Bertolotti Syndrome With Articulated L5 Transverse Process Causing Intractable Back Pain: Surgical Video Showcasing a Minimally Invasive Approach for Disconnection: 2-Dimensional Operative Video

Abstract Bertolotti syndrome is a commonly missed cause of intractable back pain that affects 4% to 8% of the general population. It involves the congenital malformation of a transitional lumbosacral vertebra, with total or partial and unilateral or bilateral transverse process (TP) fusion or articulation to the sacrum. The pain can be debilitating, and the tethering of the spine to the sacrum can encourage deformity formation in the coronal plane and lead to early degenerative changes, especially if present only unilaterally. We present the case of a 24-yr-old woman with no notable prior medical history who presented with years of lower axial back pain radiating to her thighs, which limited her activities of daily living and was resistant to conservative management. Her imaging showed an abnormally large left L5 TP, which was articulated to the sacrum, and signs of early coronal deformity. She had responded almost completely to repeated steroid injections into the TP-sacral joint, but that effect was very transient. Informed patient consent was obtained prior to her surgery. She underwent a minimally invasive tube disconnection of the abnormal joint with partial distal resection of the TP, and her symptoms completely resolved. This case highlights the importance of correlating clinical symptoms with aberrant anatomy, and the role of selective surgery in providing symptomatic relief. This case report was written in compliance with our institutional ethical review board approval, and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern institutional review board.

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Minimally Invasive Surgical Treatment of Bertolotti's Syndrome: Case Report

Operative Neurosurgery ◽

10.1227/01.neu.0000326034.77585.88 ◽

2008 ◽

Vol 62 (suppl_5) ◽

pp. ONS454-ONS455 ◽

Cited By ~ 3

Author(s):

Kene T. Ugokwe ◽

Tsu-Lee Chen ◽

Eric Klineberg ◽

Michael P. Steinmetz

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Case Report ◽

Surgical Treatment ◽

Minimally Invasive ◽

Lumbar Vertebra ◽

Transverse Process ◽

Low Back ◽

X Rays ◽

Invasive Approach

Abstract Objective: This article aims to provide more insight into the presentation, diagnosis, and treatment of Bertolotti's syndrome, which is a rare spinal disorder that is very difficult to recognize and diagnose correctly. The syndrome was first described by Bertolotti in 1917 and affects approximately 4 to 8% of the population. It is characterized by an enlarged transverse process at the most caudal lumbar vertebra with a pseudoarticulation of the transverse process and the sacral ala. It tends to present with low back pain and may be confused with facet and sacroiliac joint disease. Methods: In this case report, we describe a 40-year-old man who presented with low back pain and was eventually diagnosed with Bertolotti's syndrome. The correct diagnosis was made based on imaging studies which included computed tomographic scans, plain x-rays, and magnetic resonance imaging scans. The patient experienced temporary relief when the abnormal pseudoarticulation was injected with a cocktail consisting of lidocaine and steroids. In order to minimize the trauma associated with surgical treatment, a minimally invasive approach was chosen to resect the anomalous transverse process with the accompanying pseudoarticulation. Results: The patient did well postoperatively and had 97% resolution of his pain at 6 months after surgery. Conclusion: As with conventional surgical approaches, a complete knowledge of anatomy is required for minimally invasive spine surgery. This case is an example of the expanding utility of minimally invasive approaches in treating spinal disorders.

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Minimally Invasive Endoscopic Aspiration of a Spinal Epidural Dermoid Cyst Extending From T10 to the Sacrum: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz237 ◽

2019 ◽

Vol 18 (5) ◽

pp. E172-E172

Author(s):

Charles V Hatchette ◽

Salah G Aoun ◽

Tarek Y El Ahmadieh ◽

Lauren Smalley ◽

Ankur R Patel ◽

...

