CASE REPORT
Interspinous bursitis in an athlete
M. J. DePalma,
C. W. Slipman,
E. Siegelman,
T. J. Bayruns,
A. Bhargava,
M. E. Frey,
K. R. Chin
From the University
of Pennsylvania,
Philadelphia, USA
M. J. DePalma, MD, Fellow
A. Bhargava, Fellow
M. E. Frey, MD, Fellow
T. J. Bayruns, PT, OCG,
CSCS, Team Leader
C. W. Slipman, MD,
Associate Professor, Director
The Penn Spine Center,
Department of Physical
Medicine and Rehabilitation
K. R. Chin, MD, Chief of
Division of Spine Surgery,
Assistant Professor
Department of Orthopaedics
E. Siegelman, MD,
Associate Professor, Chief of
Magnetic Resonance
Imaging Section,
Department of Radiology
Hospital of the University of
Pennsylvania, 3400 Spruce
Street, Philadelphia 19104,
USA.
Correspondence should be
sent to Dr C. W. Slipman.
©2004 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.86B7.
15154 $2.00
J Bone Joint Surg [Br]
2004;86-B:1062-4.
Received 19 November 2003;
Accepted 7 January 2004
1062
We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous
investigations have used fluoroscopically guided spinal injections to confirm the clinical
relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased
incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present
with localised, midline lower lumbar pain exacerbated by extension. In young athletes these
symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior
elements.
Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for
confirmation and treatment of pain from such bursae.
Persistent lumbosacral pain in the adolescent athlete
typically arises from injury to the posterior elements.1 Spondylolysis is a common cause. 1,2
Patients usually present with localised lumbosacral
pain with or without referred pain to the lower
limbs, tight hamstrings, a normal neurological
examination, and pain on extension. 2 CT can help
identify and stage a defect of the pars interarticularis.3 MRI may be useful to identify patterns of
oedema in early pars lesions, and to differentiate
from pathology such as disc herniation, infection or
tumour.2
Repetitive lumbar spinal movements in the sagittal plane precipitate injury to various posterior elements.2,4 Strain of the posterior soft tissues can lead
to structural changes in the lumbar interspinous ligaments.5 Rupture of the supraspinous and interspinous ligaments may occur; this is most common
in women aged between 15 and 35 years. Bursae
filled with synovial fluid between lumbar spinous
processes secondary to trauma have been described.4,6-28 Most commonly these occur in the
mid- and lower-lumbar segments,4,7,10 and increase
in frequency with advancing age.7,10 However, they
may occur in young athletes.15,16 Spondylolysis and
interspinous bursae have similar clinical features.
MRI of the lumbosacral spine allows detection of
interspinous abnormalities.4,29,30 Fluoroscopically
guided, diagnostic extraspinal injections can be used
to confirm that pain arises from the interspinous soft
tissue. Therapeutic injections have been used with
benefit.4,15,17 We present a case of an athlete with a
symptomatic lumbar interspinous bursitis, successfully managed with therapeutic injections into an
interspinous bursa.
Case Report
An 18-year-old woman, a collegiate basketball
player, presented with an acute exacerbation of
Fig. 1
Sagittal view of a T2-weighted MRI shows increased
signal intensity (black arrow) in the soft-tissue between
the spinous processes of L2 and L3.
chronic, episodic lumbosacral pain. She had had a
week of low back pain following a day of intensive
exercise. She developed symptoms after basketball
having undertaken sprinting and weight lifting
workouts earlier in the day. There was no history of
THE JOURNAL OF BONE AND JOINT SURGERY
CASE REPORTS
trauma, but there was a history of similar intermittent pain for five
years. The pain was stabbing in character, confined to the midline
upper lumbar spine, and of an intensity rated six out of ten on a
visual analogue scale (VAS). Standing, walking, and extension of
the spine aggravated the pain, while sitting or lying on her left or
right lateral side relieved it. There was no referred pain or disturbance of bowel or bladder function. She had a past medical history
of asthma.
Physical examination revealed a well-developed, well-nourished athletic woman. Her lumbar spine movements were full, but
mid to terminal extension was painful. Returning to the full
upright position from forward flexion did not evoke pain. She was
slightly tender over the spinous processes of L2/4. There were no
abnormal neurological signs in the upper or lower limbs.
Plain radiographs of the lumbosacral spine including flexion
and extension views, showed normal bony alignment without evidence of instability, tumour, or fracture. Single photon electron
emission tomography (SPECT) imaging of the lumbosacral spine
was unremarkable. MRI revealed some mild disc desiccation at L3
to S1 and a focal increase in soft-tissue signal intensity on T2weighted images between the spinous processes of L2 and L3 in
the midline sagittal view (Fig. 1). Previous reports have indicated
that fluorine-18-deoxyglucose (FDG) positron emission tomography (PET) scanning can detect a stress reaction despite a negative
MRI and bone scan,31 and this showed increased uptake in the
inferior aspect of the spinous process of L2 and the superior aspect
of the spinous process of L3 without evidence of a pars fracture.
Thus, these investigations suggested a diagnosis of interspinous
bursitis at L2/3.
