Identifying treatment patterns in patients with Bertolotti syndrome: an elusive cause of chronic low back pain.

Abstract

Bertolotti 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. To examine spine and regional injection patterns and clinical outcomes for patients with diagnosed and undiagnosed Bertolotti Syndrome. Retrospective observational cohort study of patients seen at a single institution's tertiary spine center over a 10-year period. Cohort 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. Self-reported clinical improvement following injections and pseudoarthrectomy. Patient 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. A 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). Undiagnosed 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.