Percutaneous therapy versus surgery in chronic back pain: how important is imaging in decision-making?

Role of FDG PET/CT in Baastrup's disease

Baastrup's disease is a benign condition, which presents as chronic low back pain. It is also known as “kissing spine syndrome” and refers to close approximation of adjacent spinous processes producing inflammation and back pain. This condition is often misdiagnosed, resulting in incorrect treatment and persistence of symptoms. Diagnosis of Baastrup's disease is verified with clinical examination and imaging studies. Conventionally, clinicians resort to magnetic resonance imaging (MRI) of spine rather than X-ray or computed tomography (CT) in the evaluation of back pain. MRI can additionally identify flattening, sclerosis, enlargement, cystic lesions, and bone edema at the articulating surfaces of the two affected spinous processes. Studies have reported that ¹⁸Fluorine fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) can detect a bursitis or an inflammation as a form of stress reaction despite a negative MRI and ^99mTc Methylene diphosphonate (MDP) bone scan. PET/CT is usually not a recommended investigation for this condition. However, this case report highlights the benefit of FDG-PET/CT in identifying the site of inflammatory pathology. It is also known to identify the exact site of inflammation where steroid or local anesthetic injection can be administered to alleviate pain, especially in patients with multilevel vertebral involvement.

A review of percutaneous techniques for low back pain and neuralgia: current trends in epidural infiltrations, intervertebral disk and facet joint therapies

Low back pain and neuralgia due to spinal pathology are very common symptoms debilitating numerous patients with peak prevalence at ages between 45 and 60 years. Intervertebral discs and facet joints act as pain sources in the vast majority of the cases. Diagnosis is based on the combination of clinical examination and imaging studies. Therapeutic armamentarium for low back pain and neuralgia due to intervertebral discs and/or facet joints includes conservative therapy, injections, percutaneous therapeutic techniques and surgical options. Percutaneous, therapeutic techniques are imaging-guided, minimally invasive treatments which can be performed as outpatient procedures. In cases of facet joint syndrome, they include, apart from injections, neurolysis with radiofrequency/cryoablation, MR-guided high-intensity focused ultrasound and percutaneous fixation techniques. In case of discogenic pain, apart from infiltrations, therapeutic techniques can be classified in to two main categories: decompression (mechanical, thermal, chemical) techniques and biomaterials implantation/disc cell therapies. Strict sterility measures are a prerequisite and should include extensive local sterility and antibiotic prophylaxis. This article will report clinical and imaging findings for each pathology type and the association with treatment decision. In addition, we will describe in detail all possible treatment techniques for low back pain and neuralgia, and we will report recently published results of these techniques summarizing the data concerning safety and effectiveness as well as the level of evidence. Finally, we will try to provide a rational approach for the therapy of low back pain and neuralgia by means of minimally invasive imaging-guided percutaneous techniques.

Baastrup's disease (kissing spines syndrome): a pictorial review

Abstract

Excessive lordosis is a common finding and may produce mechanical pressure that causes repetitive strains of the interspinous ligament with subsequent degeneration and collapse. Baastrup’s disease (kissing spine syndrome) is a term referring to close approximation of adjacent spinous processes due to degenerative changes of the spine. Baastrup’s disease usually affects the lumbar spine, with L4-L5 being the most commonly affected level. There is higher occurrence at ages over 70 and no gender predilection. Symptoms include back pain with midline distribution that worsens during extension, is relieved during flexion and is exaggerated upon finger pressure at the level of interest. Diagnosis rests on clinical examination and imaging studies. The hallmark of imaging findings is the 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. Proposed therapies include conservative treatment, percutaneous infiltrations or surgical therapies such as excision of the bursa or osteotomy. The purpose of this study is to illustrate the spectrum of imaging findings in Baastrup’s disease and to emphasise upon including the syndrome in the list of potential causes of low-back pain.

Teaching Points

• Baastrup’s disease refers to close approximation of adjacent spinous processes.

• Diagnosis of Baastrup’s disease is verified with clinical examination and imaging studies.

• Contact of adjacent spinous processes results in oedema, sclerosis, flattening and enlargement.

• Proposed therapies include conservative treatment, percutaneous infiltrations or surgical therapies.

Percutaneous treatment of cervical and lumbar herniated disc

Therapeutic armamentarium for symptomatic intervertebral disc herniation includes conservative therapy, epidural infiltrations (interlaminar or trans-foraminal), percutaneous therapeutic techniques and surgical options. Percutaneous, therapeutic techniques are imaging-guided, minimally invasive treatments for intervertebral disc herniation which can be performed as outpatient procedures. They can be classified in 4 main categories: mechanical, thermal, chemical decompression and biomaterials implantation. Strict sterility measures are a prerequisite and should include extensive local sterility and antibiotic prophylaxis. Indications include the presence of a symptomatic, small to medium sized contained intervertebral disc herniation non-responding to a 4-6 weeks course of conservative therapy. Contraindications include sequestration, infection, segmental instability (spondylolisthesis), uncorrected coagulopathy or a patient unwilling to provide informed consent. Decompression techniques are feasible and reproducible, efficient (75-94% success rate) and safe (>0.5% mean complications rate) therapies for the treatment of symptomatic intervertebral disc herniation. Percutaneous, imaging guided, intervertebral disc therapeutic techniques can be proposed either as an initial treatment or as an attractive alternative prior to surgery for the therapy of symptomatic herniation in both cervical and lumbar spine. This article will describe the mechanism of action for different therapeutic techniques applied to intervertebral discs of cervical and lumbar spine, summarize the data concerning safety and effectiveness of these treatments, and provide a rational approach for the therapy of symptomatic intervertebral disc herniation in cervical and lumbar spine.