The symptoms were not relieved by a four-week trial of a nonsteroidal anti-inflammatory medication and stabilisation exercises
for the lumbar spine. In order to determine if there was a bursa
present and if the symptoms were relieved following the instillation of a local anaesthetic, Ominipaque dye (1.5 cc) was injected
into the L2/3 interspinous oedema before reaching a firm endpoint. The pattern did not display a typical fascial spread. The dye
collected in a cotton-ball appearance. A similar amount of dye was
injected into the L1/2 intraspinous soft tissue demonstrating fascial spread and a soft end-point. An injection of 1.5 cc of 4% xylocaine into the L1/2 interspinous soft-tissue did not produce any
change in the symptoms but an injection into the L2/3 space
relieved the symptoms. We concluded the diagnosis of L2/3 bursitis was accurate. Two subsequent injections of 1 cc of Celestone
Soluspan (betamethasone) and 0.25 cc of 4% xylocaine were performed at the L2/3 level over a 14-day interval. There was a
marked reduction in pain. The VAS score changed from 6 to 2, and
there was a decrease in the Oswestery disability index score following physiotherapy from 20 to 8. She was able to complete a
conditioning programme and return to full activity. At follow-up
two months after the second further injection, she remained symptom-free which continued over the ensuing year.
Discussion
Baastrup’s disease or ‘kissing spines’ was first described in 1933.32
It is caused by chronic contact between adjacent spinous processes, and characterised by sclerosis and flattening of the opposing superior and inferior surfaces of the spinous processes. 15,32,33
However, in 1825 Mayer had discovered lumbar interspinous synovial fluid filled cavities in ‘well exercised soldiers’ most commonly between the overgrown and facetted L3/4 spinous
processes.6 Subsequently Rissanen7,10 and Hazlett17 observed
VOL. 86-B, No. 7, SEPTEMBER 2004
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interspinous bursal cavities between L4/5 and L3/4 in autopsy
studies occurring with increasing frequency with advancing age,
85% of subjects between the age of 61 and 70 years having had
bursal cavities in the midline L4/5 interspinous ligament at
autopsy.4 The healthy interspinous ligament has a thin central portion, which tends to undergo fatty degeneration with cavitation in
patients in their sixth decade.17 Structurally, these bursae had a
cellular lining with microscopic variations of chronic and acute
bursitis.17 No such cavities have been found in autopsy studies of
the spines of patients under the age of ten years, 7,11 perhaps
explained by the development of adult lumbar lordotic curvature
after this age.4
The incidence of Baastrup’s syndrome in collegiate athletes is
6.3%16 and most commonly affects gymnasts. 15 Repetitive flexion
and extension strain the interspinous ligaments and cause adjacent
spinous processes to abut each other.4,15
During flexion the interspinous ligaments are maximally
stretched to limit further flexion. Subsequent extension allows
adjacent spinous processes to approximate subjecting the intervening soft tissues to compressive forces. 15 Repetitive movements
involving normal or physiological loads can produce structural
changes in the interspinous soft tissue. 15 The supraspinous and
interspinous ligaments are less resilient to stress than the intervertebral disc and capsular ligaments. Thus, the posterior ligaments
are sprained first following extreme forward flexion.4 Repetitive
or excessive forward flexion strains the attachments of the interspinous ligaments resulting in tenderness at the junction of bone
and ligament and the formation of a spur.9,15 Repetitive extension
compresses these inflamed tissues disrupting healing and producing impingement of painful structures. 14,15
There is an abundant nerve supply to the interspinous ligaments.34 The junction of the interspinous ligament and spinous
process has a very active metabolism 20 which may be related to the
development of highly vascularised granulation tissue in response
to injury, including reconstruction in the bone and cartilaginous
zone.4 Bone SPECT can detect increased osteoblast activity in true
Baastrup’s disease in which reactive sclerosis can be identified on
radiography.35 In the absence of bony eburnation and sclerosis,
SPECT may not detect any abnormality. Although the assessment
of Baastrup’s disease by PET imaging has not been validated,
increased uptake of FDG might occur at the interspinous ligament
due to the strain-induced inflammatory reaction. Our case presentation supports this theory by the demonstration of an abnormality on PET imaging, but not on SPECT imaging. Although
conclusive evidence is lacking, it is reasonable to presume that
lumbar interspinous bursitis precedes the development of Baastrup’s disease. Conclusive evidence does exist of the presence of
bursal cavities in lumbar interspinous ligaments. 4,6-17
Relating the MRI finding of interspinous bursitis to the clinical
presentation of lumbar pain can be difficult. Various studies have
recorded the efficacy of therapeutic extraspinal injections in the
treatment of lumbar interspinous bursitis. 4,15,17,36 Yet, none have
examined the use of diagnostic injections employed at noninvolved segments to confirm the clinical response at the involved
segment, or have described the fluoroscopic contrast pattern supportive of the existence of a bursal cavity. In our case, we observed
a firm end-point after the injection of a finite volume of contrast
into a fixed cavity. Real-time imaging revealed a concise and localised collection of contrast consistent with a cavity of fixed dimensions. In contrast, injection of a similar amount of contrast at a
non-involved level demonstrated a fascial spread of contrast with-
1064
CASE REPORTS
out a firm end-point. Subsequent injection of anaesthetic into this
uninvolved level did not alleviate the patient’s symptoms. Yet,
injection of anaesthetic into the bursal cavity relieved the symptoms. Complete resolution of symptoms ensued after two therapeutic injections with steroid and anaesthetic. Presumably the
therapeutic injections arrested the local inflammatory cascade
allowing the athlete to move freely.
This case report is the first published presentation to characterise the fluoroscopic features of lumbar interspinous bursitis, and
to use diagnostic injections to confirm this as the cause of pain.
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