Interspinous Oedema

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There are a variable number of bursae in the spinal column. They are normally located between the spinous processes of the cervical and lumbar segments. Bursitis of these structures can result in neck or back pain. In the neck, interspinous bursitis has been associated with several rheumatological conditions such as polymyalgia rheumatica, rheumatoid arthritis, and crystalopathies. In the lumbar spine the condition is also known as "kissing-spine" or Baastrup's disease and occurs in the context of degenerative change. An open access review of kissing spines is available by Filippiadis et al.

Anatomy

There are several soft tissue structures located in the posterior aspect of the lumbar spines. Namely, the multifidi muscles, interspinalis muscles, interspinous ligaments, and fat. These structures are innervated by the medial branches of the lumbar dorsal rami, the same innervation as the facet joints.

Aetiology

Bogduk theorises that the pain arises as a result of a periostitis of the spinous processes, or inflammation of the interspinous ligament. The periosteum of the spinous processes and the interspinous spaces are innervated by the medial branches of the lumbar dorsal rami.

Lumbar Kissing Spines

MRI, STIR sequence, sagittal reconstruction illustrating bone oedema at both the spinous processes of L3-L4 level.

This condition, also known as Baastrup's disease, arises due to excessive lumbar lordosis, or following extension injuries to the lumbar spine. The adjacent spinous processes, the most common level being L4/5, compresses the intervening interspinous ligament. It is more common in the degenerative lumbar spine in those aged 70 and older, with no gender predilection, with changes occurring in the context of disc height loss, spondylolisthesis, and spondylosis.

Clinical Features

Patients may have midline back pain that worsens with extension and relieved by flexion. On examination the patient may be tender over the suspected level. Rarely an epidural cystic mass may cause neurogenic claudication with extension.

Imaging

MRI T2 coronal and sagittal images showing interspinous oedema at the L4/5 interspace.

Kissing Spines

Lumbar spine X-ray, AP (left image) and lateral (right image) views illustrating close approximation and contact of spinous processes at L4-L5 level with sclerosis and flattening of the articulating surfaces (white arrow).

Imaging includes radiography, CT, and MRI. The hallmark finding suggestive of kissing spines is close approximation and contact of adjacent spinous processes with all the subsequent findings, including oedema, cystic lesions, sclerosis, flattening and enlargement of the articulating surfaces, bursitis and occasionally epidural cysts or midline epidural fibrotic masses.

On x-rays, the most common finding is the close approximation and contact of adjacent spinous processes. There may be sclerosis of the articulating surfaces. In more severe cases, there is flattening and enlargement of the articulating surfaces or articulation of the two affected spinous processes. Usually generalised degenerative spinal changes are seen, most prominent at the affected level.

CT shows close approximation and contact of the adjacent spinous processes. There is sclerosis, flattening, and enlargement of the articulating surfaces or the articulation of the two affected spinous processes. In rare cases there may be soft tissue nodules on the sides of the spinous process, and this could represent dissection of the spinal bursa superficial to the erector spinae. There are usually findings of degenerative changes such as facet joint hypertrophy, disc herniation, and spondylolisthesis.

MRI, sagittal reconstruction: STIR sequence (a) illustrating high signal intensity and fat-suppression T1-weighted sequence, post intravenous gadolinium injection (b) illustrating uptake of the contrast medium at the L3-L4 interspinous ligament (white arrow)

On MRI, under 10% of symptomatic patients have findings of interspinous bursitis. Bursitis appears as a fluid-like signal located between the two suspect spinous processes. Other findings include flattening, sclerosis, enlargement, cystic lesions, and bone oedema affecting the articulating surfaces of the two spinous processes. There may be oedema of the interspinous ligament. Gadolinium administration may show enhancement of this area. Rarely there may be epidural cysts or epidural fibrotic masses causing dural compression.

Treatment

Treatment options include NSAIDs, corticosteroid injections, and surgical therapies which include excision of the bursa or osteotomy. There may be additional factors in the patients pain such as facet joint irritation which may need to be addressed.

Injections

Fluoroscopic corticosteroid injection of the interspinous space of L4/5

Injections are performed at the level of the interspinous ligament. This should ideally be done with imaging guidance to ensure accurate needle positioning. In New Zealand, fluoroscopic guidance is normally used, but ultrasound could theoretically be used as an alternative.

The technique used by one Musculoskeletal Physician in New Zealand is as follows:

• Advance a 9 cm 22-gauge spinal needle into the interspinous space using AP and lateral projections.
• Infiltrated 1 mL Omnipaque 300 into the interspinous space to ensure position.
• Infiltrate a mixture of 40 mg Kenacort A and 0.5 mL 0.75% Ropivacaine into the affected interspinous space.

Surgery

Surgical therapy is not always successful.

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,