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Bhagchandani C, Murugan C, Arumugam T, Karuppanan Sukumaran SVA, Shetty AP, Kanna RM, Rajasekaran S. A Whole-Spine Magnetic Resonance Imaging-Based Cross-Sectional Study of the Clinicoradiological Association of Lumbosacral Transitional Vertebra with Degenerative Disc Disease, End Plate Degeneration, Low Back Pain, and Facet Tropism. World Neurosurg 2024; 185:e1121-e1128. [PMID: 38492662 DOI: 10.1016/j.wneu.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To understand lumbosacral transitional vertebra (LSTV)-associated degenerative pathologies and their correlation to low back pain and radicular pain. METHODS Whole-spine magnetic resonance imaging was evaluated for disc degeneration using Pfirrmann grading, end plate changes using total end plate score (TEPS), and facet tropism in patients with low back pain and radicular pain, and their association with LSTV was analyzed. RESULTS In group 1, LSTV was seen in 15% of patients with 83% of these patients having sacralization. Disc degeneration was seen in 58%, 51%, and 63% of patients at levels C, B, and A, respectively; patients with sacralization had significant degeneration at all 3 levels. Similarly, the total end plate score and facet tropism were significantly higher in patients with sacralization. Facet tropism was observed in 31%, 40%, and 35% of patients with no -LSTV, patients with sacralization, and patients with lumbarization, respectively. In group 2, LSTV was seen in 17% of patients with sacralization accounting for 82%. Disc degeneration was seen in 44%, 36%, and 54% patients at levels C, B, and A, respectively. No significant difference was observed in the mean total end plate score between groups. Facet tropism was identified in 89% and 81% of patients with sacralization and patients with lumbarization, respectively, compared with only 19% of patients with no LSTV. CONCLUSIONS Patients with low back pain had a higher incidence of sacralization with corresponding disc degeneration, facet tropism ,and end plate changes. In patients with radicular pain, lumbarization was associated only with facet tropism. These findings may aid clinicians in prognostication and patient counseling.
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Affiliation(s)
| | - Chandhan Murugan
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Thirumurugan Arumugam
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | | | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India.
| | - Rishi Mugesh Kanna
- Department of Spine Surgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
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Kojo S, Takahashi K, Tsubakino T, Hashimoto K, Aizawa T, Tanaka Y. Lumbar radiculopathy due to Bertolotti's syndrome: Alternative method to reveal the "hidden zone" - A report of two cases and review of literature. J Orthop Sci 2024; 29:366-369. [PMID: 35305864 DOI: 10.1016/j.jos.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/13/2022] [Accepted: 02/17/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Shigeaki Kojo
- Department of Orthopaedic Surgery, Tohoku Central Hospital
| | - Kohei Takahashi
- Department of Orthopaedic Surgery, Tohoku Central Hospital; Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
| | | | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku Central Hospital; Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine.
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine
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Afana H, Raffat M, Figueiredo N. Surgical Pitfalls in Bertolotti's syndrome management: A case report. Medicine (Baltimore) 2022; 101:e32293. [PMID: 36550915 PMCID: PMC9771345 DOI: 10.1097/md.0000000000032293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Bertolotti's syndrome is one of the differential causes of low back pain, especially within young people. The etiopathogenesis of the typical paramedian low back pain, associated with Bertolotti's syndrome remains controversial, and there is no worldwide acceptance of treatment. PATIENT CONCERNS This article presents the authors experience with surgical treatment of symptomatic patients with Bertolotti's syndrome. DIAGNOSES Retrospective study of a selected series of patients with symptomatic Bertolotti's syndrome submitted to surgical treatment. INTERVENTIONS This study included 16 patients, being 8 submitted to the new modified mini-open tubular microsurgical transverse processectomy, Among those patients, intraoperative fluoroscopy was used in 6 surgeries to locate the base of the enlarged transverse process (6/8); intraoperative neuromonitoring was used in 6 patients (6/8), 3D intraoperative advanced spinal image (O-arm) with neuronavigation was used to localize the base of the pseudojoint to be removed and to check the final bone resection for the last 5 cases (5/8). OUTCOMES The average paramedian lower back pain before surgery on the visual analogue scale for pain in the 8 patients was 6.6 (range: 5-8) and reduced to 1.5 (range: 0-3) at the latest follow-up after surgery, while the average pain score of the radicular pain on the right or left side before the surgery was 1.3 (range: 0-6) and reduced to 0.6 (range: 0-7) after the surgery. LESSONS The mini-open tubular microsurgical transverse processectomy seems to be potentially safe and effective for the surgical treatment of selected symptomatic patients with Bertolotti's syndrome.
