Lumbosacral transitional vertebral articulation: evaluation by planar and SPECT bone scintigraphy

Update on Pediatric Nuclear Medicine in Acute Care

Various radiopharmaceuticals are available for imaging pediatric patients in the acute care setting. This article focuses on the common applications used on a pediatric patient in acute care. To confirm the clinical diagnosis of brain death, brain scintigraphy is considered accurate and has been favorably compared with other methods of detecting the presence or absence of cerebral blood flow. Ventilation-perfusion lung scans are easy and safe to perform with less radiation exposure than computed tomography pulmonary angiography and remain an appropriate procedure to perform on children with suspected pulmonary embolism as a first imaging test in a hemodynamically stable patient with no history of lung disease and normal chest radiograph. 99mTc-pertechnetate scintigraphy (Meckel's scan) is the best noninvasive procedure to establish the diagnosis of ectopic gastric mucosa in Meckel's diverticulum. 99mTcred blood cell scintigraphy generally is useful for assessing lower GI bleeding in patients from any cause. Hepatobiliary scintigraphy is the most accurate diagnostic imaging modality for acute cholecystitis. 99mTc-dimercaptosuccinic acid scintigraphy is the simplest, and the most reliable and sensitive method for the early diagnosis of focal or diffuse functional cortical damage. 99mTcmercaptoacetyltriglycine scintigraphy is used to evaluate for early and late complications of renal transplantation. Bone scintigraphy is a sensitive and noninvasive technique for diagnosis of bone disorders such as osteomyelitis and fracture. 18F-fluorodeoxyglucose-positron emission tomography could be valuable in the evaluation of fever of unknown origin in pediatric patients, with better sensitivity and significantly less radiation exposure than a gallium scan. Moving forward, further refinement of pediatric radiopharmaceutical administered activities, including dose reduction, greater radiopharmaceutical applications, and updated consensus guidelines is warranted, with the use of radionuclide imaging likely to increase.

Quality-of-life and postoperative satisfaction following pseudoarthrectomy in patients with Bertolotti syndrome

BACKGROUND CONTEXT

Bertolotti syndrome is a clinical diagnosis given to patients with back pain arising from a lumbosacral transitional vertebra (LSTV). A particular class of LSTV involves a pseudoarticulation between the fifth lumbar transverse process and the sacral ala, and surgical resection of the pseudoarticulation may be offered to patients failing conservative management. Bertolotti syndrome is still not well understood, particularly regarding how patients respond to surgical resection of the LSTV pseudoarticulation.

PURPOSE

To examine change in quality-of-life (QOL) and patient satisfaction following surgical resection of the LSTV pseudoarticulation in patients with Bertolotti syndrome.

DESIGN

Ambidirectional observational cohort study of patients seen at a single institution's tertiary spine center over a 10-year period.

PATIENT SAMPLE

Cohort consisted of 31 patients with Bertolotti Syndrome who underwent surgical resection of the pseudoarticulation.

OUTCOME MEASURES

Preoperative and postoperative Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) Mental and Physical Health T-scores, and a single-item postoperative satisfaction questionnaire.

METHODS

Patients were identified through diagnostic and procedural codes. Immediate preoperative PROMIS-GH scores available in the chart were gathered retrospectively, and postoperative PROMIS-GH and satisfaction scores were gathered prospectively through a mail-in survey.

RESULTS

Mean (SD) improvement of PROMIS-GH Physical Health T-score was 8.7 (10.5) (p<.001). Mean (SD) improvement of PROMIS-GH Mental Health T-scores was 5.9 (9.2) (p=.001). When stratifying PROMIS-GH T-scores by response to the patient satisfaction survey, there were significant group differences in mean change for Physical Health T-scores (p<.001), and Mental Health T-score (p=.009). Patients who stated, "The treatment met my expectations" had much greater mean improvement in the PROMIS-GH T-scores.

CONCLUSIONS

Patients undergoing a pseudoarticulation resection procedure may experience a significant improvement in quality-of-life as measured by PROMIS-GH Mental and Physical Health.

Identifying the relationship between lumbar sacralization and adjacent ligamentous anatomy in patients with Bertolotti syndrome and healthy controls

OBJECTIVE

Bertolotti syndrome is a diagnosis given to patients experiencing low-back pain due to a lumbosacral transitional vertebra (LSTV). LSTVs cause altered biomechanics at the lumbosacral junction, predisposing these patients to degenerative disease. It has been proposed that these patients have additional non-osseous variation such as ligamentous differences in the lumbar spine. The iliolumbar ligament, which attaches from the iliac crest to the transverse process of L4 and L5, plays a significant role in reducing lumbar motion in all six degrees of freedom; therefore, altered ligament anatomy can have a significant impact on stability. The purpose of this study was to examine the iliolumbar ligament complex in patients with Bertolotti syndrome and anatomically normal controls to determine if underdevelopment of the iliolumbar ligament complex is seen in Bertolotti syndrome.

