Onyiuke Grading Scale: A Clinical Classification System for the Diagnosis and Management of Bertolotti Syndrome

Abstract INTRODUCTION Lumbosacral transitional vertebrae (LSTV) is a common anatomic variant of the spine, characterized by the formation of a pseudoarticulation between the transverse process of the lumbar vertebrae and sacrum or ilium. The altered biomechanics and instability of the spine have been implicated as a potential source of low back pain dubbed Bertolotti Syndrome, named for the Italian physician who initially reported such a rare condition. Traditionally, lumbosacral transitional vertebra have been subdivided into types I-IV based on the Castellvi radiographic classification system.1 However, identifying the type of LSTV in this way fails to consider these findings within the clinical context and provides no clinical relevance to the treatment of Bertolotti Syndrome. METHODS Patients presenting with back pain between 2011 and 2018 attributable to a lumbosacral transitional vertebra were identified retrospectively. Data was collected from these patients' charts regarding demographic information, clinical presentation, diagnostic imaging, treatment, and outcomes. Based on evaluation of these cases and review of the literature, a diagnostic-therapeutic algorithm is proposed. RESULTS Based on our experiences evaluating and treating these patients and review of the existing literature, we propose a clinical classification system for Bertolotti Syndrome, we proposed a 4-grade scale for patients with Bertolotti syndrome based upon location, severity, and characteristics of pain experienced due to LSTVs. CONCLUSION Based on our experience with the cases illustrated here, we recommend managing patients with LSTV based on our diagnostic-therapeutic algorithm. Moving forward, a larger prospective study with a larger patient cohort is needed to further validate the treatment paradigm.

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Transverse sacralization of lumbar vertebrae: prevalence according to Castellvi classification

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20164835 ◽

2016 ◽

Vol 3 (1) ◽

pp. 116

Author(s):

Juhi V. Patel ◽

Chetan M. Mehta ◽

Nandakishore G. Patil ◽

Shreya R. Sehgal

Keyword(s):

Lumbar Vertebrae ◽

Lumbar Vertebra ◽

Transverse Process ◽

The Body ◽

Type I ◽

Transitional Vertebra ◽

Spinal Movement ◽

Vertebral Disc ◽

Fifth Lumbar Vertebra ◽

Lumbosacral Transitional Vertebra

Background: Sacralization of L5 is a congenital anomaly, in which the lumbar vertebra, mainly its transverse process, gets fused or semi-fused with the sacrum or the ilium or to both. This fusion can occur in one or both sides of the body. Sacralization leads to fusion of the L5 (fifth lumbar vertebra) and S1 (first sacral vertebra) and the inter-vertebral disc between them may be narrow. Sacralization of lumbar vertebra may be asymptomatic but is not always clinically insignificant. While sacralization may not affect at all, it can cause problems in some cases. Sacralization may be at times associated with problems in biomechanics and affect the ways of movement and posture control. Sacralization may also be an important consideration in disc surgeries. This study has been carried out to find out prevalence of sacralisation of transverse process of fifth lumbar vertebrae.Methods: The present study of transverse sacralisation of fifth lumbar vertebra was carried out on 35 randomly selected patients. The sample consisted of patients undergoing CT scan for abdominal complains. Bone window of all patients were evaluated to look for lumbosacral transitional vertebra.Results: The prevalence of transverse sacralization of lumbar vertebra turned out to be 25.7% out of which Castellvi type IIb was found to be most common, accounting for 33.3% cases. 5.7% comprised the group of normal variant (Castellvi’s type I) and 68.6% were normal. Conclusions: It is important to determine lumbosacral transitional vertebra as it can affect spinal movement and put excess stress on the lumbar vertebrae and in between disc. Moreover it can have a bearing on counting of vertebral levels specially during planning of spinal surgey.

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Bertolotti Syndrome

10.2310/pm.15017 ◽

2016 ◽

Author(s):