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Affiliation(s)
- Hatem Afana
- Orthopaedic Surgeon, Department of Orthopaedic & Spinal Surgery, King’s College Hospital London, Dubai, UAE
- * Correspondence: Hatem B. Afana, Orthopaedic Surgeon, Department of Orthopaedic & Spinal Surgery, King’s College Hospital London, Dubai, UAE (e-mail: )
| | - Muhammad Raffat
- Orthopaedic Surgeon, Department of Orthopaedic & Spinal Surgery, King’s College Hospital London, Dubai, UAE
| | - Nicandro Figueiredo
- Spinal Neurosurgeon, Department of Orthopaedic & Spinal Surgery, King’s College Hospital London, Dubai, UAE
- Medical School, Federal University of Mato Grosso (UFMT) and University of Cuiaba (UNIC), Cuiaba, MT, Brazil
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Mao G, Lubelski D, Zakaria HM, Theodore N. Image-Guided Minimally Invasive Surgery for Treatment of the Bertolotti Syndrome—A Case Study: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:e222-e223. [DOI: 10.1227/ons.0000000000000132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/27/2021] [Indexed: 11/19/2022] Open
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Zhou S, Du L, Liu X, Wang Q, Zhao J, Lv Y, Yang H. Quantitative measurements at the lumbosacral junction are more reliable parameters for identifying and numbering lumbosacral transitional vertebrae. Eur Radiol 2022; 32:5650-5658. [PMID: 35258678 DOI: 10.1007/s00330-022-08613-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/18/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate quantitative parameters to identify the anatomic variation lumbosacral transitional vertebrae (LSTV) and compare them with the landmarks commonly used at present. METHODS A total of 2,845 PET/CT scans were reviewed, and the patients with 23 and 25 presacral vertebrae were included. The quantitative parameters, including the anterior-edge vertebral angle (AVA) of the lowest lumbar-type vertebra, the ratio of the length of the inferior endplate to that of the superior endplate (RISE) of the uppermost sacral-type vertebra and the lumbosacral intervertebral disc angle (LSIVDA), and the anatomical landmarks, including the iliac crest tangent (ICT) level, the iliolumbar ligament (ILL) origin level and psoas proximal insertion, were all evaluated to determine their ability to identify LSTV. RESULTS The values of AVA and RISE were significantly different between the LSTV group and the control group, and between subgroups of LSTV. The cutoff value for AVA was 73.0°, with an accuracy, sensitivity, and specificity of 91.1%, 77.5%, and 88.3%, and that for RISE was 0.79, with an accuracy, sensitivity, and specificity of 90.3%, 77.5%, and 94.2%, while that for LSIVDA was 14.15°, with an accuracy, sensitivity, and specificity of 75.9%, 65.7%, and 78.3%, to differentiate L5 sacralization from S1 lumbarization. For differentiating the controls from LSTV, the accuracy, sensitivity, and specificity of the ICT level and proximal psoas insertion were 78.0%, 70.2%, and 95.0%, versus 71.7%, 61.7%, and 94.0%. CONCLUSIONS Compared with the anatomical landmarks, the quantitative measurements at the lumbosacral junction, including AVA and RISE, may be more helpful for differentiating subgroups of LSTV especially if only lumbar spine imaging is available. KEY POINTS • The quantitative parameters, the anterior-edge vertebral angle (AVA) of the lowest lumbar-type vertebra and the ratio of the length of the inferior endplate to that of the superior endplate (RISE) of the uppermost sacral-type vertebra, are more helpful for distinguishing L5 sacralization from S1 lumbarization than the previously proposed anatomic landmarks. • AVA and RISE represent relevant changes in the curvature at the lumbosacral region and the shape of the transitional vertebral body, respectively. • AVA and RISE are easily assessed, with high intra- and inter-reader reliability.
