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Title: Isolated Atraumatic Rupture of the Supraspinous Ligament: A Case Report 2014

Category General Spine Vivek Joshi, MD Andrew Casden, MD Branko Skovrlj, MD Amish Doshi, MD Purpose We report a unique presentation of isolated atraumatic injury to the supraspinous and interspinous ligaments in a healthy woman. To our knowledge, this has not been described previously in the literature. In addition, we describe radiologic modalities and imaging findings which may aid in diagnosis and in treatment of equivocal cases. Materials & Methods A 33-year-old female with no significant past medical history outside of a treated, uncomplicated pneumonia one month prior to presentation, complained of one month of progressively worsening lumbar back pain that had become excruciating. The patient reported no history of trauma. Plain radiographs and magnetic resonance imaging (MRI) of her lumbar spine demonstrated no abnormality of the vertebral bodies and discs. On the T2 weighted fat saturated sequence (T2 FS), interruption of the supraspinous ligament (SSL) and interspinous ligament (ISL) was noted concerning for a SSL rupture and likely partial tear of the ISL. An associated fluid collection was also suspected based on MR imaging. Given this patient’s atypical history and presentation, a spine ultrasound was performed to assess the fluid collection for possible aspiration. MethodFigures.docx Results The ultrasound examination revealed disruption of the supraspinous and interspinous ligaments, along with a heterogeneously circumscribed echogenic area. An ultrasound guided aspiration of the suspected collection was performed to exclude infection but did not return fluid. This area was thought to represent disrupted elements of the SSL and ISL, and/or hematoma. With ultrasound guidance, bupivacaine was injected into this area. The patient reported near complete resolution of pain within five minutes, and on follow up examination three days after the procedure, she reported continued resolution of pain and full mobility of her lumbar spine. ResultsFigures.docx Conclusion Isolated damage to the supraspinous and interspinous ligaments is a very rare finding in patients who present without history of trauma. Awareness of this entity may help draw attention to PLC injury as a rare, but possible cause of back pain in a non-traumatic setting. While MRI is the favored modality to evaluate injury to the posterior ligament complex, ultrasound is an additional modality that may aid in equivocal cases, particular when a fluid collection is suspected and may also be used to guide treatment. References 1. Pizones J, Izquierdo E, Sánchez-Mariscal F, Zúñiga L, Álvarez P, Gómez-Rice A. Sequential damage assessment of the different components of the posterior ligamentous complex after magnetic resonance imaging interpretation: prospective study of 74 traumatic fractures. Spine; 2012; 37(11):E662-7. 2. Pizones J, Zúñiga L, Sánchez-Mariscal F, Alvarez P, Gómez-Rice A, et. al. MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures. European Spine Journal; 2012; 21(11):2222-31.