Jiang Wu ◽

Jianguo Cheng

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Compression Fracture ◽

Lumbar Vertebra ◽

Transverse Process ◽

Lumbosacral Spine ◽

Medial Branch ◽

Low Back ◽

Transitional Vertebra ◽

Lumbosacral Transitional Vertebra

Bertolotti syndrome is caused by a lumbosacral transitional vertebra, a congenital variation of the most caudal lumbar vertebra, characterized by an enlarged transverse process that articulates or fuses with the sacrum, ilium, or both. This syndrome accounts for 4.6 to 7% of cases of low back pain in adults and for more than 11% of patients with low back pain who are under 30 years old. The primary effect of lumbosacral transitional vertebra is reduced and asymmetrical motion between the transitional vertebra and the sacrum, resulting in early arthritic changes at pseudoarticulation; the secondary effect is the progressively compensatory modifications in the biomechanics of the mobile vertebral segments superior to the transitional vertebra related to restriction in rotation and bending motion at the lumbosacral articulation. Bertolotti syndrome should be considered in the differential diagnosis of low back pain. Clinical findings include low back pain in the midline or paramedian area that is reproduced with palpation along the base of the lumbosacral spine and near the posterosuperior iliac spine and aggravated by forward flexion, excessive extension, or lateralization of the back to the same side of the mega-apophysis. A plain x-ray is diagnostic; the extension-flexion lumbosacral radiographs in anteroposterior, lateral, and oblique views demonstrate lumbosacral transitional vertebra, with an enlarged unilateral or bilateral transverse process of the most distal lumbar vertebra, abnormally articulating with the ala of the sacrum and degenerative changes of the pseudarthrosis. Other imaging studies, such as computed tomography and magnetic resonance imaging of the lumbosacral spine and selective radiculography of the spinal nerve, could provide additional detailed anatomic information. Major differential diagnoses of Bertolotti syndrome include sacroiliac joint pain, myofascial pain, lumbar facet pain, lumbar disk herniation, compression fracture, and Baastrup disease/interspinous bursitis. These conditions are not mutually exclusive and, in fact, often coexist. A course of conservative management, including activity modification, medication management with nonsteroidal antiinflammatory drugs, muscle relaxants, and rehabilitative physical therapy, should be offered initially. Due to the multifactorial etiology of low back pain in patients with Bertolotti syndrome, procedures such as diagnostic intrapseudoarticular block for arthritis, medial branch block for facet arthropathy, diskography for diskogenic pain, and selective nerve roots block for radiculopathy can potentially help identify the primary and secondary origins of the pain. Surgical treatment of Bertolotti syndrome was only slightly better than conservative treatment and should only be used in very selective patients with disk pathology. To achieve long-term improvement by any of these therapeutic options, a continuing physical rehabilitation program is often needed. Key words: Bertolotti syndrome, intrapseudoarticular block, transitional lumbosacral vertebra, transverse process

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Association between lumbar sacralization and increased degree of vertebral slippage and disc degeneration in patients with L4 spondylolysis

Journal of Neurosurgery Spine ◽

10.3171/2018.11.spine18900 ◽

2019 ◽

Vol 30 (6) ◽

pp. 767-771

Author(s):

Xinqiang Yao ◽

Ruoting Ding ◽

Junhao Liu ◽

Siyuan Zhu ◽

Jingshen Zhuang ◽

...

Keyword(s):

Surgical Treatment ◽

Disc Degeneration ◽

Transverse Process ◽

Modic Changes ◽

Bony Fusion ◽

Transitional Vertebra ◽

Type Iiia ◽

Type Iiib ◽

Significant Difference ◽

Lumbosacral Transitional Vertebra

OBJECTIVEThe aim of this study was to evaluate the effect of lumbar sacralization on the level of vertebral slip and disc degeneration in patients with L4 spondylolysis.METHODSThe authors analyzed data from 102 cases in which patients underwent surgical treatment for L4 spondylolysis and spondylolisthesis at their institution between March 2007 and September 2016. Lumbar sacralization was characterized by the presence of pseudarthrosis and/or bony fusion between the L5 transverse process and sacrum, and the type of lumbosacral transitional vertebra (LSTV) was evaluated with the Castellvi classification. The amount of vertebral slippage was measured using the Taillard technique and Meyerding grade. Degeneration of the L4–5 segment was quantified using the Pfirrmann and Modic classifications. Patients were divided into 2 groups based on the presence or absence of sacralization, and the amount of vertebral slip and degeneration of the L4–5 segment was compared between groups.RESULTSLumbar sacralization was present in 37 (36%) of 102 patients with L4 spondylolysis. The LSTV was type IIa in 10 cases, type IIb in 7, type IIIa in 2, and type IIIb in 18. The levels of vertebral slip and disc degeneration in the group of patients with sacralization were significantly greater than in the group without sacralization. No significant difference was found between the 2 groups with respect to Modic changes.CONCLUSIONSThe increased stability between a sacralized L5 and the sacrum may predispose the L4–5 segment to greater instability and disc degeneration in patients with L4 spondylolysis.

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Prevalence and clinical significance of lumbosacral transitional vertebra (LSTV) in a young back pain population with suspected axial spondyloarthritis: results of the SPondyloArthritis Caught Early (SPACE) cohort

Skeletal Radiology ◽

10.1007/s00256-017-2581-1 ◽

2017 ◽

Vol 46 (5) ◽

pp. 633-639 ◽

Cited By ~ 5

Author(s):

F. de Bruin ◽

S. ter Horst ◽

J. L. Bloem ◽

R. van den Berg ◽

M. de Hooge ◽

...

