Tuesday, December 6, 2011

Baastrup disease: Lumbar interspinous bursitis





This disease is named after Danish radiologist (1855 - 1950) Christian Ingerslev Baastrup.

Introduction & Epidemiology:
It is claimed that Baastrup disease is responsible for intractable LBA (1). Though it is reported in mostly lumbar spine it’s cervical spine variant is also reported (2). Gardella called Baastrup disease as spinous process syndrome (3). It is reported in many occupational areas such as miners (4) & heavy vehicle drivers (8). Among of much debate now it is considered mostly a case of aging related problem. Let us discuss in little more detail:

The Baastrup disease is characterized by the development of abnormal contact between adjacent spinous processes of the lumbar spine that results in rubbing against each other producing a bursitis which further result in focal midline pain and tenderness relieved by flexion and aggravated by extension.

Epidemiology:
It tends to be more common in the elderly. According to Maes et al (5) the prevalence of Baastrup disease is 8.2% (44 of 539) of the study population. In this study the lumbar spine was studied. This study also revealed that Baastrup disease is associated with age (P = 0.001), central canal stenosis (P = 0.0013), disc bulging (P = 0.0341), and anterolisthesis (P = 0.0429). There were no associations between Baastrup disease and disc degeneration, disc herniation, endplate findings, retrolisthesis, scoliosis, lordosis, or gender.
According to Kwong et al (6); Baastrup disease occurs with high frequency among the elderly. This study suggests that Baastrup disease develops with increasing age and is part of the expected degenerative changes in the aging spine. According to these researchers (6) in their CT scan based study of 1008 patients evidence of Baastrup disease was found in 413 patients (41.0%). A decade-on-decade increase in frequency was found with a peak of 81.3% among patients older than 80 years. As many as five spinal levels were found to be affected in some patients (4.1% of 413), but in most patients (35.4%), one level was affected. Baastrup disease was most common at L4-L5. Associated degenerative changes were found at almost all affected levels (899/901). Hence Kwong et al urged the clinicians that because of the nearly universal association with other degenerative changes, caution must be taken before diagnosing Baastrup disease as the cause of back pain.
According to Hanger (8) prevalence rate of this disease in a group of heavy automotive vehicles drivers is 13% of the test population.

Pathology
Patients with Baastrup disease may experience pain owing to irritation of the periosteum or adventitial bursae between abutting spinous processes. This process can result in a degenerative hypertrophy, inflammatory change and even a pseudarthrosis with bursa formation. This interspinous bursa may extend between the ligamentum flavae in the midline forming an epidural cyst and further contributing to the already existing canal stenosis.
This condition is usually seen patients with excessive lordosis of the lumbar spine. Often Baastrup lesions of the lumbar spine are located at L3-L4 and L4-L5 segments (8).

Palpation
I myself employ the following technique to find a Interspinous bursa is swollen or not.
First the spinous processes are palpated. The gap between the spinous process (Interspinous area) is located and palpating finger (usually the thumb) is slided on the slope following a parallel path way to that of laminas. Reaching on to the area between the spinous process from the side is easy & if Baastrup disease is present then obviously high degree of tenderness is elicited.This palpation also gives us the idea if the crowding of (kissing of ) spinous process as compared with other interspinous spaces & further it may reveal the tissue texture of the local tissue. Inflammed bursa with cyst may impart a "bouggy" feeling to the palpating hand. 

Radiographic features (9)
Plain film and CT
 •    often shows close approximation and contact of adjacent spinous processes (kissing spines)
•    there is resultant enlargement, flattening and reactive sclerosis of apposing interspinous surfaces.

MRI
May demonstrate interspinous bursal fluid and a postero-central epidural cyst(s). MRI can be very helpful in determining whether there is resulting posterior compression of the thecal sac.

Baastrup's sign: Also known as kissing spine, is an radiographic sign. It is characterized by posterior spinous processes 'kissing' and touching one another on sagittal plane.

Treatment (9)
Both conservative and surgical options are available for treatment. Local steroid injection into the interspinous processes will often ease the back pain. Surgical options include interspinous process decompression devices (e.g, Wallis system, X STOP), and steroid / local anaesthetic injection into the bursa.

Physiotherapy:

No references are there about physiotherapy. However electro-analgesia & thermo-analgesia are quite effective. SWD, PSWD, MWD & FIR exert powerful anti-inflammatory effect with thermo-analgesia. IFT gives anti-inflammatory effect with electro-analgesia. UST in pulsed mode directed appropriately to the focal tissue is both anti-inflammatory & analgesic.
Manual mobilization techniques are tried once the local tenderness is less. Contrast heat in acute inflammation & Hot fomentation thrice a day is also very effective in long standing cases which should be used as a home remedy. Egronomic corrective methods & postural awareness are of utmost importance as they may be primary factor that produced such a disorder. Manual therapists well versed with soft tissue & fascial techniques should try out techniques that may lengthen the thoracolumbar fascia.
The outcome of physiotherapy is so satisfactory that author opine on his clinical experience, steroid infiltration & surgery are rarest of rare probabilities to be employed. 

