A Case of Severe Low Back Pain Associated with Richard Disease (Lumbosacral Transitional Vertebra)

Abstract

The imaging findings in some cases of low back pain are difficult to describe and the pathophysiology is not clear because subjective findings are usually difficult to document. This report concerns a rare case about the lumbosacral joint causing persistent severe back pain which in itself does not usually have any pathological meaning. We describe the diagnosis, treatment, and outcome of a patient suffering from low back pain with lumbosacral transitional vertebra. The radiological examination showed the congenitally malformed transverse processes of the 5th lumbar vertebra to create a facet joint-like shape at the sacral ala region on both sides. Surgery resulted in immediate disappearance of the low back pain. When the lumbosacral junction shows some instability without fusion, the joint-like region could be the cause of low back pain. The lumbosacral transitional vertebra may be associated with low back pain. Electric denervation of the space between the transverse process of 5th lumbar vertebra and sacral ala is minimally invasive and effective for pain eradication.

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

“…The authors advocated electric denervation as a minimally invasive and potentially effective method for pain eradication. 73 Injections of steroids or local anesthetics into the transverse process pseudoarticulation site can be both diagnostic and provide immediate, albeit temporary, pain relief. 64 Almeida et al advocated performing these blocks with a minimal amount of anesthetic delivered precisely to the point of interest.…”

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

“…These blocks should be performed with a minimal amount of anesthetic delivered precisely to the point of interest. In our experience, conventional radiofrequency neurolysis proved to be a safe, non-invasive procedure for those cases that had improved with anesthetic blocks, providing significant pain relief and aiding future physical rehabilitation programs 6 . Nevertheless, the relief may be temporary, whereby major studies concerning about the efficacy of radiofrequency denervation are required.…”

“…of them, we selected only studies written in english regarding diagnosis and treatment of Bertolotti's syndrome, which resulted in 18 articles revised 1,2,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] .…”

“…Although Bertolotti's syndrome is a congenital abnormality, it is often clinically recognized only after the second decade of life 5 . Nevertheless, there is evidence that a typical transverse megaapophysis may be the cause of low back pain in the region of the neo-articulation 6 . Due to the multifactorial etiology of low back pain in patients with Bertolotti' s syndrome, there are several therapeutic options, whereas the most appropriate treatment for each case, as well as the specific role of surgical resection of the transverse mega-apophysis in the therapeutic armamentarium, still remain a matter of controversy.…”

The clinical assessment of transitional vertebrae and back pain

“…The most well known condition, Bertolotti syndrome, is pain that arises from the anomalous articulation between the LTV and the sacrum. There may be increased uptake on SPECT imaging in this area (Connolly, 2003) and there are several case reports of pain relief after injection, sclerosis or removal of the anomalous joint (Connolly, 2003;Brault, 2001;Endo, 2004, Jonsson et al, 1989, Avimadje et al, 1999. Second, the central spinal canal and nerve root canal may be narrower in the area of a LTV and this change may increase the risk of developing back pain (Santiago et al, 2001).…”