Identifying treatment patterns in patients with Bertolotti syndrome: an elusive cause of chronic low back pain |
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| Affiliation: | 1. Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, 9500 Euclid Av, Suite S40, Cleveland, OH, 44195, USA;2. School of Medicine, Case Western Reserve University, Cleveland, OH, USA;3. Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA;1. Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Medical Imaging Department, Ningbo First Hospital, Ningbo, China;2. Department of Orthopedics, Ningbo First Hospital, Ningbo, China;3. Department of Radiology, Ningbo Ninth Hospital, Ningbo, China;4. Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China;1. Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, 301 East 17th St, New York, NY, USA;2. Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke''s/Rocky Mountain Hospital for Children, Denver, CO, USA;3. Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA;4. Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA;5. Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA;6. Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA;7. Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA;8. Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA;9. Department of Neurologic Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA;10. Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA;11. Department of Orthopaedic Surgery, University of California Davis, Davis, CA, USA;1. Department of Orthopaedic Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea;2. Department of Orthopaedic Surgery, School of Medicine, Kyungpook National University, 130 Dongduk-ro, Jung-gu, Daegu, Republic of Korea;3. Department of Orthopaedic Surgery, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, Republic of Korea;4. Department of Anatomy, School of Medicine, Kyungpook National University, 130 Dongduk-ro, Jung-gu, Daegu, Republic of Korea;5. Biomedical Research Institute, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, Republic of Korea;1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;2. Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA |
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| Abstract: | BACKGROUND CONTEXTBertolotti Syndrome is a diagnosis given to patients with lower back pain arising from a lumbosacral transitional vertebra (LSTV). These patients can experience symptomatology similar to common degenerative diseases of the spine, making Bertolotti Syndrome difficult to diagnose with clinical presentation alone. Castellvi classified the LSTV seen in this condition and specifically in types IIa and IIb, a “pseudoarticulation” is present between the fifth lumbar transverse process and the sacral ala, resulting in a semi-mobile joint with cartilaginous surfaces.Treatment outcomes for Bertolotti Syndrome are poorly understood but can involve diagnostic and therapeutic injections and ultimately surgical resection of the pseudoarticulation (pseudoarthrectomy) or fusion of surrounding segments.PURPOSETo examine spine and regional injection patterns and clinical outcomes for patients with diagnosed and undiagnosed Bertolotti Syndrome.DESIGNRetrospective observational cohort study of patients seen at a single institution's tertiary spine center over a 10-year period.PATIENT SAMPLECohort consisted of 67 patients with an identified or unidentified LSTV who were provided injections or surgery for symptoms related to their chronic low back pain and radiculopathy.OUTCOME MEASURESSelf-reported clinical improvement following injections and pseudoarthrectomy.METHODSPatient charts were reviewed. Identification of a type II LSTV was confirmed through provider notes and imaging. Variables collected included demographics, injection history and outcomes, and surgical history for those who underwent pseudoarthrectomy.RESULTSA total of 22 out of 67 patients (33%) had an LSTV that was not identified by their provider. Diagnosed patients underwent fewer injections for their symptoms than those whose LSTV was never previously identified (p = 0.031). Only those diagnosed received an injection at the LSTV pseudoarticulation, which demonstrated significant symptomatic improvement at immediate follow up compared to all other injection types (p = 0.002). Patients who responded well to pseudoarticulation injections were offered a pseudoarthrectomy, which was more likely to result in symptom relief at most recent follow up than patients who underwent further injections without surgery (p < 0.001).CONCLUSIONSUndiagnosed patients are subject to a higher quantity of injections at locations less likely to provide relief than pseudoarticulation injections. These patients in turn cannot be offered a pseudoarthrectomy which can result in significant relief compared to continued injections alone. Proper and timely identification of an LSTV dramatically alters the clinical course of these patients as they can only be offered treatment directed towards the LSTV once it is identified. |
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