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Bertolottis Syndrome

From WikiSM

Other Names

  • Bertolottis Syndrome
  • Bertolotti's Syndrome
  • Lumbosacral transitional vertebra (LSTV)

Background

  • This page covers Bertolottis Syndrome, a cause of chronic back pain characterized by transitional lumbosacral vertebra

History

  • Needs to be updated

Epidemiology: Incidence

  • Controversial and widely debated
  • It is estimated that 4% to 36% of people have LSTV[1]
  • Using radiographic findings, Ucar estimated 18.7% of the general population has LSTV[2]
  • Many are asymptomatic, leading to debate about whether LSTV is a true cause of back pain

Epidemiology: Prevalence

  • Elster estimated 7% of patients had LSTV and were diagnosed with Bertolotti's Syndrome[3]

Demographics

  • More men have LSTV than women
  • Significantly more man than women have sacralization of their LSTV[2]
  • Average is 30s to 40s

Introduction

Illustration of a posterior skeletal view of the spine and pelvis showing a Left type IIa LSTV with the aberrant portion of the L5 transverse process (TP) highlighted (red)[4]
AP pelvis showing lumbosacral transitional vertebra (LSTV)
Ferguson radiograph in a 35-year-old man. AP radiograph angled cranially at 30° allows better characterization of the transverse processes of L5. LSTVs have been classically described as best imaged by using Ferguson radiographs.[5]

General

  • A cause of chronic back pain characterized by congenital lumbosacral transitional vertebra (LSTV) defect
  • Clinical presentation varies, most commonly associated with pain at the sacroiliac, groin and hip
  • Diagnosis is made through clinical presentation and imaging, however it is challenging due to the uncommon nature and variable presentation
  • Initial management is conservative however surgical removal is indicated in refractory cases

Pathophysiology

  • Congenital lumbosacral transitional vertebra (LSTV)
    • Enlargement of the caudal lumbar vertebrae at the transverse process
    • Leads to the fusion or articulation of the transverse process with the sacrum or the ilium
  • Presence of an LSTV causes changes in the biomechanics of the spine[6]
    • Has been shown to cause hypomobility at the L5/S1 level
    • Hypermobility at the superjacent and superior lumbar levels
  • Lower back pain etiology hypothesized to be from[7]
    • Arthritic changes, disc herniation, disc degeneration, or spinal canal and foraminal stenosis
    • These changes are seen are higher incidence in those with LSTV than those without[8]

Associated Conditions

Lumbosacral Transitional Vertebrae

  • Relatively common variant seen in approximately 25% of the population[11]
  • Must be recognized by radiologist/ spine surgeon to avoid incorrect/ erroneous procedures/ operations
  • Can be thought of as "lumbarized S1" or "sacralized L5" segment
  • The degree of transition can vary from partial to complete fusion

Risk Factors

Demographic

  • Male
  • Age 30s to 40s

Differential Diagnosis

Differential Diagnosis Back Pain

Clinical Features

History

  • Typically presents as back pain during the 3rd or 4th decade of life
  • Pain is not uniform and can characterized as coming from the sacroiliac, hip and groin
  • Radicular or neuropathic pain can occur due to the transitional vertebra causing compression
  • Patients rate the pain as 5/10 on average[12]

Physical Exam

  • Patients may have pain and tenderness at the sacroiliac, hip and groin
  • The pain can be asymmetric or asymmetric

Special Tests

  • Needs to be updated

Evaluation

Neo-articulation between a left mega apophysis transverse and the sacral bone.[13]

Radiographs

  • Lumbosacral Radiographs
  • Findings[14]
    • Unilateral or bilateral enlargement of the transverse processes
    • Potential articulation with the sacrum or ilium

MRI

  • Needs to be updated

CT

  • Needs to be updated

Diagnostic Injection

  • A diagnostic injection of the Sacroiliac Joint can be performed
  • An 80% decrease in pain following this injection is considered diagnostic[9]

Classification

Jenkins classification schematic

Castellvi classification[15]

  • Type I
    • Dysplastic transverse process that is at least 19 cm wide
    • 42%
  • Type II
    • Transverse process growth leading to an incomplete sacralization or lumbarization of the transverse process
    • 38%
  • Type III
    • Complete transverse process sacralization/lumbarization
    • 8%
  • Type IV
    • Mixed complete sacralization and incomplete sacralization
    • 5%

