 Fig. 2: MR scan, STIR sequence, sagital reconstruction: there is high signal intensity at the level of L5-SI interspinous ligament References: 2nd Radiology Dpt, University General Hospital" ATTIKON", Athens/GR Page 6 of 23

7 Images for this section: Page 7 of 23

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9 Fig. 1: MR scan, T1-weighted sequence, sagittal reconstruction. Low signal intensity due to edema and sclerosis at the opposing surfaces of L4 and L5 spinous processes Page 9 of 23

10 Fig. 2: MR scan, STIR sequence, sagital reconstruction: there is high signal intensity at the level of L5-SI interspinous ligament Page 10 of 23

11 Findings and procedure details Imaging findings of Baastrup disease in MRI include interspinous bursitis and/or bone edema at the level of opposing spinous processes. In addition, high signal intensity can be illustrated at the level of interspinous ligament as well as small degenerative cysts at the opposing spinous processes. Page 11 of 23

12 Fig. 3: MR scan, sagital STIR sequence shows high signal intensity at the level of interspinous ligament and bone edema in the opposing surfaces of the spinous processes at L3-L4 level. References: 2nd Radiology Dpt, University General Hospital" ATTIKON", Athens/GR Whenever CT is the modality of choice for the imaging of Baastrup disease, findings include close approximation and contact between opposing spinous processes with flattening and sclerosis as well as small degenerative cysts at the opposed surfaces. Similar imaging findings are seen in x-rays of the spine. Fig. 4: Computed Tomography saggital (A) and axial (B) reconstructions show enlargement, flattening, sclerosis and cyst formation in the opposing surfaces of the spinous processes at L3-L4 level. References: 2nd Radiology Dpt, University General Hospital" ATTIKON", Athens/GR Therapeutic armamentarium includes a course of conservative therapy including combinations analgesics, myorelaxants, NSAID and physiotherapy. Alternative treatments include infiltrations at the level of interspinous ligament or surgical therapies (osteotomy). Percutaneous infiltrations can be performed blindly or under imaging guidance with a percutaneous posterior approach. Imaging guidance increases technical and clinical efficacy and at the same time decreases potential complication rates. Page 12 of 23

13 Fig. 5: Fluoroscopy-guided infiltration (A: A-P and B: lateral view) at the level of L4-L5 interspinous ligament in a patient with Baastrup disease suffering from low back pain References: 2nd Radiology Dpt, University General Hospital" ATTIKON", Athens/GR Images for this section: Page 13 of 23

14 Fig. 3: MR scan, sagital STIR sequence shows high signal intensity at the level of interspinous ligament and bone edema in the opposing surfaces of the spinous processes at L3-L4 level. Page 14 of 23

15 Fig. 4: Computed Tomography saggital (A) and axial (B) reconstructions show enlargement, flattening, sclerosis and cyst formation in the opposing surfaces of the spinous processes at L3-L4 level. Page 15 of 23

16 Fig. 5: Fluoroscopy-guided infiltration (A: A-P and B: lateral view) at the level of L4-L5 interspinous ligament in a patient with Baastrup disease suffering from low back pain Page 16 of 23

17 Conclusion Chronic degenerative changes of the spine result in repetitive microtrauma and inflammation of adjacent spinous processes (Baastrup disease-kissing spines syndrome). Diagnosis apart from clinical examination is verified with imaging findings as well. CT findings include close approximation and contact between opposing spinous processes with flattening and sclerosis of the opposed surfaces. MR findings include interspinous bursitis and/or bone edema at the level of opposing spinous processes. Imaging-guided infiltrations at interspinous ligament seem to be a feasible, efficacious and safe therapy for symptomatic Baastrup disease. Imaging guidance facilitates needle placement and minimizes risk of complications with excellent results upon pain reduction. Images for this section: Page 17 of 23

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19 Fig. 1: MR scan, T1-weighted sequence, sagittal reconstruction. Low signal intensity due to edema and sclerosis at the opposing surfaces of L4 and L5 spinous processes Page 19 of 23

20 Fig. 2: MR scan, STIR sequence, sagital reconstruction: there is high signal intensity at the level of L5-SI interspinous ligament Fig. 3: MR scan, sagital STIR sequence shows high signal intensity at the level of interspinous ligament and bone edema in the opposing surfaces of the spinous processes at L3-L4 level. Page 20 of 23

21 Fig. 4: Computed Tomography saggital (A) and axial (B) reconstructions show enlargement, flattening, sclerosis and cyst formation in the opposing surfaces of the spinous processes at L3-L4 level. Page 21 of 23

22 Fig. 5: Fluoroscopy-guided infiltration (A: A-P and B: lateral view) at the level of L4-L5 interspinous ligament in a patient with Baastrup disease suffering from low back pain Page 22 of 23

23 Personal information Dimitrios K Filippiadis MD, PhD Interventional Radiologist - Consultant 2nd Radiology Dpt, University General Hospital "ATTIKON" Address: 1 Rimini str, Haidari/Athens Tel: Fax: E mail: dfilippiadis@yahoo.gr References 1. Maes R, Morrison WB, Parker L, Schweitzer ME, Carrino J. Lumbar interspinous bursitis (Baastrup disease) in a symptomatic population: prevalence on magnetic resonance imaging. Spine (Phial Pa 1976) 2008 Apr 1;33(7):E Bywaters EG, Evans S. The lumbar interspinous bursae and Baastrup's syndrome an autopsy study. Rheumatol Int 1982;2: Kwong Y, Rao N, Latief K. MDCT findings in Baastrup disease: disease or normal feature of the aging spine? AJR 2011 May;196(5): Page 23 of 23