References:
1. FERNANDEZ DE LA MELA I; Medicamenta (Madr). 1951 Dec 10;9(210):404-5.[Lumbar interspinal nearthrosis (Baastrup disease) as responsible for some intractable backaches].

2. VIALLET P J Radiol Electrol Arch Electr Medicale. 1950;31(3-4):206-7. [Two cases of cervical localization of Baastrup disease].

3. GARDELLA G; Ann Radiol Diagn (Bologna). 1952;24(4):260-74.[Spinous process syndrome (Baastrup disease)].

4. Gajdek D; Chir Narzadow Ruchu Ortop Pol. 1976;41(2):171-4. Polish. No abstract available. [Baastrup syndrome of the lumbar spine in miners].

5. Maes R et al; Spine (Phila Pa 1976). 2008 Apr 1;33(7):E211-5. [Lumbar interspinous bursitis (Baastrup disease) in a symptomatic population: prevalence on magnetic resonance imaging.]

6. Kwong Y et al AJR Am J Roentgenol. 2011 May;196(5):1156-9. MDCT findings in Baastrup disease: disease or normal feature of the aging spine?

7. Pinto PS et al Clin Imaging. 2004 May-Jun;28(3):219-22. [Spinous process fractures associated with Baastrup disease.]

8. Hagner W; Med Pr. 1988;39(1):65-70. [Baastrup's disease of the lumbar segment of the spine among drivers of heavy motor vehicles].

9. http://radiopaedia.org/articles/baastrup_syndrome

Monday, December 5, 2011

Classification of spinal cord injury: ASIA classification Vs Frankel classification


Clinicians have long used a clinical scale to grade severity of neurological loss in SCI. First devised at Stokes Manville before World War II and popularized by Frankel in the 1970's, the original scoring approach segregated patients into five categories.

Frankel classification:Grade A:  no function
Grade B: sensory only
Grade C: some sensory and motor preservation
Grade D: useful motor function
Grade E: normal function

ASIA classification:Grade A:  Complete. No motor or sensory function preserved in the sacral segments (S4-S5)
Grade B: Incomplete. Sensory function is preserved but motor function is affected below the neurological level & includes the sacral segments (S4-S5)
Grade C: Incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade less than 3.
Grade D: Incomplete. Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle more than 3.
Grade E: Normal. Motor & sensory functions are normal.

5-Clinical syndromes in incomplete SCI by ASIA classification:1. Central cord syndrome 2. Brown-Sequard syndrome 3. Anterior cord syndrome 4. Conus medullaris syndrome 5. Cauda equina syndrome
The ASIA committee also classified incomplete spinal cord injuries into five types. A central cord syndrome is associated with greater loss of upper limb function compared to the lower limbs. The Brown-Sequard syndrome results from a hemisection lesion of the spinal cord. Anterior cord syndrome occurs when the injury affects the anterior spinal tracts, including the vestibulospnal tract. Conus medullaris and cauda equina syndromes occur with damage to the conus or spinal roots of the cord.

Advantages of ASIA impairment scale:
1. First, instead of no function below the injury level, ASIA A is defined as a person with no motor or sensory function preserved in the sacral segments S4-S5. This definition is clear and unambiguous.
The new ASIA A categorization turns out to be more predictive of prognosis than the previous definition where the presence of function several segments below the injury site but the absence of function below a given level could be interpreted as an "incomplete" spinal cord injury.
2. ASIA B is essentially identical to Frankel B but adds the requirement of preserved sacral S4-S5 function. It should be noted that ASIA A and B classification depend entirely on a single observation, i.e. the preservation of motor and sensory function of S4-5.
3. The ASIA scale also added quantitative criteria for C and D. The original Frankel scale asked clinicians to evaluate the usefulness of lower limb function. This not only introduced a subjective element to the scale but ignored arm and hand function in patients with cervical spinal cord injury. To get around this problem, ASIA stipulated that a patient would be an ASIA C if more than half of the muscles evaluated had a grade of less than 3/5. If not, the person was assigned to ASIA D.
4. ASIA E is of interest because it implies that somebody can have spinal cord injury without having any neurological deficits at least detectable on a neurological examination of this type. Also, the ASIA motor and sensory scoring may not be sensitive to subtle weakness, presence of spasticity, pain, and certain forms of dyesthesia that could be a result of spinal cord injury. Note that such a person would be categorized as an ASIA E.

These changes in the ASIA scale significantly improved the reliability and consistency of the classification. Although it was more logical, the new definition of "complete" injury does not necessarily mean that it better reflects injury severity.



