Surgical interventions for Bertolotti's syndrome: case report and review of unsatisfactory cases in the literature

[Bertolotti syndrome: an often overlooked cause of specific back pain]

BACKGROUND

Lumbosacral transitional vertebrae (LSTV) are common, with a prevalence of 15-35%, and can be a cause of specific low back pain. The insufficient awareness of this anomaly often leads to delayed diagnosis and treatment.

OBJECTIVE

This study explains the anatomical and biomechanical basis of Bertolotti syndrome and discusses diagnostic and therapeutic options.

MATERIALS AND METHODS

This systematic review was conducted in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The SCOPE criteria (Structuring Comparative Outcome Reporting in Epidemiology) were considered to ensure comprehensive and transparent reporting. A systematic search was performed in PubMed using the search terms 'Bertolotti', 'Bertolotti syndrome', and 'Lumbosacral transitional vertebrae' by a single investigator, resulting in the inclusion of 112 studies. Articles that were not available in English or German were excluded.

RESULTS

Patients with symptomatic Bertolotti syndrome often suffer from chronic low back pain and radiculopathies. Imaging techniques, particularly X‑rays and MRI, play a key role in diagnosis. Conservative treatments show limited success. Surgical resection of the transverse process (processectomy), especially after positive test infiltrations, leads to significant pain relief, particularly in younger patients without degenerative changes.

DISCUSSION

Treatment choice depends on individual anatomy and the presence of degenerative changes. While conservative measures are initially recommended, processectomy shows promising results in carefully selected patients. Fusion surgeries should only be considered in cases of instability. Further studies are needed to confirm the effectiveness of invasive procedures.

Oral pharmacological management of Bertolotti syndrome presenting as chronic low back pain - A case report and review of literature

Background

Bertolotti syndrome (BS) is often a missed cause of chronic lower back pain in young individuals, commonly associated with the presence of anomalous lumbosacral transitional vertebrae.

Case presentation

A 19-year-old female with no significant medical or family history presented with persistent lower back pain localized to the gluteal region and posterolateral aspect of the left lower back. The pain worsened over time and limited their movements, including walking. A Ferguson radiograph revealed fusion of the left transverse process of the L5 vertebral segment with the left sacral ala. History, examination findings, and radiological workup confirmed the diagnosis of BS. The patient preferred conservative management, receiving oral pharmacological therapy for six weeks, along with education on preventive measures and routine exercises for postural stability. At a six-month follow-up, the patient remained asymptomatic and managed well.

Conclusions

Conservative oral pharmacological treatment presents a unique and viable alternative to traditional methods for managing BS, which often involve surgery or steroids/anesthetics at the pseudo-articulation site. Given that BS is common yet underdiagnosed in young patients with chronic back pain, this report also underscores the importance of including it in differential diagnoses for chronic lower back pain in this demographic.

Integrative Korean medicine treatment for low back pain with radiculopathy caused by Bertolotti syndrome: A CARE-compliant article and retrospective review of medical records

RATIONALE

Bertolotti syndrome (BS) is characterized by radiculopathy caused by structural anomalies. Despite the structural deformity, conservative treatment is predominantly recommended due to surgery-related complications. Because of the diagnosis complexity, the incidence and contributing factors of BS, remain controversial. We report the case of a patient with BS who was treated with integrative Korean medicine (IKM). Moreover, we evaluated the epidemiological characteristics of lumbosacral transitional vertebrae (LSTV) from medical records of patients diagnosed with LSTV at 4 different medical clinics of Korean medicine.

PATIENT CONCERNS

A 33-year-old male patient with low back pain and severe radiculopathy was diagnosed with BS (Castellvi Type II) on magnetic resonance imaging at a local orthopedic clinic. Additionally, the medical records of patients with BS who had been treated with IKM in 4 different institutions of Korean medicine were analyzed, and the characteristics of patients suffering from BS were identified.

DIAGNOSES, INTERVENTIONS, AND OUTCOMES

The patient underwent IKM treatment for 40 days as an inpatient. The patient's condition was assessed using the Euroqol 5-dimension index and Oswestry Disability Index, and symptom severity was measured using the Numeric Rating Scale. IKM was effective in improving pain and functional disability without causing any adverse effects. In a retrospective review of medical records, the study identified symptom trends reported by patients with LSTV.