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Affiliation(s)
- Suying Zhou
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Lin Du
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Xin Liu
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Qiqi Wang
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Jie Zhao
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Yuchan Lv
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Haitao Yang
- Department of Radiology, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
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Chang CJ, Chiu YP, Ji HR, Chu CH, Chiu CD. Surgical interventions for Bertolotti's syndrome: case report and review of unsatisfactory cases in the literature. BMC Surg 2022; 22:36. [PMID: 35109844 PMCID: PMC8812153 DOI: 10.1186/s12893-022-01498-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/25/2022] [Indexed: 12/03/2022] Open
Abstract
Background Bertolotti’s syndrome (BS) is characterized by the enlargement of transverse processes in caudal lumbar segments, causing chronic and persistent low back pain or sciatica. The present study aimed to describe our surgical technique for BS treatment and to review existing literature describing unsatisfactory outcomes.
Case presentation We report a patient who complained of lower back pain and soreness that intermittently radiated to his left leg for longer than 10 years. Based on an examination of his symptoms and signs, including imaging and electrical physiology assessments, in addition to the report of temporary pain relief after a local steroid injection to a diagnostic trigger site (articulation between the transverse process and the sacral ala or iliac crest), the patient was diagnosed with BS. The applied surgical techniques included minimally invasive, three-dimensional C-arm guidance, a tubing approach, and microscopic and bone cavitron ultrasonic surgical aspirator–assisted operations. After surgery, improvements were reported on the visual analog scale (from 8 to 2 points on a 10-point scale) and the straight leg raising test for the left leg (20° to 90°) within 3 days. The patient gained an ordinary life and returned to work within one week of surgery, with no observed postoperative complications. Conclusions Minimally invasive tubular microscopic decompression and disarticulation is an effective method for treating BS. However, to achieve a successful outcome, it is recommended to use physician-proficient techniques that are in line with the patient’s diagnosis.
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Affiliation(s)
- Chun-Jen Chang
- Department of Neurosurgery, China Medical University Hospital, No.2, Yu-Der Road, North Area, Taichung, 40447, Taiwan, ROC.,Spine Center, China Medical University Hospital, Taichung, Taiwan
| | - You-Pen Chiu
- Department of Neurosurgery, China Medical University Hospital, No.2, Yu-Der Road, North Area, Taichung, 40447, Taiwan, ROC.,Spine Center, China Medical University Hospital, Taichung, Taiwan.,Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan
| | - Hui-Ru Ji
- Department of Neurosurgery, China Medical University Hospital, No.2, Yu-Der Road, North Area, Taichung, 40447, Taiwan, ROC.,School of Medicine, China Medical University, Taichung, Taiwan
| | - Chang-Hung Chu
- Department of Emergency, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Di Chiu
- Department of Neurosurgery, China Medical University Hospital, No.2, Yu-Der Road, North Area, Taichung, 40447, Taiwan, ROC. .,Spine Center, China Medical University Hospital, Taichung, Taiwan. .,Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan. .,School of Medicine, China Medical University, Taichung, Taiwan.
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Dhanjani S, Altaleb M, Margalit A, Puvanesarajah V, Jain A. Pediatric Back Pain Associated with Bertolotti Syndrome: A Report of 3 Cases with Varying Treatment Strategies. JBJS Case Connect 2021; 11:01709767-202112000-00058. [PMID: 34788257 DOI: 10.2106/jbjs.cc.21.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Three pediatric patients with back pain associated with Bertolotti syndrome are presented. After failing conservative management, 1 patient underwent mega-apophysis resection, another underwent resection with decompression, and the final underwent posterior fusion. All patients had complete resolution of back pain and returned to full activity at final follow-up. CONCLUSION Lumbosacral transitional vertebrae are congenital anomalies spanning a spectrum from partial/complete L5 sacralization to partial/complete S1 lumbarization with varying clinical presentations. Identification of variable anatomy and symptoms guides surgical management. We present 3 cases with differing surgical techniques including pseudoarticulation resection, arthrodesis of the involved levels, and neuroforaminal decompression.