Keyword(s):

Minimally Invasive ◽

Dermoid Cyst ◽

Complex Disease ◽

Interdisciplinary Cooperation ◽

Conus Medullaris ◽

Tumor Burden ◽

Neurological Function ◽

Ethical Review ◽

University Of Texas ◽

Patient Consent

Abstract Dermoid cysts are space-occupying tumors that can occur anywhere in the neuroaxis. Although categorized as benign lesions, they can compromise normal structures, causing neurological function loss, and have a tendency to recur often requiring repeated surgical resections. We illustrate the case of an extensive epidural dermoid cyst in a 22-yr-old woman who presented with progressive loss of neurological motor function in her lower extremities as well as bowel and bladder incontinence. The tumor extended from T10 to the sacrum, and a conventional operation would have entailed serial laminectomies that would cross the thoracolumbar and lumbosacral junctions, possibly requiring an instrumented fusion. Given the fact that operation would have carried significant morbidity, especially with the high likelihood of symptomatic tumoral recurrence, we consulted with our urology colleagues to find a minimally invasive way of reducing the tumor burden and decompressing the neural elements. The patient was taken to the operating room and a limited open lumbosacral durotomy was performed. A flexible cystoscope was then passed in the epidural space and used to suction the tumor. Postoperative imaging showed adequate resection, and the patient recovered neurological function completely. She had mini-mal recurrence at 3 yr and remained asymptomatic. This technical video note showcases the potential for use of endoscopy for spine tumors that have an amenable consistency, even in highly eloquent areas such as the conus medullaris. It also serves to highlight the benefits of interdisciplinary cooperation when treating complex disease. This case report was written in compliance with our institutional ethical review board. Institutional Review Board (IRB) approval and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas SouthWestern IRB. Patient consent was waived for writing this manuscript in light of the retrospective and deidentified nature of the data presented in accordance with our institutional IRB.

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Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study

Journal of Neurosurgery Spine ◽

10.3171/2020.4.spine20169 ◽

2020 ◽

Vol 33 (5) ◽

pp. 601-606

Author(s):

Paul Park ◽

Khoi D. Than ◽

Praveen V. Mummaneni ◽

Pierce D. Nunley ◽

Robert K. Eastlack ◽

...

Keyword(s):

Back Pain ◽

Minimally Invasive ◽

Pain Score ◽

Spinal Deformity ◽

Open Surgery ◽

Rating Scale ◽

Adult Spinal Deformity ◽

Open Approach ◽

Invasive Approach ◽

Selection Of

OBJECTIVESurgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD.METHODSThe study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection.RESULTSSignificant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence–lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection.CONCLUSIONSIncreasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.

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Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Macroadenoma as Minimal Invasive Approach: Case Report

JBN (Jurnal Bedah Nasional) ◽

10.24843/jbn.2019.v03.i01.p01 ◽

2019 ◽

Vol 3 (1) ◽

pp. 1

Author(s):

Febyan Febyan ◽

Handrianto Setiajaya

Keyword(s):

Minimally Invasive ◽

Transsphenoidal Surgery ◽

Clinical Symptoms ◽

Minimal Invasive ◽

Invasive Technique ◽

Endoscopic Endonasal ◽

Invasive Approach ◽

Minimal Invasive Approach ◽

Endoscopic Endonasal Transsphenoidal Surgery ◽

Visual Disturbances

Background: pituitary tumor accounted for 15% of benign intracranial tumors. Clinical symptoms found in the form of visual disturbances, and hormonal manifestations, surgery is one of the main managements. Endoscopic endonasal transsphenoidal surgery (EETS) is a minimally invasive approach for this case. The advantages of EETS is better efficacy than traditional technique, and shorter hospital stays, less mean blood loss, and earlier return to daily activities. Case: we reported a rare example of a male patient aged 37 years old with the main clinical features were visual disturbances, sexual malfunction and bitemporal hemianopsia on physical examination. Magnetic resonance imaging (MRI) showed macroadenoma pituitary, the size 2.41 x 2.98 x 3.20 cm. We explained about minimally invasive surgery such as EETS and the patient was agreed to performed EETS. Conclusion: endoscopic endonasal transsphenoidal surgery is a minimally invasive technique for tumor pituitary cases and safe when compared to traditional medicine.

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Retrieval of an Intracranially Migrated Dental Injection Needle Through the Foramen Ovale: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz329 ◽

2019 ◽

Vol 19 (2) ◽

pp. E168-E168 ◽

Cited By ~ 1

Author(s):

Salah G Aoun ◽

Tarek Y El Ahmadieh ◽

Vin Shen Ban ◽

Vishal J Patel ◽

Awais Vance ◽

...

