Bertolotti’s Syndrome: An Underdiagnosed Cause of Lower Back Pain; A Case Report of Two Cases and Current Management Options
Asian Journal of Orthopaedic Research,
Page 1-7
Abstract
Bertolotti’s syndrome is a disorder of the spine characterized by chronic lower back pain associated with lumbosacral transitional vertebra (LSTV) in which there is an abnormal enlargement of the transverse process of the fifth lumbar vertebra. It may be a source of chronic pain in 10% of lower back pain patients younger than 30 years. In Bertolotti’s syndrome, the fifth lumbar vertebra transverse process may be enlarged either unilaterally or bilaterally and may articulate or fuse with the sacrum or ilium. It is an anatomical variant of sacralization of fifth lumbar vertebra. This causes alterations in the biomechanical characteristics of the lumbar spine resulting from asymmetrical motion between the sacrum and LSTV. It is often a factor that is not taken into consideration in the workup and management of lower back pain. The syndrome affects 4% to 8% of the population. It can cause pain due to involvement of various structures: lumbosacral neo-articulation, contralateral facet arthrosis, sciatica, discogenic, or sacroiliac pain. Physical examination usually shows normal findings. Bertolotti’s syndrome is oftentimes underdiagnosed and should be suspected as a differential diagnosis for lower back pain. Therefore, this case report highlights two cases with Bertolotti’s syndrome and explains its epidemiology, pathophysiology and management which is an important topic of general knowledge to all doctors.
Keywords:
- Bertolotti syndrome
- lumbar transitional vertebra
- lower back pain
- sacralization.
How to Cite
Lee Siang, L., Soon Teck, S., & A/L C. Nadarajah, S. (2019). Bertolotti’s Syndrome: An Underdiagnosed Cause of Lower Back Pain; A Case Report of Two Cases and Current Management Options. Asian Journal of Orthopaedic Research, 2(4), 1-7. Retrieved from https://journalajorr.com/index.php/AJORR/article/view/30108
References
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Bertolotti M. Contributo alla conoscenza dei vizi differenzazione regionale del rachide con speciale riguardo all assimilazione sacrale della V. lombare. Radiol Med. 1917;4:113-144.
Quinlan JF, Duke D, Eustace S. Bertolotti’s syndrome. A cause of back pain in young people. J Bone Joint Surg. 2006;88:1183-1186.
Li Y, Lubelski D, Abdullah KG, Mroz TE, Steinmetz MP. Minimally invasive tubular resection of the anomalous transverse process in patients with Bertolotti’s syndrome. Journal of Neurosurgery: Spine SPI. 2014;20(3):283-290.
Brault JS, Smith J, Currier BL. Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain. Spine (Phila Pa 1976). 2001;26:226–29.
Burnham R. Radiofrequency sensory ablation as a treatment for symptomatic unilateral lumbosacral junction pseudarticulation (Bertolotti's syndrome): A case report. Pain Med. 2010; 11(6):853–855.
Elster AD. Bertolotti’s syndrome revisited: transitional vertebrae of the lumbar spine. Spine. 1989;14:1373–7.
O’Driscoll CM, Irwin A, Saifuddin A. Variations in morphol¬ogy of the lumbosacral junction on sagittal MRI: Correlation with plain radiography. Skeletal Radiol. 1996;25:225–230.
Otani K, Konno S, Kikuchi S. Lumbosacral transitional ver¬tebrae and nerve-root symptoms. J Bone Joint Surg Br. 2001;83: 1137–1140.
Seçer M, Muradov JM, Dalgiç A. Evaluation of congenital lumbosacral malformations and neurological findings in pa¬tients with low back pain. Turk Neurosurg. 2009;19:145–148.
Tilley P. Is sacralization a significant factor in lumbar pain? J Am Osteopath Assoc. 1970;70:238–241.