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Affiliation(s)
- Suraj Dhanjani
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
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8
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McGrath K, Schmidt E, Rabah N, Abubakr M, Steinmetz M. Clinical assessment and management of Bertolotti Syndrome: a review of the literature. Spine J 2021; 21:1286-1296. [PMID: 33676018 DOI: 10.1016/j.spinee.2021.02.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/10/2021] [Accepted: 02/27/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Kyle McGrath
- Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Eric Schmidt
- Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Rabah
- Case Western Reserve College of Medicine, Cleveland, OH, USA
| | | | - Michael Steinmetz
- Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Kanematsu R, Hanakita J, Takahashi T, Minami M, Tomita Y, Honda F. Extraforaminal entrapment of the fifth lumbar spinal nerve by nearthrosis in patients with lumbosacral transitional vertebrae. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2215-2221. [DOI: 10.1007/s00586-020-06460-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/10/2020] [Indexed: 11/28/2022]
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10
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Kanematsu R, Hanakita J, Takahashi T, Tomita Y, Minami M. Pulsed Radiofrequency Treatment for Bertolotti’s Syndrome Presenting With Low Back Pain: Report of Four Cases. Pain Pract 2020; 20:568-570. [DOI: 10.1111/papr.12877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ryo Kanematsu
- Department of Spinal Disorders Center Fujieda Heisei Memorial Hospital Shizuoka Japan
| | - Junya Hanakita
- Department of Spinal Disorders Center Fujieda Heisei Memorial Hospital Shizuoka Japan
| | - Toshiyuki Takahashi
- Department of Spinal Disorders Center Fujieda Heisei Memorial Hospital Shizuoka Japan
| | - Yosuke Tomita
- Department of Spinal Disorders Center Fujieda Heisei Memorial Hospital Shizuoka Japan
| | - Manabu Minami
- Department of Spinal Disorders Center Fujieda Heisei Memorial Hospital Shizuoka Japan
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Louie CE, Hong J, Bauer DF. Surgical management of Bertolotti's syndrome in two adolescents and literature review. Surg Neurol Int 2019; 10:135. [PMID: 31528470 PMCID: PMC6744759 DOI: 10.25259/sni-305-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/05/2019] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jennifer Hong
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - David F Bauer
- Geisel School of Medicine at Dartmouth, Hanover.,Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Lumbosacral Transitional Vertebra-Related Low Back Pain: Resolving the Controversy. Asian Spine J 2018; 12:407-415. [PMID: 29879766 PMCID: PMC6002172 DOI: 10.4184/asj.2018.12.3.407] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/18/2017] [Accepted: 10/30/2017] [Indexed: 12/02/2022] Open
Abstract
Study Design Case control study. Purpose The association of lumbosacral transitional vertebra (LSTV) with low back pain (LBP) is controversial, as is the role of occupational physical activity and radiological spinal abnormalities suggestive of other spinal disorders (OSDs) such as spinal degeneration and instability. This study aimed to determine if any association of LSTV with LBP exists. If so, the association of the level of physical activity and presence of OSD with LSTV-related LBP was determined. Overview of Literature The cause of LBP has been linked to proximal level disc degeneration, arthritic pseudoarticulation between LSTV and the sacral ala, facet joint degeneration, and nerve root compression due to a broadened transverse process. LSTV associated with LBP is present among individuals who are involved in high-level physical activity, including military recruits and athletes. Methods This was an unmatched study comprising 372 cases and 224 controls consecutively recruited with clinical and radiographic documentation. The relationship between LSTV and LBP was analyzed, and the effects of LSTV and OSD on this relationship were also assessed and statistically controlled. Results The presence of LSTV (p =0.039) was significantly associated with LBP, and the presence of OSD was associated with LTSV-related LBP, after statistically controlling for the level of physical activity (p =0.024). The level of physical activity was not associated with LBP. Demographic analysis revealed female predominance with an advanced age (>45 years) among those with LSTV-related LBP who have OSD. Conclusions The presence of LSTV was associated with an increased prevalence of LBP. This association was probably due to the confounding effect of OSD. The level of occupational physical activity was not associated with LSTV-related LBP. We speculate that advanced age and female sex caused the spurious association of LSTV with LBP in our study, rendering LSTV-related LBP controversial in published literature.
