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

Abstract

-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.Key WorDs: low back pain, lumbosacral region, spine.dor lombar associada à vértebra de transição lombossacra: dificuldades no diagnóstico e manejo da síndrome de bertolotti resumo -Objetivo: A síndrome de Bertolotti é uma desordem congênita da coluna vertebral caracterizada pela ocorrência de uma mega-apófise transversa lombar em uma vértebra de aspecto transicional, que geralmente se articula com o sacro ou com o osso ilíaco. Tal síndrome tem sido considerada possível causa de dor lombar. Método: Análise dos casos de síndrome de Bertolotti que apresentavam dor lombar sem melhora com tratamento conservador e revisão dos artigos publicados. Resultados: Foram revisados cinco pacientes que não apresentaram melhora com o tratamento clínico, sendo que dois foram submetidos à ressecção cirúrgica da mega-apófise transversa. Considerando a experiência adquirida com estes casos, os autores propõem um algoritmo para diagnóstico e tratamento da síndrome de Bertolotti. Conclusão: Ainda não há consenso sobre qual é a terapia mais apropriada para a síndrome de Bertolotti. em pacientes em que a mega-apófise parece ser a origem da lombalgia, a ressecção cirúrgica parece ser um procedimento seguro e efetivo.PAlAvrAs-ChAve: dor lombar, região lombossacral, coluna vertebral.

Lumbosacral Transitional Vertebrae: Classification, Imaging Findings, and Clinical Relevance

“…Jonsson et al 38 reported relief of pain in 9 of 11 patients following surgical resection of a unilateral LSTV pseudoarticulation. Ugokwe et al 54 and Almeida et al 55 similarly describe successful treatment after surgical resection. In a case series of 8 patients who underwent surgical resection of the unilateral anomalous articulation and 8 patients who underwent posterolateral fusion of the LSTV, Santavirta et al 44 reported improvement in pain in 10 of 16 patients at 9-year follow-up without a difference between the fusion or resection groups.…”

“…44 Direct local anesthetic and steroid injection or surgical resection of the anomalous or contralateral facet joint has produced successful relief of pain and can yield valuable diagnostic information. 30,38,44,[53][54][55] Operative treatment is suggested in select patients. For example, resection of the transverse process may be beneficial for those who demonstrate pain truly emanating from a transitional joint and fail conservative treatment.…”

“…In a case series of 8 patients who underwent surgical resection of the unilateral anomalous articulation and 8 patients who underwent posterolateral fusion of the LSTV, Santavirta et al 44 reported improvement in pain in 10 of 16 patients at 9-year follow-up without a difference between the fusion or resection groups. Finally, radio-frequency denervation is another possible treatment option and provided temporary relief of pain due to an anomalous articulation in a case report by Almeida et al 55 …”

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

“…64 As with other causes of low back pain, the initial treatment of symptomatic LSTV is clinical, including a combination of NSAIDS and rehabilitative physical therapy. 65 There is a lack of consensus, however, regarding the treatment of this condition, and the number of studies and case reports in the literature reporting on the diagnosis and outcomes of patients with symptomatic LSTV is sparse. 64,66 The literature includes 4 reports of either chiropractic management or physical therapy to treat symptomatic LSTV.…”

“…64 Almeida et al advocated performing these blocks with a minimal amount of anesthetic delivered precisely to the point of interest. 65 Mitra et al reported an improved Oswestry score from 33 to 26 in a 64-year-old female with a Type IIb LSTV 1 month following a local anesthetic and corticosteroid injection administered to the transverse process-ilium articulation. 74 In a retrospective study of 12 patients with unilateral lumbo-sacral anomalous articulation with same side low back or buttock pain, 9 patients reported a 50% decrease in pain after 1 month.…”