Ju CI, Kim SW, Kim JG, Lee SM, Shin H, Lee HY, et al. Decompressive L5 transverse processectomy for Bertolotti’s syndrome: A preliminary study. Pain Physician. 2017;20:E923-E932.
Ravikanth R, Majumdar P. Bertolotti’s syndrome in low‑backache population: Classification and imaging findings. Tzu Chi Med J. 2019;31(2):90-5.
Delport EG, Cucuzzella TR, Kim N, Marley J, Pruitt C, Delport AG, et al. Lumbosacral transitional vertebrae: Incidence in a consecutive patient series. Pain Physician. 2006;9:53‑6.
Anderson GBJ. The epidemiology of spinal disorders, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. Philadelphia, Lippincott-Raven. 1997;4:93–141.
Grøn S, Jensen RK, Jensen TS, Kongsted A. Back beliefs in patients with low back pain: A primary care cohort study. BMC Musculoskeletal Disorders. 2019;20(1):578.
Castellvi AE, Goldstein LA, Chan DPK. Lumbosacral transitional vertebra and their relationship with lumbar extradural defects. Spine. 1983;9:493-495.
Jancuska JM, Spivak JM, Bendo JA. A review of symptomatic lumbosacral transitional vertebrae: bertolotti’s syndrome. Int J Spine Surg. 201;9:42.
Neelakantan S, Anandarajan R, Shyam K, Philip B. Multimodality imaging in Bertolotti’s syndrome: An important cause of low back pain in young adults. BMJ Case Rep. pii: Bcr2016217121; 2016.
Kapetanakis S, Chaniotakis C, Paraskevopoulos C, Pavlidis P. An Unusual Case Report of Bertolotti’s Syndrome: Extraforaminal Stenosis and L5 Unilateral Root Compression (Castellvi Type III an LSTV). J Orthop Case Rep. 2017;7(3):9-12.
Mahato NK. Morphometric analysis and identification of characteristic features in sacra bearing accessory articulations with L5 vertebra. Spine J. 2010;10(7):616-621.
Nardo L, Alizai H, Virayavanich W, Liu F, Hernandez A, Lynch JA, et al. Lumbosacral transitional vertebrae: association with low back pain. Radiology. 201;265(2):497-503.
Almeida DB, Mattei TA, Soria MG, et al. Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti’s syndrome. Arq Neuropsiquiatr. 2009;67:268–72.
Apazidis A, Ricart PA, Diefenbach CM, Spivak JM. The prevalence of transitional vertebrae in the lumbar spine. The Spine Journal: Official Journal of the North American Spine Society. 2011; 11(9):858-862.
Aihara T, Takahashi K, Ogasawara A, Itadera E, Ono Y, Moriya H. Intervertebral disc degeneration associated with lumbosacral transitional vertebra: A clinical and anatomical study. J Bone Joint Surg Br. 2005;87:687–691.
Luoma K, Vehmas T, Raininko R, Luukkonen R, Riihimaki H: Lumbosacral transitional vertebra: Relation to disc degeneration and low back pain. Spine. 2004;29:200–205.
Brown MF, Rockall AG, Hallam P, Hall-Craggs MA, Edgar MA. Transitional lumbosacral vertebra: Incidence of disc degeneration above and below. J Bone Joint Surg Br. 2000;82-B (Suppl II):180.
Cuenca C, et al. Bertolotti’s syndrome in children: From low-back pain to surgery. A Case Report. Neurochirurgie; 2009.
Marks RC, Thulbourne T. Infiltration of anomalous lumbosacral articulations. Steroid and anesthetic injections in 10 back-pain patients,” Acta Orthop Scandi. 1991;62(2):139–141.
Mitra R, Carlisle M. Bertolotti’s syndrome: A case report. Pain Practice. 2009;9(2): 152–154.
Konin GP, Walz DM. Lumbosacral transitional vertebrae: Classification, imaging findings and clinical relevance. Am J Neuroradiol. 2010;31(10):1778-1786.