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Lian J, Levine N, Cho W. A review of lumbosacral transitional vertebrae and associated vertebral numeration. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:995-1004. [PMID: 29564611 DOI: 10.1007/s00586-018-5554-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/01/2018] [Accepted: 03/16/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE To review the current literature on methods of accurate numeration of vertebral segments in patients with Lumbosacral transitional vertebrae (LSTVs). LSTVs are a common congenital anomaly of the L5-S1 junction. While their clinical significance has been debated, unquestionable is the need for their identification prior to spinal surgery. We hypothesize that there are no reliable landmarks by which we can accurately number transitional vertebrae, and thus a full spinal radiograph is required. METHODS A Pubmed and EMBASE search using various combinations of specific key words including "LSTV", "lumbosacral transitional vertebrae", "count", "vertebral numbering", and "number" was performed. RESULTS The gold standard for spinal segment numeration in patients with LSTV remains whole spine imaging and counting caudally, starting from C2. If whole spine imaging is not available, the use of the iliac crest tangent sign on coronal magnetic resonance imaging (MRI) has fairly reliable sensitivity and specificity (81 and 64-88%, respectively) for accurate numeration of LSTV. The role of paraspinal anatomic markers such as the right renal artery, superior mesenteric artery, aortic bifurcation, and conus medullaris, for identification of vertebral levels is unreliable and should not be used. CONCLUSIONS A sagittal whole spine view should be added as a scout view when patients obtain lumbar MRI to standardize the vertebral numbering technique. To date, there has been no other method for accurate numeration of a transitional vertebral segment, other than counting caudally from C2. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Jayson Lian
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Nicole Levine
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Woojin Cho
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA. .,Department of Orthopaedic Surgery, Montefiore Medical Center, 3400 Bainbridge Ave, 6th Fl., Bronx, NY, 10467, USA.
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14
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Holm EK, Bünger C, Foldager CB. Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention. SICOT J 2017; 3:71. [PMID: 29243586 PMCID: PMC5731823 DOI: 10.1051/sicotj/2017055] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 10/22/2017] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Emil Kongsted Holm
- Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Cody Bünger
- Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
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Voin V, Davis M, Cox MA, Loukas M, Chapman J, Oskouian RJ, Tubbs RS. A Previously Unreported Variant of a Thoracic Vertebra. Cureus 2017; 9:e1522. [PMID: 32175213 PMCID: PMC7053791 DOI: 10.7759/cureus.1522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pathology associated with anomalous transverse processes is uncommon and usually involves elongated C7 transverse processes in the so-called cervical rib syndrome. We report a single adult thoracic vertebra found to have duplicated transverse processes on the left side. We believe this to be the first report of a duplicated transverse process in man. The clinician and anatomist who view osteological material or imaging should consider this an extremely rare anatomical variation of the thoracic spine.