Keyword(s):

Trigeminal Nerve ◽

Rare Complication ◽

Middle Cranial Fossa ◽

Ethical Review ◽

Foramen Ovale ◽

University Of Texas ◽

Injection Needle ◽

Facial Musculature ◽

Patient Consent ◽

The Right

Abstract Dental injection needle migration is a rare complication of orthodontal procedures. When these needles fracture, they typically dislodge into the cervical space or the facial musculature. Migration into the cranial vault is difficult because of the obstacle created by the skull base. We report a rare case of intracranial migration of an anesthetic injection needle through the foramen ovale. A 59-yr-old man underwent the extraction of a right maxillary molar. The distal end of a 25-gauge injection needle broke into his pterygoid musculature, causing him pain while chewing. Vascular imaging obtained after a computed tomography scan of his face showed that the needle had migrated, potentially because of his efforts of mastication, and had traversed the foramen ovale into the middle cranial fossa. The patient started experiencing intermittent right facial numbness, likely due to compression or injury to the right trigeminal nerve. Our oral and maxillofacial colleagues did not believe that the needle could be retrieved from its facial end. The patient elected to undergo the recovery of the needle through a craniotomy given the fact that the object was contaminated and because he was becoming increasingly symptomatic. A right pterional craniotomy was planned. Extradural dissection was performed until the dura going into the foramen ovale was revealed. We could feel the metallic needle under the dural sheath of the trigeminal nerve. The dura was opened sharply directly over the needle. We then proceeded to mobilize the needle into the face, and then pulled it out completely through the craniotomy to avoid injury to the temporal lobe. The patient recovered well and was asymptomatic at the time of discharge. This case report was written in compliance with our institutional ethical review board. Institutional review board (IRB) approval and patient consent were waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern (UTSW) IRB.

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Percutaneous Peripheral Nerve Stimulation for Pain Reduction and Improvements in Functional Outcomes in Chronic Low Back Pain

Military Medicine ◽

10.1093/milmed/usy310 ◽

2019 ◽

Vol 184 (Supplement_1) ◽

pp. 537-541 ◽

Cited By ~ 3

Author(s):

Steven Cohen ◽

Christopher Gilmore ◽

Leonardo Kapural ◽

Steven Hanling ◽

Anthony Plunkett ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Minimally Invasive ◽

Peripheral Nerve ◽

Nerve Stimulation ◽

Chronic Low Back Pain ◽

Chronic Back Pain ◽

Peripheral Nerve Stimulation ◽

Low Back ◽

Invasive Approach

Abstract Chronic low back pain represents one of the most common sources of disability and a significant healthcare burden for the U.S. military. Present treatments for chronic back pain are often ineffective, poorly tolerated, invasive, destructive, and/or associated with complications and lead to the progression to invasive surgical procedures. There have been multiple calls for the development of a minimally invasive system that is effective without the risks or complications of existing surgical therapies, which could prevent the need for surgery and the recurrence of pain. The goal of this study was to evaluate a novel, minimally invasive approach using a percutaneous peripheral nerve stimulation (PNS) system designed to provide pain relief without surgery, to reduce complications, and provide a less-invasive treatment option. In nine subjects, percutaneous PNS improved participants’ function, as evidenced by clinically and statistically significant reductions in pain, disability, and pain interference. Subjects also experienced reductions in opioid and non-opioid analgesic medication usage and reported improvements in quality of life with treatment. There were no serious or unanticipated adverse events. These results demonstrate the potential of percutaneous PNS as a non-surgical therapy to treat chronic back pain without opioids.

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Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz278 ◽

2019 ◽

Vol 19 (1) ◽

pp. E63-E64 ◽

Cited By ~ 1

Author(s):

Kyle Mueller ◽

Islam Fayed ◽

Steven Spitz ◽

Nathan Nair ◽

Jean-Marc Voyadzis ◽

...

