Minimally Invasive Microendoscopic Resection of the Transverse Process for Treatment of Low Back Pain with Bertolotti's Syndrome

Techniques for restoring optimal spinal biomechanics to alleviate symptoms in Bertolotti syndrome: illustrative case

BACKGROUND

Lumbosacral transitional vertebrae (LSTVs) are congenital anomalies that occur in the spinal segments of L5-S1. These vertebrae result from sacralization of the lowermost lumbar segment or lumbarization of the uppermost sacral segment. When the lowest lumbar vertebra fuses or forms a false joint with the sacrum (pseudoarticulation), it can cause pain and manifest clinically as Bertolotti syndrome.

OBSERVATIONS

A 36-year-old female presented with severe right-sided low-back pain. Computed tomography was unremarkable except for a right-sided Castellvi type IIA LSTV. The pain proved refractory to physical therapy and lumbar epidural spinal injections, but targeted steroid and bupivacaine injection of the pseudoarticulation led to 2 weeks of complete pain relief. She subsequently underwent minimally invasive resection of the pseudoarticulation, with immediate improvement in her low-back pain. The patient continued to be pain free at the 3-year follow-up.

LESSONS

LSTVs alter the biomechanics of the lumbosacral spine, which can lead to medically refractory mechanical pain requiring surgical intervention. Select patients with Bertolotti syndrome can benefit from operative management, including resection, fusion, or decompression of the pathologic joint.

Surgical outcome of a patient with Bertolotti's syndrome in whom the established Castellvi classification system failed: illustrative case

BACKGROUND

Bertolotti's syndrome is a condition of the lower back and/or L5 distribution leg pain caused by a lumbosacral transitional vertebra (LSTV). Diagnosing the LSTV as the cause of the symptoms and condition is essential for accurate management of this syndrome. Castellvi's classification system is widely accepted for LSTV anatomy, but it measures only one aspect of transitional anatomy and was intended primarily to identify target-level disk herniations.

OBSERVATIONS

In this case, the Castellvi classification system failed to identify the patient (with 2 years of back and L5 pain) as having an LSTV, even though he displayed LSTV-like anatomy because both L5 transverse process heights measured less than 19 mm. He attained brief but significant relief from bilateral injections into the L5-S1 transverse/ala region and underwent a minimally invasive bilateral decompression of L5-S1 with almost complete relief of his symptoms maintained more than 6 months postoperatively.

LESSONS

Given that the patient gained significant relief from treatment of transitional anatomy that failed to be identified using Castellvi's classification system, this case suggests that transverse process height may not be adequate or even the most clinically relevant indicator in identifying LSTV anatomy, which is a precursor to the diagnosis of Bertolotti's syndrome.

Identifying treatment patterns in patients with Bertolotti syndrome: an elusive cause of chronic low back pain

BACKGROUND CONTEXT

Bertolotti Syndrome is a diagnosis given to patients with lower back pain arising from a lumbosacral transitional vertebra (LSTV). These patients can experience symptomatology similar to common degenerative diseases of the spine, making Bertolotti Syndrome difficult to diagnose with clinical presentation alone. Castellvi classified the LSTV seen in this condition and specifically in types IIa and IIb, a "pseudoarticulation" is present between the fifth lumbar transverse process and the sacral ala, resulting in a semi-mobile joint with cartilaginous surfaces.Treatment outcomes for Bertolotti Syndrome are poorly understood but can involve diagnostic and therapeutic injections and ultimately surgical resection of the pseudoarticulation (pseudoarthrectomy) or fusion of surrounding segments.

PURPOSE

To examine spine and regional injection patterns and clinical outcomes for patients with diagnosed and undiagnosed Bertolotti Syndrome.

DESIGN

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

PATIENT SAMPLE

Cohort consisted of 67 patients with an identified or unidentified LSTV who were provided injections or surgery for symptoms related to their chronic low back pain and radiculopathy.

OUTCOME MEASURES

Self-reported clinical improvement following injections and pseudoarthrectomy.

METHODS

Patient charts were reviewed. Identification of a type II LSTV was confirmed through provider notes and imaging. Variables collected included demographics, injection history and outcomes, and surgical history for those who underwent pseudoarthrectomy.