Management

Proposed algorithm for Bertolotti Syndrome[16]

Nonoperative

  • Indications
    • First line therapy in virtually all cases
  • Activity modification
  • Physical Therapy
    • Case report utilizing lumbosacral manipulation, exercises resulting in improvements in pain and mobility over two weeks[17]
  • Manual Therapy
    • Two patients noted substantial but incomplete improvement[18]
  • Pilates
    • Shown to help in non specific chronic low back pain, not specific to Bertolottis[19]

Procedures

  • Corticosteroid Injection of the articulation of the ilium and transverse process
    • Case reports have shown reduction in pain at 1 month follow up[20]
  • Transforaminal or interlaminar epidural steroid injections
    • May provide some benefit when presentations are consistent with irritation of the nerve root[21]
  • Glemrec et al: comparison of lidocaine + saline to lidocaine + corticosteroid[22]
    • No differences between groups
    • However, all patients had relief at 4 weeks and 12 weeks
  • Marks et al injected corticosteroids in 10 patients[23]
    • All had relief within 30 minutes of injection
    • Duration of relief lasted from 1 day to 27 months
  • Radiofrequency Ablation
    • One patient had bipolar RFA with complete pain relief until the last 16 month follow up[24]

Operative

  • Indications
    • Failure of conservative management
  • Technique
    • Processesctomy (of the lumbosacral transitional vertebra)
    • Surgical resection
    • Spinal Fusion
    • Decompression of the stenosed foramen

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Holm et al compared steroid management with surgery in 11 patients[25]
    • Limited comparison due to heterogenous studies
    • Eventually all 11 required surgical management
    • 9/11 had improvement or pain free following surgery
    • Hypothesize that response to anesthetic injection may correlate to successful surgery
  • Santavirta looked patients who received anesthetic injections in the transitional articulation[26]
    • 6 had local with temporary pain relief
    • However only 4 of these 6 had relief with surgical intervention
  • Surgical resection of the LSTV
    • Jonsson et al: 7/11 patients were completely pain free, 2 more had improved pain[27]
    • Retrospective study showed 50% improvement in preoperative pain[28]
  • Surgical fusion
    • Patients with previous disc degeneration of LSTV disc but not the disc above did better than transverse process resection