Keyword(s):

Minimally Invasive ◽

Conservative Management ◽

Case Reports ◽

Synovial Cyst ◽

Leg Pain ◽

Epidural Steroid Injections ◽

Institutional Review ◽

Patient Consent ◽

Epidural Steroid ◽

Tissue Trauma

Abstract Synovial cysts of the lumbar spine result from degeneration of the facet capsule, and their prevalence may be as high as 10% in symptomatic patients. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption, minimizes soft-tissue trauma, and limits disruption of the ligamentous and bony structures. Additionally, by approaching contralateral, the cyst/dura interface is better visualized especially at the depths of the lateral recess. Seeing the full extent of this interface from an ipsilateral approach is very difficult without decompressing the cyst, which, in turn, makes dissecting and separating the remaining cyst wall more difficult and increases the risk of durotomies.1,2 We report the case of a 53-yr-old female who presented with persistent left leg pain in an L5 distribution that was associated with some mild lower back pain. She was refractory to conservative management that included physical therapy along with a series of epidural steroid injections. She was noted to have some weakness with dorsiflexion on the left side and as absent a straight leg raise. Given the predominance of her leg over her back symptoms along with the patient's age, a minimally invasive contralateral approach for resection of the synovial cyst was offered as opposed to more traditional decompression and fusion. Institutional Review Board approval and patient consent for solitary case reports are not needed at our institution.

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A case of Bertolotti’s syndrome as a cause of sciatica

Surgical Neurology International ◽

10.25259/sni_756_2021 ◽

2021 ◽

Vol 12 ◽

pp. 516

Author(s):

Sarah Kawtharani ◽

Shadi Abdelatif Bsat ◽

Mohamad El Housheimy ◽

Charbel Moussalem ◽

Adham Halaoui ◽

...

Keyword(s):

Back Pain ◽

Lumbar Vertebra ◽

Transverse Process ◽

Invasive Approach ◽

Surgery Patient ◽

Patient Reported ◽

Disc Herniations ◽

Sacral Segment ◽

The Right ◽

Lumbosacral Transitional Vertebrae

Background: Bertolotti’s syndrome (i.e., varying extent of fusion between the last lumbar vertebra and the first sacral segment) or lumbosacral transitional vertebrae is a rare cause of back pain. Notably, this syndrome is one of the differential diagnoses for patients with refractory back pain/sciatica. Case Description: A 71-year-old male presented with low back pain of 3 years duration that radiated into the right lower extremity resulting in numbness in the L5 distribution. He then underwent a minimally invasive approach to resect the L5 “wide” transverse process following the CT diagnosis of Bertolotti’s syndrome. Prior to surgery, patient reported pain that was exacerbated by ambulation that resolved post-operative. Conclusion: Bertolotti’s syndrome is one of the rare causes of sciatica that often goes undiagnosed. Nevertheless, it should be ruled out for patients with back pain without disc herniations or other focal pathology diagnosed on lumbar MR scans.

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Minimally Invasive Microendoscopic Resection of the Transverse Process for Treatment of Low Back Pain with Bertolotti’s Syndrome

Case Reports in Orthopedics ◽

10.1155/2014/613971 ◽

2014 ◽

Vol 2014 ◽

pp. 1-5

Author(s):

Yoichiro Takata ◽

Toshinori Sakai ◽

Kosaku Higashino ◽

Yuichiro Goda ◽

Kazuaki Mineta ◽

...

Keyword(s):

Low Back Pain ◽

Back Pain ◽

Minimally Invasive ◽

Lumbar Disc ◽

Transverse Process ◽

Local Injection ◽

Low Back ◽

Sciatic Pain ◽

Lumbar Segment ◽

Recurrent Lumbar Disc Herniation

Bertolotti’s syndrome is characterized by anomalous enlargement of the transverse process of the most caudal lumbar segment, causing chronic and persistent low back pain or sciatica. We describe the case of a 45-year-old woman who presented with left sciatic pain and low back pain due to a recurrent lumbar disc herniation at L4-5 with Bertolotti’s syndrome. Selective L5 nerve root block and local injection of lidocaine into the articulation between the transverse process and sacral ala temporarily relieved the left sciatic pain and low back pain, respectively. To confirm the effect of local injection on low back pain, we gave a second local injection, which once again relieved the low back pain. Microendoscopic resection of the pseudoarticulation region and discectomy successfully relieved all symptoms. This report illustrates the effectiveness of minimally invasive resection of the transverse process for the treatment of low back pain with Bertolotti’s syndrome.

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