RESULTS

A total of 22 out of 67 patients (33%) had an LSTV that was not identified by their provider. Diagnosed patients underwent fewer injections for their symptoms than those whose LSTV was never previously identified (p = 0.031). Only those diagnosed received an injection at the LSTV pseudoarticulation, which demonstrated significant symptomatic improvement at immediate follow up compared to all other injection types (p = 0.002). Patients who responded well to pseudoarticulation injections were offered a pseudoarthrectomy, which was more likely to result in symptom relief at most recent follow up than patients who underwent further injections without surgery (p < 0.001).

CONCLUSIONS

Undiagnosed patients are subject to a higher quantity of injections at locations less likely to provide relief than pseudoarticulation injections. These patients in turn cannot be offered a pseudoarthrectomy which can result in significant relief compared to continued injections alone. Proper and timely identification of an LSTV dramatically alters the clinical course of these patients as they can only be offered treatment directed towards the LSTV once it is identified.

Clinical assessment and management of Bertolotti Syndrome: a review of the literature

Bertolotti Syndrome is a diagnosis given to patients experiencing pain caused by the presence of a lumbosacral transitional vertebra (LSTV), which is characterized by enlargement of the L5 transverse process(es), with potential pseudoarticulation or fusion with the sacrum. The Castellvi classification system is commonly utilized to grade LSTVs based on the degree of contact between the L5 transverse process(es) and the sacrum. LSTVs present a diagnostic dilemma to the treating clinician, as they may remain unidentified on plain x-rays and even advanced imaging; additionally, even if the malformation is identified, patients with a LSTV may be asymptomatic or have nonspecific symptoms, such as low back pain with or without radicular symptoms. With low back pain being extremely prevalent in the general population; it can be difficult to implicate the LSTV as the source of this pain. Care should be taken however, to exclude Bertolotti Syndrome in patients under 30 years old presenting with persisting low back pain given its congenital origin. If a LSTV is identified, typically with acquisition of a MRI or CT scan of the lumbosacral spine, and there is an absence of a more compelling or obvious source for the patient's symptoms, a conservative, step-wise management plan is recommended. This may include assessing for improvement in symptoms with injections prior to proceeding with surgical intervention. Additional concerns arise from the biomechanical alterations that a LSTV induces in adjacent spinal levels, predisposing this patient population to a more rapid-onset of adjacent segment disease, raising the question as to the most appropriate surgery (resection of LSTV pseudoarticulation with or without fusion). Postoperative outcome data for patients undergoing surgical treatment is limited in the literature with promising, but variable, results. More large-scale, controlled studies must be performed to gain further insight into the ideal work-up and management of this pathology.

The effectiveness of preoperative assessment using a patient-specific three-dimensional pseudoarticulation model for minimally invasive posterior resection in a patient with Bertolotti's syndrome: a case report

Background

Bertolotti’s syndrome is widely known to cause low back pain in young patients and must be considered as a differential diagnosis. Its treatment such as conservative therapy or surgery remains controversial. Surgical procedure is recommended for intractable low back pain. The three-dimensional (3D) lumbosacral transitional vertebrae anatomy should be completely understood for a successful surgery. Using an intraoperative 3D navigation and preoperative preliminary surgical planning with a patient-specific 3D plaster model contribute for safe surgery and good outcome.

Case presentation

A case of a 22-year-old Japanese male patient with intractable left low back pain due to lumbosacral transitional vertebrae with Bertolotti’s syndrome. The symptom resisted the conservative treatment, and anesthetic injection at pseudoarticulation only provided a short-term pain relief. Posterior resection using intraoperative three-dimensional (3D) navigation has been performed through microendoscopic view. Pseudoarticulation was totally and successfully resected in a safe manner.

Conclusions

Preoperative surgical planning and rehearsal using a patient-specific 3D plaster model was greatly useful and effective for surgeons in performing accurate and safe pseudoarticulation resection.

Surgical management of Bertolotti's syndrome in two adolescents and literature review

Background:

Bertolotti’s syndrome is defined by back pain and/or radicular symptoms attributed to a congenital lumbosacral transitional vertebra (LSTV). There are few studies that discuss the surgical management of Bertolotti’s syndrome. Here, we report long-term outcomes after resecting a pseudoarthrosis between the sacrum and L5 in two teenage patients, along with a review of literature.

Case Descriptions:

Surgical resection of a lumbosacral bridging articulation (LSTV type IIa) was performed in two patients, 15 and 16 years of age who presented with intractable back pain. The adequacy of surgery was confirmed with postoperative studies. In both patients, pain and functional status improved within 6 weeks and have remained improved at last follow-up.