Complications

See Also

Internal

External

References

  1. ↑ Bron, Johannes L., Barend J. van Royen, and P. I. J. M. Wuisman. "The clinical significance of lumbosacral transitional anomalies." Acta Orthopaedica Belgica 73.6 (2007): 687.
  2. ↑ 2.0 2.1 Uçar, Demet, et al. "Retrospective cohort study of the prevalence of lumbosacral transitional vertebra in a wide and well‐represented population." Arthritis 2013.1 (2013): 461425.
  3. ↑ Elster, ALLEN D. "Bertolotti's syndrome revisited: transitional vertebrae of the lumbar spine." Spine 14.12 (1989): 1373-1377.
  4. ↑ McGrath, Kyle A., et al. "Quality-of-life and postoperative satisfaction following pseudoarthrectomy in patients with Bertolotti syndrome." The Spine Journal 22.8 (2022): 1292-1300.
  5. ↑ Konin, G. P., and DM20203111 Walz. "Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance." American Journal of Neuroradiology 31.10 (2010): 1778-1786.
  6. ↑ Golubovsky, Joshua L., et al. "Development of a novel in vitro cadaveric model for analysis of biomechanics and surgical treatment of Bertolotti syndrome." The Spine Journal 20.4 (2020): 638-656.
  7. ↑ Paik, Nam Chull, Chun Soo Lim, and Ho Suk Jang. "Numeric and morphological verification of lumbosacral segments in 8280 consecutive patients." Spine 38.10 (2013): E573-E578.
  8. ↑ Vergauwen, S., et al. "Distribution and incidence of degenerative spine changes in patients with a lumbo-sacral transitional vertebra." European Spine Journal 6 (1997): 168-172.
  9. ↑ 9.0 9.1 Jain, Anuj, et al. "Bertolotti syndrome: a diagnostic and management dilemma for pain physicians." The Korean journal of pain 26.4 (2013): 368.
  10. ↑ Otani, K., S. Konno, and S. Kikuchi. "Lumbosacral transitional vertebrae and nerve-root symptoms." The Journal of Bone & Joint Surgery British Volume 83.8 (2001): 1137-1140.
  11. ↑ Carrino JA, Campbell PD, Lin DC et-al. Effect of Spinal Segment Variants on Numbering Vertebral Levels at Lumbar MR Imaging. Radiology. 2011;259 (1): 196-202. doi:10.1148/radiol.11081511
  12. ↑ Peterson, Cynthia K., et al. "A cross-sectional study comparing pain and disability levels in patients with low back pain with and without transitional lumbosacral vertebrae." Journal of manipulative and physiological therapeutics 28.8 (2005): 570-574.
  13. ↑ Case courtesy of David Cuete, Radiopaedia.org, rID: 24864
  14. ↑ Manmohan, S., et al. "Bertolotti’s syndrome: A commonly missed cause of back pain in young patients." Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia 10.2 (2015): 55.
  15. ↑ Castellvi, ANTONIO E., LOUIS A. Goldstein, and DONALD PK Chan. "Lumbosacral transitional vertebrae and their relationship with lumbar extradural defects." Spine 9.5 (1984): 493-495.
  16. ↑ Jancuska, Jeffrey M., Jeffrey M. Spivak, and John A. Bendo. “A review of symptomatic lumbosacral transitional vertebrae: Bertolotti’s syndrome.” International journal of spine surgery 9 (2015).
  17. ↑ Brenner, Alexander Karl. "Use of lumbosacral region manipulation and therapeutic exercises for a patient with a lumbosacral transitional vertebra and low back pain." Journal of Orthopaedic & Sports Physical Therapy 35.6 (2005): 368-376.
  18. ↑ Muir, Jeffrey M. "Partial lumbosacral transitional vertebrae: 2 cases of unilateral sacralization." Journal of chiropractic medicine 11.2 (2012): 77-83.
  19. ↑ Patti, Antonino, et al. "Effects of Pilates exercise programs in people with chronic low back pain: a systematic review." Medicine 94.4 (2015): e383.
  20. ↑ Mitra, Raj, Mark Carlisle, and R. Vallejo. "Images in pain practice. Bertolotti's syndrome: a case report." Pain Practice 9.2 (2009).
  21. ↑ Zhang, Rui, and Jianguo Cheng. "Interventional Management of Chronic Low Back Pain Associated with Bertolotti's Syndrome: Report of Case Series." Ann Clin Case Rep. 2017; 2 1348 (2017).
  22. ↑ Glémarec, Joëlle, et al. "Efficacy of local glucocorticoid after local anesthetic in low back pain with lumbosacral transitional vertebra: a randomized placebo-controlled double-blind trial." Joint Bone Spine 85.3 (2018): 359-363.
  23. ↑ Marks, Robert C., and Terry Thulbourne. "Infiltration of anomalous lumbosacral articulations: Steroid and anesthetic injections in 10 back-pain patients." Acta Orthopaedica Scandinavica 62.2 (1991): 139-141.
  24. ↑ Burnham, Robert. "Radiofrequency sensory ablation as a treatment for symptomatic unilateral lumbosacral junction pseudarticulation (Bertolotti's syndrome): a case report." Pain Medicine 11.6 (2010): 853-855.
  25. ↑ Holm, Emil Kongsted, Cody Bünger, and Casper Bindzus Foldager. "Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention." Sicot-j 3 (2017).
  26. ↑ Santavirta, S., et al. "Surgical treatment of Bertolotti's syndrome: follow-up of 16 patients." Archives of orthopaedic and trauma surgery 112 (1993): 82-87.
  27. ↑ Jönsson, B. O., B. J. Ö. R. N. Strömqvist, and N. I. E. L. S. Egund. "Anomalous lumbosacral articulations and low-back pain: evaluation and treatment." Spine 14.8 (1989): 831-834.
  28. ↑ il Ju, Chang, et al. "Decompressive L5 transverse processectomy for Bertolotti’s syndrome: a preliminary study." Pain Physician 20.6 (2017): E923.
Created by:
John Kiel on 15 September 2024 20:30:00
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Last edited:
1 May 2025 15:29:02
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