METHODS

This is a retrospective analysis of patients with Bertolotti syndrome and anatomically normal controls who received care at the authors' institution between 2010 and 2020. Axial thickness of the iliolumbar ligament at the L5 vertebral level was assessed via MRI. Results were compared between the defective and normal side within unilaterally affected (Castellvi types IIa and IIIa) Bertolotti syndrome patients, between defective sides in bilaterally affected Bertolotti syndrome patients (Castellvi types IIb, IIIb, and IV), and between the affected side in Bertolotti syndrome patients and the corresponding location in normal controls.

RESULTS

A total of 173 patients were included in the study, 102 with Bertolotti syndrome and 71 controls. Among the Bertolotti patients, 49 had left LSTVs, 29 had right LSTVs, and 24 had bilateral LSTVs. For patients with unilateral defects, defective side ligaments were thinner than ligaments on the normal side (p < 0.05). For bilateral LSTVs, ligament thickness on each side was considered statistically equivalent (p < 0.05) and not significantly different from that in controls.

CONCLUSIONS

Bertolotti syndrome correlates to significant underdevelopment of the iliolumbar ligament corresponding to the side of the LSTV as compared to the ligament on the contralateral side. In patients with bilateral LSTVs, no difference in the iliolumbar ligament compared to that in controls was seen. Developmental changes in the iliolumbar ligament may further exacerbate the altered lumbosacral biomechanics seen in patients with unilateral LSTV, whereas bilateral LSTVs may still allow normal development of the ligament complex. Further research should be done to examine the discrepancies seen in this study.

A Review of Symptomatic Lumbosacral Transitional Vertebrae: Bertolotti's Syndrome

BACKGROUND

Lumbosacral transitional vertebrae (LSTV) are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes. This review will focus on the clinical significance of LSTV, disruptions in normal spine biomechanics, imaging techniques, diagnosis, and treatment.

METHODS

A Pubmed search using the specific key words "LSTV," "lumbosacral transitional vertebrae," and "Bertolotti's Syndrome" was performed. The resulting group of manuscripts from our search was evaluated.

RESULTS

LSTV are associated with alterations in biomechanics and anatomy of spinal and paraspinal structures, which have important implications on surgical approaches and techniques. LSTV are often inaccurately detected and classified on standard AP radiographs and MRI. The use of whole-spine images as well as geometric relationships between the sacrum and lumbar vertebra increase accuracy. Uncertainty regarding the cause, clinical significance, and treatment of LSTV persists. Some authors suggest an association between LSTV types II and IV and low back pain. Pseudoarticulation between the transverse process and the sacrum creates a "false joint" susceptible to arthritic changes and osteophyte formation potentially leading to nerve root entrapment. The diagnosis of symptomatic LSTV is considered with appropriate patient history, imaging studies, and diagnostic injections. A positive radionuclide study along with a positive effect from a local injection helps distinguish the transitional vertebra as a significant pain source. Surgical resection is reserved for a subgroup of LSTV patients who fail conservative treatment and whose pain is definitively attributed to the anomalous pseudoarticulation.

CONCLUSIONS

Due to the common finding of low back pain and the wide prevalence of LSTV in the general population, it is essential to differentiate between symptoms originating from an anomalous psuedoarticulation from other potential sources of low back pain. Further studies with larger sample sizes and longer follow-up time would better demonstrate the effectiveness of surgical resection and help guide treatment.

Relationship of sacral articular surfaces and gender with occurrence of lumbosacral transitional vertebrae

BACKGROUND CONTEXT

Research on lumbosacral transitional vertebra (LSTV) has yielded important information on the structural alterations of the sacrum associated with LSTV. Nevertheless, very little data are available on the relationship of a given type of LSTV with either a typical pattern of sacral morphology or its gender distribution in the population.

PURPOSE

To investigate the probable relationship between different variants of LSTVs with sacral morphology at the articular surfaces of the bone and the gender distribution of the anomalies in the population.

STUDY DESIGN

Cross-sectional descriptive study involving dried human sacral bones and meta-analysis of data available related to LSTVs.

METHODS

Three hundred twenty sacra were screened for the presence of LSTV, the type of auricular surface, and facet joints in them. Samples were grouped against their sexes, type of the auricular surfaces present in them, the nature of facet joints, and the variety of LSTV (if present). Data on LSTV from reliable Internet databases were collected to account for the prevalence of LSTV in the population in terms of the types of the anomaly and their gender distribution.

RESULTS

The detection rates of LSTV in the present study were similar to those observed in available literature. Accessory L5-S1 articulations and lumbarization of S1 were more commonly observed in the women. Sacralization was seen to be predominantly distributed in men. Higher auricular surfaces were associated with accessory articulations; lower auricular surfaces were present with partially separated S1 segment and in L5-S1 specimens. Morphology of the facets significantly altered in LSTV with accessory articulations.

CONCLUSIONS

Different lumbosacral transitions share a stronger, definite, and specific patterns of relationship with certain sacral morphologies and gender. It is important to recognize the nuances of these connections so as to understand low back pain conditions in the setting of a typical sacral articular morphology or the sex of the individual.

Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti's syndrome

OBJECTIVE

Bertolotti's syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain.

METHOD

We analyzed the cases of Bertolotti's syndrome that failed clinical treatment and reviewed the literature concerning this subject.

RESULTS

Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm.

CONCLUSION

There is still no consensus about the most appropriate therapy for Bertolotti's syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.