Percutaneous Full Endoscopic Treatment of Bertolotti Syndrome: A Report of Three Cases with Technical Note

Background Bertolotti syndrome is characterized by an abnormal enlargement of the transverse process of the most caudal lumbar vertebra. Most of the time it is asymptomatic, but when it is symptomatic it is associated with low back pain, radiating leg pain, or both. There is no consensus regarding management of this pathology. Open to minimal invasive tubular resection techniques are described in the literature, but a full endoscopic resection technique has not yet been described. Endoscopic technique is a less invasive target-oriented iliolumbar ligament preserving technique. We report our percutaneous full endoscopic technique for the treatment of symptomatic Bertolotti syndrome. Method We have treated three symptomatic cases of Bertolotti syndrome with the percutaneous endoscopic technique. We review the feasibility of this technique and the outcomes. Result Full endoscopic resection of Bertolotti syndrome is feasible and safe with comparable good outcomes and the added benefits of minimal invasive surgery. Conclusion We believe this novel percutaneous full endoscopic technique will yield good results in the hands of expert endoscopic spine surgeons and can be an alternative treatment method in cases of symptomatic Bertolotti syndrome. To our knowledge this is the first report of percutaneous full endoscopic treatment of Bertolotti syndrome in the world.

Sonoanatomy and Injection Technique of the Iliolumbar Ligament

Background: The iliolumbar ligament plays an important biomechanic role in anchoring the spine to the pelvic ring and stabilizing the sacroiliac joint. Iliolumbar syndrome is a back pain condition caused by pathology of the iliolumbar ligament. History and physical examination are important in the assessment of back pain, but they lack sufficient specificity. Injection of small volumes of local anesthetic into the structure considered to be the source of the pain (i.e. the iliolumbar ligament) increases the specificity of the diagnostic workup. Objective: To describe an ultrasound - guided technique for injecting the iliolumbar ligament. Study design: Case report based on knowledge of topographic anatomy and sonoanatomy. Setting: Outpatient clinic. Methods: A patient with a clinical picture suggestive of iliolumbar syndrome was selected. An ultrasound-guided injection of the iliolumbar ligament with local anesthetic was performed. We recorded the patient’s subjective assessment of pain and the change in range of movement and pain scores during provocative tests. Results: Following the injection, the patient’s pain score decreased, provocation tests became negative, and the range of movement increased. Limitations: Case report. Target specificity and dispersion of local anesthetic spread not confirmed with an independent technique (i.e. magnetic resonance imaging). Conclusions: Ultrasound guidance allows the selective deposition of small volumes of local anesthetic into structures believed to cause soft tissue back pain and thus to confirm or exclude the working diagnosis. Further studies are needed to confirm our conclusions and to prove the clinical feasibility of this technique. Key words: Technique, visualization, real-time, ultrasound, iliolumbar ligament,iliolumbar syndrome, diagnostic injection, low back pain, groin pain.