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Patients will commonly seek medical attention for refractory abdominal pain. The many causes of abdominal pain include pathologies of the gastrointestinal, genitourinary, musculoskeletal, and nervous systems. Unfortunately, a large number of patients will develop chronic abdominal pain that is recalcitrant to definitive therapies and nonspecific treatments such as cognitive-behavioral, physical, and pharmacologic therapies. Although spinal cord stimulation is classically used for neuropathic and ischemic conditions, a growing number of reports describe its efficacy in visceral disease. We describe our experience with spinal cord stimulation in two patients with refractory abdominal pain. Although the exact etiology in these complex patients is not defined, it is theorized that visceral hypersensitivity is at least one component. Finally, we will summarize the applicable literature in order to explain a possible mechanism of analgesia in visceral disease.

Background: Any spine structure that is innervated by afferent nociceptive nerve fibers is a potential pain generator. In the lumbar spine, the most studied pain generators include: sacroiliac joints, the zygapophysial joints, the intervertebral discs, myofascial structures. Anomalous lumbosacral articulations, the spinous processes, and lumbar spine osteophytes are less commonly reported. Objective: To describe the diagnostic and therapeutic features of “kissing spine” disease or Baastrup’s Sign with particular attention to MRI findings and fluoroscopicallyguided injection therapy. Design: A series of 3 patients with axial low back pain presented with exam findings and MRI changes suggestive of pain emanating from adjacent spinous processes that appeared to be in direct contact or very closely opposed. This has been described in the literature as “kissing spine” disease or Baastrup’s sign. Fluoroscopically-guided injections were performed and the responses were studied. Results: The 3 patients had MRI findings consisting of inflammation and/or edema in the spinous processes and surrounding soft tissues. Fluoroscopically-guided injections provided pain relief in all 3 patients. One patient with recurrent pain eventually underwent successful surgical resection of the involved spinous processes. Conclusion: Painful adjacent and closely opposed spinous processes can be a source of axial low back pain. We have described MRI features and the responses to fluoroscopically-guided injections in 3 patients with this condition. Key words: Baastrup’s, kissing spine, spine injection

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Introduction: Image-guided sacroiliac joint injections are frequently employed for both diagnostic and therapeutic relief of low back pain. Case Report: An 83-year-old male with chronic lumbrosacral pain previously responsive to right sacroliac joint injections presented for repeat injection. His medical history included Parkinsonism and stool incontinence. Forty-two hours after the injection, he developed fever, dyspnea, and crepitus on the right buttock and thigh. Surgical debridement was recommended, but the family wished for comfort care only. The patient died hours later. The autopsy revealed Gram positive bacilli consistent with Clostridial myonecrosis. Discussion: Pyogenic sacroiliitis is rare and usually occurs in the setting of trauma, drug abuse, or extraspinal infections. Joint infections with Clostridium have been reported after traumatic events including puncture, surgery, and abrasions. Clostridium spores are resistant to chemical preparations used for skin sterilization and require high heat for destruction. Possible practice guidelines with patients that are stool incontinent include mechanical wash prior to sterile preparation and placement of an occlusive sterile dressing after injection to prevent stool contamination of the needle puncture site. As with all rare complications, large scale studies are needed to better identify risk factors to formulate practice management strategies. Key words: Sacroiliac joint, sacroiliac joint injection, pyogenic sacroilitis, fecal incontinence, clostridium