Endoscopic Resection of Pseudoarticulation as a Treatment for Bertolotti's Syndrome

A Case of Endoscopic Partial Transverse Process and Sacral Alar Resection for Bertolotti's Syndrome and Continued Basketball Playing Two Years After Surgery

Bertolotti's syndrome is a syndrome in which the transverse process of the most caudal lumbar vertebra becomes enlarged and articulates with the sacral alar, causing back pain. Here, we report a case of an adolescent basketball player with Bertolotti's syndrome who was unable to resume playing despite conservative treatment and underwent an endoscopic partial transverse process and sacral alar resection. A 16-year-old male basketball player presented to our hospital with a chief complaint of left low back pain during exercise and prolonged sitting for over one month. No obvious neurological abnormality was found. X-rays and CT showed lumbosacral transitional vertebrae, and the left transverse process of the sixth lumbar vertebra articulated with the sacrum and iliac, which was the Castellvi classification IIA. A block injection into the articulated surface produced improvement in pain, but the effect was not sustained. Since the patient was refractory to conservative treatments, such as medication and physiotherapy, surgery was performed. During surgery, the articulated transverse process and sacral alar were partially resected endoscopically. Because of the proximity of the resection site to the S1 nerve root, intraoperative electromyography (free-run EMG) was used to detect nerve root irritation symptoms in real time. The patient had no postoperative complications, his low back pain improved immediately, and he returned to play basketball three months after surgery. One year after surgery, the bone resection site showed gradual bone regeneration, and two years after surgery, the transverse process and sacral alar showed a bony bridge. The transverse process was enlarged compared to immediately after surgery but remained smaller than that before surgery. The patient continued to play basketball for two years after surgery without back pain, and no symptoms due to bone regeneration appeared. In the present case, a partial resection of the transverse process and sacral alar was performed with good results. Because the bone resection site was close to the S1 nerve root, the use of an endoscope and intraoperative free-run EMG allowed for a safer procedure during the bone resection. In addition, the patient did not present with symptoms that would affect his basketball performance, although the bone regenerated and bridging occurred between the transverse process and sacral alar over a two-year postoperative course.

[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.