Friday, December 2, 2011

Shoulder: Bankart surgery rehabilitation




Bankart surgery:
Bankart lesion is an injury of the anterior (inferior) glenoid labrum due to repeated (anterior) shoulder dislocation. Repeated dislocation forms a pocket at the front of the glenoid that allows the humeral head to dislocate into it. It is often accompanied by a Hill-Sachs lesion (damage to the posterior humeral head seen as a depression on X-ray). A bony bankart is a Bankart lesion that includes a fracture in of the anterior-inferior glenoid cavity.
Bankart lesion warrants surgery. In Bankart surgery the anterior (inferior) glenoid labrum is reattached to the glenoid. Generally there is a anterior approach to this shoulder operation. Rehabilitation is the key to successful reinstitution of functional activities. As it is a very common injury in sports like javelin throwing return to sports is heavily dependant on post operation physiotherapy. The following is an sample schema of physiotherapy & rehabilitation approach to the Bankart surgery.    

Don’ts:

Restrictions up to 4 weeks: (To protect the reattached anterior capsule & labrum)
  
1. Shoulder extension (backwards) past the plane of the body
2. Shoulder external rotation (arm rotation outwards) greater than 0° (straight in front); extensive repairs may require more restrictions

For posterior repairs (To protect the reattached posterior capsule & labrum)

1. Avoid any shoulder internal rotation (turning in) past the body i.e. hand behind back.

Restrictions up to 3 months:
No passive forceful stretching into external rotation/extension following an anterior repair and into internal rotation for a posterior repair.

Dos:

- Good posture is critical throughout the rehabilitation process to improve healing and decrease the risk of developing poor mechanics

- Aerobic conditioning throughout the rehabilitation process

- MD follow-ups Day 1, Day 8 - 10, 1 month, 4 months, 6 months and 1 year post-op

- All active exercises should be carefully monitored to minimize substitution or compensation

1 - 5 Days Post-op

1. Use of arm sling
2. Ice pack for first 3 - 5 days. (Apply over the dressing but should not sip into the dressing)
3. Postural education & sleeping posture advice (semi-reclined is most comfortable) 
4. Other general exercises: Stationary bike, stair machine etc
5. Codmann’s Pendulum exercise to reduce muscular spasms, Scapulothoracic stabilizer training, elbow flexion/extension, wrist and forearm strengthening, gentle passive/active assistive exercises of the arm in flexion (front) keeping below the level of the shoulder & finally cervical muscle stretching.

* Surgeon’s check up to change dressing etc.

5 - 14 Days Post-op

1. To reduce pain: IFT or TENS/ massage / contrast heat etc
2. Russian current for strengthening
3. Increase PROM and active assistive (AAROM) exercises as tolerated (from flexion out into the scapular plane) up to 90° unless otherwise indicated
4. Soft tissue therapy to developing scar as appropriate.
5. Scapulothoracic mobilization
6. General conditioning as tolerated (include trunk flexion & extension exercises)

2 - 4 Weeks Post-op

1. Now at this stage passive and active assisted flexion out to scaption (plane of the scapula) as tolerated.
 2. Sub-maximal isometrics (as dictated by pain) & Isotonic wrist, forearm.
 3. Resisted exercises using theraband are started from this phase onwards.
a.    Theraband resisted pull-downs from the front and the scapular plane
b.    Theraband resisted elbow flexion (high reps and low resistance)
4. Active scapular elevation, depression, and retraction exercises
5. Light weight bearing exercises

4 - 6 Weeks Post-op

1. By 4-6 weeks resting pain is substantially less.
2. Continue with passive and AAROM exercises (cane exercises, wall walking, table slide) from flexion & scaption out to abduction as tolerated
3.  Maximal isometrics
4. Active exercises from flexion into the scapular plane against gravity as tolerated
5. No resistance until able to perform 30 reps at limb weight with perfect mechanics
6. Rested internal rotation 0° to the body. (Only light resistance)
7. Add proprioceptive training exercises. (Alphabet writing, fine motor skills, work/sport specific exercises)

6 - 8 Weeks Post-op

1. Increase AROM exercises as tolerated (serratus anterior, upper, and lower trapezius).
2. Eccentrics exercises are added into protected ranges 
3. From this phase onwards begin LIGHT stretching into external rotation
4. GHJ joints play + mobilizations as tolerated
5. Increase proprioceptive training (prone on elbows, quadruped position ("on all four's") for rhythmic stabilization
6. Okay to begin jogging, road cycling, and standing arm resistance exercises in the pool

8 - 12 Weeks Post-op

Emphasis on regaining strength and endurance

1. PNF patterns (proprioceptive neuromuscular facilitation) can be started safely
2. AROM exercises: internal rotation and external rotation as motion allows
3. AROM exercises: lateral raises and supraspinatus isolation
4. Rower with a high seat, decline bench press, military press in front of body
5. Running, road or mountain biking, no activities with forceful, ballistic arm movement


3 - 6 Months Post-op

1. Aggressive stretching.
2. Start strenuous resistive exercises
3. Add light throwing exercises with attention to proper mechanics

6 Months Post-op

1.  Increase throwing program with focus on return-to-throwing sports as mechanics
2.  Sports conditioning with all of the normal shoulder movements


NB: Progression is based on individual patient presentation, which is assessed throughout the treatment process. People well versed with soft tissue & fascial tissue manipulations can appropriately employ them from 2nd week onwards.