Keyword(s):

Back Pain ◽

Clinical Significance ◽

Axial Spondyloarthritis ◽

Transitional Vertebra ◽

Lumbosacral Transitional Vertebra

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Lumbar plain radiograph is not reliable to identify lumbosacral transitional vertebra types according to Castellvi Classification principle

10.21203/rs.3.rs-17532/v1 ◽

2020 ◽

Author(s):

Lisheng Hou ◽

Xuedong Bai ◽

Haifeng Li ◽

Tianjun Gao ◽

Wei Li ◽

...

Keyword(s):

Plain Radiograph ◽

Transverse Process ◽

Bony Union ◽

Transitional Vertebra ◽

Type Iiia ◽

Final Study ◽

Lumbosacral Transitional Vertebra ◽

Anteroposterior View ◽

Type Classification ◽

Real Type

Abstract Background: The anteroposterior view of lumbar plain radiograph (AP-LPR) was chosen as the original and first radiographic tool to determine and classify lumbosacral transitional vertebra with morphological abnormality (MA-LSTV) according to Castellvi Classification. However, recent studies found that AP-LPR might not sufficient to detect or classify MA-LSTV correctly. The present study aims to verify the reliability of AP-LPR on detecting and classifying MA-LSTV types, taking coronal reconstructed CT images (CT-CRIs) as gold criteria. Methods : Patients with suspected MA-LSTVs determined by AP-LPR were initially enrolled. Among them, those who received CT-CRIs were formally enrolled to verify the sensitivity of AP-LPR on detecting and classifying MA-LSTV types according to Castellvi classification principle. Results : 298 cases were initially enrolled as suspected MA-LSTV ones, among whom 91 cases who received CT-CRIs were enrolled into the final study group. All suspected MA-LSTVs were verified to be real MA-LSTV ones by CT-CRIs. However, 35.2% of the suspected MA-LSTVs types judged by AP –LPR were not consistent with final types judged by CT-CRIs. Two suspected type IIIa and 20 suspected IIIb ones were verified to be true, while 9 of 39 suspected IIa, 9 and 3 of 17 suspected IIb , and 11 of 13 suspected IV ones were verified to be real type IIIa, IIIb, IV and IIIb ones by CT-CRIs, respectively. Incomplete joint-like structure (JLS) or bony union structure (BUS), and remnants of sclerotic band (RSB) between the transverse process (TP) and sacrum were considered to be the main reasons for misclassification. Conclusion : Although AP-LPR could detect MA-LSTV correctly, it could not give accurate type classification. CT-CRIs could provide detailed information between the TP and sacrum area, and could be taken as gold standard to detect and classify MA-LSTV.

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Use of Lumbosacral Region Manipulation and Therapeutic Exercises for a Patient With a Lumbosacral Transitional Vertebra and Low Back Pain

Journal of Orthopaedic and Sports Physical Therapy ◽

10.2519/jospt.2005.1769 ◽

2005 ◽

Author(s):

Alexander Karl Brenner

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Low Back ◽

Lumbosacral Region ◽

Transitional Vertebra ◽

Therapeutic Exercises ◽

Lumbosacral Transitional Vertebra

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Surgical management of Bertolotti’s syndrome in two adolescents and literature review

Surgical Neurology International ◽

10.25259/sni-305-2019 ◽

2019 ◽

Vol 10 ◽

pp. 135

Author(s):

Christopher E. Louie ◽

Jennifer Hong ◽

David F. Bauer

Keyword(s):

Back Pain ◽

Surgical Management ◽

Young Patients ◽

Transverse Process ◽

Surgical Removal ◽

Long Term Outcomes ◽

Lumbosacral Transitional Vertebra ◽

Radicular Symptoms

Background: Bertolotti’s syndrome is defined by back pain and/or radicular symptoms attributed to a congenital lumbosacral transitional vertebra (LSTV). There are few studies that discuss the surgical management of Bertolotti’s syndrome. Here, we report long-term outcomes after resecting a pseudoarthrosis between the sacrum and L5 in two teenage patients, along with a review of literature. Case Descriptions: Surgical resection of a lumbosacral bridging articulation (LSTV type IIa) was performed in two patients, 15 and 16 years of age who presented with intractable back pain. The adequacy of surgery was confirmed with postoperative studies. In both patients, pain and functional status improved within 6 weeks and have remained improved at last follow-up. Conclusion: Surgical removal of a pathologic L5 transverse process fused to the sacral ala in two young patients with Bertolotti’s syndrome improved postoperative pain and increased overall function. Given the progressive nature of Bertolotti’s syndrome, surgical intervention in young patients should be considered to mitigate years of chronic pain and attendant morbidity.

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