Bertolotti's syndrome

A syndrome that affects L5 and S1 Vertebral bodies. Also known as Lumbosacral transitional vertebrae (LSTV) in which an elongated transverse process of the last lumbar vertebra fuses with varying degree to the “first” sacral segment.

1. Bertolotti's syndrome S lides by Dr Ntambi Rogers

2. Introduction Lumbosacral transitional vertebrae (LSTV) are a relatively common variant and can be seen in ~25% (range 15-35%) of the general population. They can be thought of as a lumbarized S1 segment or sacralized L5 segment It is an important cause of low back pain in young patients.

3. Introduction The term lumbosacral transitional vertebra (Bertolotti's syndrome) refers to a total or partial unilateral or bilateral fusion of the transverse process of the lowest lumbar vertebra to the sacrum. The syndrome affects 4% to 8% of the population. BS is characterized by anomalous enlargement of the transverse processes of the most caudal lumbar vertebra, which may articulate or fuse with the sacrum or ilium and cause isolated L4-5 disc disease.

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5. Pathoanatomy The causes of back pain in BS are multifactorial. Most of the affected patients have scoliosis. The abnormal mechanical stress leads to facet joint arthropathy, as well as iliopsoas and quadratus lumborum strain. Nerve root compression due to narrowing of the intervertebral foramina by the enlarged fan-shaped transverse foramina may lead to neurogenic claudication. An increased prevalence of disc protrusion or extrusion in the disc above the transitional L5 vertebra has been found in patients with LBP.

6. Pathoanatomy A decreased prevalence of disc protrusion or extrusion was found in the disc below the transitional vertebra. Pseudoarticulation between the transverse process and the sacrum creates a “false joint” susceptible to arthritic changes and osteophyte formation potentially leading to nerve root entrapment .

7. Pathoanatomy The presence of an LSTV disrupts normal spine biomechanics and anatomy. The sacrum, lying at the base of the vertebral column, optimizes the dissipation of the weight of the upper body toward the sacroiliac (SI) joint by working as a fused mass of boney elements. The sacrum's ability to dissipate load depends on its size and its surface area with the SI joint.

8. Pathoanatomy The formation of transitional states at the lumbosacral junction may be greatly influenced by the functional requirements of load transmission at the SI junction . Sacra incorporating L5 possess significantly smaller heights than the normal sacra if the fused L5 vertebra is excluded from the measurement.

9. Pathoanatomy Disc degeneration is an important component in the pathophysiology of LBP in BS. The intervertebral disc most commonly involved is that of the L4-5 level, i.e., the level just above the level of hemisacralization

10. Types . The commonly used Castellvi classification is: Type 1: a fusion at least 19 mm in width on one (1a) or both sides (1b) Type 2: incomplete fusion with a pseudo joint created on one side (2a) or both sides (2b) Type 3: complete fusion of the L5 to the sacrum on one side (3a) or the other (3b) Type 4: combination of Type 2 and Type 3

11. Signs and symptoms Sacralization often has no symptoms. It’s sometimes is associated with lower back pain or problems with posture and movement.. Biomechanical difficulties in movement L imits to range of motion P osture control problems S coliosis L eg pain, buttock pain

12. Diagnosis Diagnosis of BS is based on radiological findings and their correlation with the clinical presentation. Plain X-rays of the lumbosacral spine in anteroposterior view are usually sufficient. Radicular features may necessitate an MRI for evaluation of prolapsed intervertebral disc (PIVD), which may co-occur.

13. Management Pain in patients with BS does not usually respond to interventional pain treatment. A very dynamic treatment approach must be pursued while managing BS patients, and the treatment plan must be individualized at various stages in order to obtain satisfactory pain relief.

14. Management Transformational (TF) steroid injections can be given using a subpedicular approach. Injections containing depomedrol 40 mg in 0.25% bupivacaine, and an interval of at least 4 weeks can be maintained between consecutive injections. A maximum of 3 injections is given to obtain the maximum therapeutic benefit of TF steroid injections Rami communicantes (RC) block can be done for palliation of discogenic pain

15. Management Physical therapy interventions are also helpful in early cases and are focused around mobilization, neural stretching, and core strengthening exercises.

16. Management Surgery may be recommended to correct specific disc or other abnormalities that result from the sacralization. For example, sacralization may cause strain on the disc between the fourth and fifth vertebrae, leading to disc slippage or degeneration . S urgically ,posterolateral fusion or resection of the transitional articulation can be done.