Marks RC, Thulbourne T. Infiltration of anomalous lumbosacral articulations: steroid and anesthetic injections in 10 back pain patients. Acta Orthop Scand. 1991; 62:139–41.
Ugokwe KT, Chen TL, Klineberg E. Minimally invasive surgical treatment of Bertolotti’s syndrome: case report. Neurosurgery. 2008;62:454–55.
Zhang R, Cheng J. Interventional management of chronic low back pain associated with Bertolotti’s syndrome: Report of case series. Ann Clin Case Rep. 2017;2:1348.
Jonsson B, Stromqvist B, Egund N. Anomalous lumbosacral articulations and low back pain: evaluation and treatment. Spine (Phila Pa 1976). 1989;14:831–34.
Yousif S, Wood M. Minimally invasive resection of lumbosacral pseudojoint resulting in complete resolution of a lower back pain – A case report and review of Bertolotti syndrome. J Clin Neurosci; 2018.
Bertolotti M. Contributo alla conoscenza dei vizi differenzazione regionale del rachide con speciale riguardo all assimilazione sacrale della V. lombare. Radiol Med. 1917;4:113-144.
Quinlan JF, Duke D, Eustace S. Bertolotti’s syndrome. A cause of back pain in young people. J Bone Joint Surg. 2006;88:1183-1186.
Li Y, Lubelski D, Abdullah KG, Mroz TE, Steinmetz MP. Minimally invasive tubular resection of the anomalous transverse process in patients with Bertolotti’s syndrome. Journal of Neurosurgery: Spine SPI. 2014;20(3):283-290.
Brault JS, Smith J, Currier BL. Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain. Spine (Phila Pa 1976). 2001;26:226–29.
Burnham R. Radiofrequency sensory ablation as a treatment for symptomatic unilateral lumbosacral junction pseudarticulation (Bertolotti's syndrome): A case report. Pain Med. 2010; 11(6):853–855.
Elster AD. Bertolotti’s syndrome revisited: transitional vertebrae of the lumbar spine. Spine. 1989;14:1373–7.
O’Driscoll CM, Irwin A, Saifuddin A. Variations in morphol¬ogy of the lumbosacral junction on sagittal MRI: Correlation with plain radiography. Skeletal Radiol. 1996;25:225–230.
Otani K, Konno S, Kikuchi S. Lumbosacral transitional ver¬tebrae and nerve-root symptoms. J Bone Joint Surg Br. 2001;83: 1137–1140.
Seçer M, Muradov JM, Dalgiç A. Evaluation of congenital lumbosacral malformations and neurological findings in pa¬tients with low back pain. Turk Neurosurg. 2009;19:145–148.
Tilley P. Is sacralization a significant factor in lumbar pain? J Am Osteopath Assoc. 1970;70:238–241.
Ju CI, Kim SW, Kim JG, Lee SM, Shin H, Lee HY, et al. Decompressive L5 transverse processectomy for Bertolotti’s syndrome: A preliminary study. Pain Physician. 2017;20:E923-E932.
Ravikanth R, Majumdar P. Bertolotti’s syndrome in low‑backache population: Classification and imaging findings. Tzu Chi Med J. 2019;31(2):90-5.
Delport EG, Cucuzzella TR, Kim N, Marley J, Pruitt C, Delport AG, et al. Lumbosacral transitional vertebrae: Incidence in a consecutive patient series. Pain Physician. 2006;9:53‑6.
Anderson GBJ. The epidemiology of spinal disorders, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. Philadelphia, Lippincott-Raven. 1997;4:93–141.
Grøn S, Jensen RK, Jensen TS, Kongsted A. Back beliefs in patients with low back pain: A primary care cohort study. BMC Musculoskeletal Disorders. 2019;20(1):578.