LESSONS

IKM demonstrates potential efficacy in BS management, with notable trends in LSTV-related symptomatology warranting further investigation.

Risks Associated with Surgical Management of Lumbosacral Transitional Vertebrae: Systematic Review of Surgical Considerations and Illustrative Case

BACKGROUND

Lumbosacral transitional vertebrae (LSTV) are congenital anomalies of the L5-S1 segments characterized by either sacralization of the most caudal lumbar vertebra or lumbarization of the most cephalad sacral vertebra. This variation in anatomy exposes patients to additional surgical risks.

METHODS

In order to shed light on surgical considerations reported for lumbar spine cases involving LSTV as described in the extant literature, we performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We also present a case example in which wrong level surgery was avoided due to anatomical understanding of LSTV.

RESULTS

A 48-year-old female presented with severe back pain after sustaining a fall from ten feet. The patient exhibited full motor function in all extremities but had begun to experience urinary retention. On initial imaging read, the patient was suspected to have an L1 burst fracture. A review of the imaging demonstrated a transitional vertebra. Therefore, based on the last rib corresponding to T12, the fractured level was L2. This case illustrates the risk LSTV carries for wrong site surgery; appropriate levels were then decompressed and instrumented. On systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a three database literature search identified 39 studies describing 885 patients with LSTV and relevant surgical considerations. The primary indications for surgery were for disc herniation (37%), Bertolotti's syndrome (35%), and spinal stenosis (25%). This cohort displayed a mean follow-up time of 23 months. Reherniation occurred in 12 patients (5.5%). Medical management through steroid injection was 24, 72% (n = 80) for the sample. Wrong level surgery occurred in 1.4% (n = 12) of patients.

CONCLUSIONS

LSTV represents a constellation of changes in anatomy beyond just a sacralized or lumbarized vertebra. These anatomical differences expose the patient to additional surgical risks. This case and review of the literature highlight avoidable complications and in particular wrong level surgery.

[Main clinical characteristics of pain in patients with lumbosacral transitional vertebrae]

OBJECTIVE

Based on an analysis of modern medical literature, to study the main clinical characteristics of pain in patients with transitional lumbosacral vertebrae.

MATERIAL AND METHODS

A search was made for articles in the scientific electronic libraries CYBERLENINKA, eLIBRARY, Google Scholar, and the electronic database of biomedical publications PubMed. Sixty-eight scientific publications corresponded to the stated goal.

RESULTS

The review of literature shows that the localization of pain in patients with transitional vertebrae corresponds to the zone of pseudarthrosis between the enlarged transverse process of the LV vertebra and the wing of the sacrum. In most patients, the pain is deep, not superficial. Pain intensity ranges from 3.0 to 8.4, reaching an average of 6.0 on the visual analog scale. Pain can radiate to one of the buttocks and the lower limb. The intensity of pain in the leg at the same time, on average, reaches 5.4 points. The pain syndrome can last for months, the course of the disease acquires a sluggish, undulating character with periodic exacerbations. The causes of exacerbations of pain may be excessive loads on the spine, concomitant vertebrogenic diseases and spinal injuries, excess weight, and in women, a history of pregnancy. Pain management can be either conservative or surgical. The scope of conservative treatment consists of using acupuncture and taking non-steroidal anti-inflammatory drugs. The greatest therapeutic effect is achieved with local injection therapy of analgesics and glucocorticoids at the neoarticulation point. The effectiveness of the course of therapeutic blockades reaches a period from several months to a year. The arsenal of surgical techniques includes pseudoartrectomy, radiofrequency denervation, minimally invasive endoscopic surgery, and transpedicular fusion. In most patients, after surgical treatment, complete relief of pain is noted.

CONCLUSION

The review provides information on the predominant localization of pain in patients with transitional vertebrae, its nature, intensity, irradiation, duration, causes of exacerbation, as well as the effectiveness of the methods of conservative and surgical treatment.

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.