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Affiliation(s)
- Vlad Voin
- Anatomical Research, Seattle Science Foundation, Seattle, USA
| | - Michele Davis
- Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Marcus A Cox
- Internal Medicine, Saint Michael's Medical Center, Newark, USA
| | - Marios Loukas
- Medical Education and Simulation, St. George's University School of Medicine, St. George, GRD
| | - Jens Chapman
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - R Shane Tubbs
- Departments of Neurosurgery and Structural & Cellular Biology, Tulane University & Ochsner Clinic Neurosurgery Program, Tulane University School of Medicine; St. George's University, Grenada, New Orleans, USA
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Jancuska JM, Spivak JM, Bendo JA. A Review of Symptomatic Lumbosacral Transitional Vertebrae: Bertolotti's Syndrome. Int J Spine Surg 2015; 9:42. [PMID: 26484005 DOI: 10.14444/2042] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jeffrey M Spivak
- Department of Orthopaedic Surgery and Hospital for Joint Diseases, New York University School of Medicine, New York, NY, USA
| | - John A Bendo
- Department of Orthopaedic Surgery and Hospital for Joint Diseases, New York University School of Medicine, New York, NY, USA
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Minimally Invasive Microendoscopic Resection of the Transverse Process for Treatment of Low Back Pain with Bertolotti's Syndrome. Case Rep Orthop 2014; 2014:613971. [PMID: 25045566 PMCID: PMC4089204 DOI: 10.1155/2014/613971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 05/30/2014] [Indexed: 11/17/2022] Open
Abstract
Bertolotti's syndrome is characterized by anomalous enlargement of the transverse process of the most caudal lumbar segment, causing chronic and persistent low back pain or sciatica. We describe the case of a 45-year-old woman who presented with left sciatic pain and low back pain due to a recurrent lumbar disc herniation at L4-5 with Bertolotti's syndrome. Selective L5 nerve root block and local injection of lidocaine into the articulation between the transverse process and sacral ala temporarily relieved the left sciatic pain and low back pain, respectively. To confirm the effect of local injection on low back pain, we gave a second local injection, which once again relieved the low back pain. Microendoscopic resection of the pseudoarticulation region and discectomy successfully relieved all symptoms. This report illustrates the effectiveness of minimally invasive resection of the transverse process for the treatment of low back pain with Bertolotti's syndrome.
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Li Y, Lubelski D, Abdullah KG, Mroz TE, Steinmetz MP. Minimally invasive tubular resection of the anomalous transverse process in patients with Bertolotti's syndrome: presented at the 2013 Joint Spine Section Meeting: clinical article. J Neurosurg Spine 2013; 20:283-90. [PMID: 24358999 DOI: 10.3171/2013.11.spine13132] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Bertolotti's syndrome consists of low-back pain caused by lumbosacral transitional vertebrae (LSTVs) and LSTV-associated biomechanical spinal changes. There is a lack of consensus regarding the cause, clinical significance, and treatment of this condition. The authors aim to characterize the clinical presentation of patients with Bertolotti's syndrome and describe a minimally invasive surgical treatment for this condition. METHODS Seven patients who underwent minimally invasive paramedian tubular-based resection of the LSTV for Bertolotti's syndrome were identified over the course of 5 years. Diagnosis was based on patient history of chronic low-back pain, radiographic findings of LSTV, and pain relief on trigger-site injection with steroid and/or anesthetics. Electronic medical records were reviewed to identify demographics, operative data, and outcomes. RESULTS All patients presented with severe, chronic low-back pain lasting an average of 8 years that was resistant to nonoperative care. At presentation, 6 (86%) of 7 patients experienced radicular pain that was ipsilateral to the LSTV. Radiographic evidence showed a presence of LSTV in all patients on the left (43%), right (29%), or bilaterally (29%). Degenerative disc changes at the L4-5 level immediately above the anomalous LSTV were observed in 6 of 7 (86%) patients; these changes were not seen at the level below the LSTV. Following pseudo-joint injection, all patients experienced temporary relief of their symptoms. All patients underwent a minimally invasive, paramedian tubular-based approach for resection of the LSTV. Three (43%) of 7 patients reported complete resolution of low-back pain, 2 (29%) of 7 patients had reduced low-back pain, and 2 patients (29%) experienced initial relief but return of low-back pain at 1 and 4 years postoperatively. Three (50%) of the 6 patients with radicular pain had complete relief of this symptom. The median follow-up time was 12 months. No intraoperative complication was reported. Two (29%) of 7 patients developed postoperative complications including one with a wound hematoma and another with new L-5 radiculopathy that resolved 2 years after surgery. CONCLUSIONS Diagnosis of Bertolotti's syndrome should be considered with adequate patient history, imaging studies, and diagnostic injections. A minimally invasive surgical approach for resection of the LSTV is presented here for symptomatic treatment of select patients with Bertolotti's syndrome whose conditions are refractory to conventional therapy and who have pain that can be attributed to the LSTV. Several short-term complications were noted with this procedure, but overall this procedure is effective for treating symptoms related to Bertolotti's syndrome.
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Affiliation(s)
- Yumeng Li
- Cleveland Clinic Lerner College of Medicine
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