Surgical Pitfalls in Bertolotti’s syndrome management: A case report

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.

Surgical Options for Bertolotti Syndrome

“…High-speed drills are then used to remove the pseudoarticulation. A tubular retractor may be used to minimize tissue damage [40][41][42][43][44], although its use may limit surgical visibility, making the surgery more challenging and possibly leading to inadequate decompression [41]. Care should be taken when selecting the incision site as the iliac crest may obstruct the surgical trajectory, with some authors reporting resection of part of the left posterior iliac crest to access the pseudo articulation [43].…”

“…Thus, confirming the most ventrolateral margin of the pseudoarticulation is recommended before beginning resection with high-speed drilling [45]. Navigation for stereotactic localization of the pseudojoint has been reported as a viable complementary method, or repeated verification with a C-arm is recommended if navigation is unavailable [42,44,46].…”