Castellvi AE, Goldstein LA, Chan DPK. Lumbosacral transitional vertebra and their relationship with lumbar extradural defects. Spine. 1983;9:493-495.
Jancuska JM, Spivak JM, Bendo JA. A review of symptomatic lumbosacral transitional vertebrae: bertolotti’s syndrome. Int J Spine Surg. 201;9:42.
Neelakantan S, Anandarajan R, Shyam K, Philip B. Multimodality imaging in Bertolotti’s syndrome: An important cause of low back pain in young adults. BMJ Case Rep. pii: Bcr2016217121; 2016.
Kapetanakis S, Chaniotakis C, Paraskevopoulos C, Pavlidis P. An Unusual Case Report of Bertolotti’s Syndrome: Extraforaminal Stenosis and L5 Unilateral Root Compression (Castellvi Type III an LSTV). J Orthop Case Rep. 2017;7(3):9-12.
Mahato NK. Morphometric analysis and identification of characteristic features in sacra bearing accessory articulations with L5 vertebra. Spine J. 2010;10(7):616-621.
Nardo L, Alizai H, Virayavanich W, Liu F, Hernandez A, Lynch JA, et al. Lumbosacral transitional vertebrae: association with low back pain. Radiology. 201;265(2):497-503.
Almeida DB, Mattei TA, Soria MG, et al. Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti’s syndrome. Arq Neuropsiquiatr. 2009;67:268–72.
Apazidis A, Ricart PA, Diefenbach CM, Spivak JM. The prevalence of transitional vertebrae in the lumbar spine. The Spine Journal: Official Journal of the North American Spine Society. 2011; 11(9):858-862.
Aihara T, Takahashi K, Ogasawara A, Itadera E, Ono Y, Moriya H. Intervertebral disc degeneration associated with lumbosacral transitional vertebra: A clinical and anatomical study. J Bone Joint Surg Br. 2005;87:687–691.
Luoma K, Vehmas T, Raininko R, Luukkonen R, Riihimaki H: Lumbosacral transitional vertebra: Relation to disc degeneration and low back pain. Spine. 2004;29:200–205.
Brown MF, Rockall AG, Hallam P, Hall-Craggs MA, Edgar MA. Transitional lumbosacral vertebra: Incidence of disc degeneration above and below. J Bone Joint Surg Br. 2000;82-B (Suppl II):180.
Cuenca C, et al. Bertolotti’s syndrome in children: From low-back pain to surgery. A Case Report. Neurochirurgie; 2009.
Marks RC, Thulbourne T. Infiltration of anomalous lumbosacral articulations. Steroid and anesthetic injections in 10 back-pain patients,” Acta Orthop Scandi. 1991;62(2):139–141.
Mitra R, Carlisle M. Bertolotti’s syndrome: A case report. Pain Practice. 2009;9(2): 152–154.
Konin GP, Walz DM. Lumbosacral transitional vertebrae: Classification, imaging findings and clinical relevance. Am J Neuroradiol. 2010;31(10):1778-1786.
Marks RC, Thulbourne T. Infiltration of anomalous lumbosacral articulations: steroid and anesthetic injections in 10 back pain patients. Acta Orthop Scand. 1991; 62:139–41.
Ugokwe KT, Chen TL, Klineberg E. Minimally invasive surgical treatment of Bertolotti’s syndrome: case report. Neurosurgery. 2008;62:454–55.
Zhang R, Cheng J. Interventional management of chronic low back pain associated with Bertolotti’s syndrome: Report of case series. Ann Clin Case Rep. 2017;2:1348.
Jonsson B, Stromqvist B, Egund N. Anomalous lumbosacral articulations and low back pain: evaluation and treatment. Spine (Phila Pa 1976). 1989;14:831–34.
Yousif S, Wood M. Minimally invasive resection of lumbosacral pseudojoint resulting in complete resolution of a lower back pain – A case report and review of Bertolotti syndrome. J Clin Neurosci; 2018.
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