Conclusion:

Surgical removal of a pathologic L5 transverse process fused to the sacral ala in two young patients with Bertolotti’s syndrome improved postoperative pain and increased overall function. Given the progressive nature of Bertolotti’s syndrome, surgical intervention in young patients should be considered to mitigate years of chronic pain and attendant morbidity.

Surgical Treatment of a Rare Presentation of Bertolotti's Syndrome from Castellvi Type IV Lumbosacral Transitional Vertebra: Case Report and Review of the Literature

Background  Advancements in radiological imaging and diagnostic criteria enable doctors to more accurately identify lumbosacral transitional vertebrae (LSTV) and their association with back and L5 distribution leg pain. It is considered the most common congenital anomaly of the lumbosacral spine with an incidence between 4 and 35%, ³ although many practitioners describe 10 to 12% overall incidence. LSTVs include sacralization of the L5 vertebral body and lumbarization of the S1 segment while demonstrating varying morphology, ranging from broadened transverse processes to complete fusion. ⁵ The most common types of LSTV that present with symptomatic Bertolotti's syndrome are the Castellvi type I and type II; type III and type IV variants rarely present with symptoms referable with confirmatory and provocative testing to the transitional vertebra itself, and therefore there is limited experience and no case reports of treatment toward this particular entity.

Case Description  We illustrated a case of a 37 years old female in which a computed tomography scan demonstrated type III LSTV on the left and a type I anomaly on the right. The patient presented with right-sided leg pain and left-sided sacroiliac (SI) region low back pain, worse with rotation and standing, for several years, and had been on daily narcotic pain medications for more than 2 years. The patient had temporary relief of her leg pain with a transverse/ALA injection on the right, but no improvement in her back pain, whereas a left-sided injection into the region around the type III interface on the left did transiently alleviate her SI pain without improvement in her leg pain. We proposed that this particular anomaly induced mechanical back pain on the left side by flexion of the bone bridge (a form of stress-fracture, with associated sclerotic changes in the interface in the transverse/ALA junction) with associated irritation of the right L5 nerve from the type I anomaly on the right in conjunction with her typical radiating leg pain on the right. A patent, but somewhat hypoplastic L5/S1 disk space was also present. Nonsegmental pedicle screw instrumentation with low-profile screws was implanted on the right side with fusion induced using allograft and off label use of infuse rh-BMP2 bone graft substitute, and the patient was discharged the same day. The patient noted immediate improvement in her preoperative symptoms, and by 2 weeks after her surgery noted complete resolution of the preoperative symptoms, and required no narcotic medications to control her incisional pain.

Conclusion  Patients who present with symptoms consistent with Bertolotti's syndrome, even if they have a type III or type IV LSTV, should be considered for surgical treatment of their LSTV. These patients can respond well, even if symptoms have been present for years. Given the prevalence of these anatomic variants in the general population (10–12% in most series), Bertolotti's syndrome should be considered in the differential diagnosis of any patient with a presentation of L5 radiculopathy and/or back pain.

Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention

Bertolotti’s syndrome (BS) refers to the possible association between the congenital malformation lumbosacral transitional vertebra (LSTV), and low back pain (LBP). Several treatments have been proposed including steroid injections, resections of the LSTV, laminectomy, and lumbar spinal fusion. The aim of this review was to compare the clinical outcomes in previous trials and case reports for these treatments in patients with LBP and LSTV. A PubMed search was conducted. We included English studies of patients diagnosed with LSTV treated with steroid injection, laminectomy, spinal fusion or resection of the transitional articulation. Of 272 articles reviewed 20 articles met the inclusion criteria. Their level of evidence were graded I–V and the clinical outcomes were evaluated. Only 1 study had high evidence level (II). The remainders were case series (level IV). Only 5 studies used validated clinical outcome measures. A total of 79 patients were reported: 31 received treatment with steroid injections, 33 were treated with surgical resection of the LSTV, 8 received lumbar spinal fusion, and 7 cases were treated with laminectomy. Surgical management seems to improve the patient’s symptoms, especially patients diagnosed with “far out syndrome” treated with laminectomy. Clinical outcomes were more heterogenetic for patient’s treated with steroid injections. The literature regarding BS is sparse and generally with low evidence. Non-surgical management (e.g., steroid injections) and surgical intervention could not directly be compared due to lack of standardization in clinical outcome. Generally, surgical management seems to improve patient’s clinical outcome over time, whereas steroid injection only improves the patient’s symptoms temporarily. Further studies with larger sample size and higher evidence are warranted for the clinical guidance in the treatment of BS.