Interventional Pain Physician Touro University California - College of Osteopathic Medicine Vallejo, California
Abstract Title: Chronic Axial Low Back Pain and Bertolotti's Syndrome in an Older Patient: A Case Report
Background: Bertolotti’s Syndrome (BS) is a rare and often refractory cause of low back pain (LBP) that typically presents in younger patients due to a lumbosacral transitional vertebrae (LSTV) articulation between the L5 transverse process (TP) and sacrum. This diagnosis is less common in older patients and the exact cause is unknown. Some attribute this pain to a change in load transmission and bone morphology1, while others propose lumbar nerve entrapment and arthritic changes due to the enlarged lumbar transverse process pseudoarticulation with the sacrum2. There is no clear standard for the diagnosis and treatment. BS can be easily missed on radiographs, indicating a need for high levels of physician suspicion when patients present with recurring LBP post-treatment. Treatment begins conservatively with physical therapy and steroid injections before usually resulting in surgical intervention3. A rigorous literature review found that minimally invasive tubular microscopic decompression and disarticulation can be used as an effective surgical treatment for BS characterized by LSTV4.
Purpose/Objectives: To demonstrate the challenges of addressing Bertolotti's Syndrome in older patients, a condition that is often missed. Bertolotti's Syndrome is usually found in patients from a younger demographic, but some cases may arise where older patients return to the clinic with unexplained low back pain, exposing the root cause as Bertolotti's Syndrome.
Methods: As this is a case report, no extraneous methods were utilized in assessing the patient outside of the standard therapy and care provided within the clinic. Standard lab results and imaging in conjunction with thorough EMR records filed over a long period of time were used to build the case report and examine the challenges associated when treating an older patient with Bertolotti's Syndrome.
Results: We present the case of a 66-year-old male with a relevant history of chronic right upper back pain who complains of axial low back pain since he was 12 years old without underlying trauma. A recent lumbar spine x-ray showed multiple findings, including the TP of the right L5 articulating with the sacrum. Despite conservative interventions for his low back pain and stiffness, symptoms persisted. A steroid injection was administered into the bilateral lower lumbar paraspinals which provided relief of symptoms. A probable Bertolotti’s Syndrome was diagnosed, explaining the presenting symptomatology.
Conclusions/Implications for future research and/or clinical care: This case underlines the importance of maintaining high levels of suspicion for Bertolotti’s syndrome in cases of chronic low back pain in older patients. A standardized treatment regimen is yet to be established for helping patients struggling with Bertolotti's syndrome. The additional references examined in conjunction with this case may provide insight into establishing a consistent standard of care for patients with this condition in the future.
References:
Golubovsky JL, Momin A, Thompson NR, et al.. Understanding quality of life and treatment history of patients with Bertolotti syndrome compared with lumbosacral radiculopathy. J Neurosurg. 2019;31:222–8.
Weber J, Ernestus RI. Transitional lumbosacral segment with unilateral transverse process anomaly (Castellvi type 2A) resulting in extraforaminal impingement of the spinal nerve. Neurosurg Rev. 2011;34:143–50.
Afana H, Raffat M, Figueiredo N. Surgical Pitfalls in Bertolotti's syndrome management: A case report. Medicine (Baltimore). 2022;101(50):1-8.
Chang CJ, Chiu YP, Ji HR, Chu CH, Chiu CD. Surgical interventions for Bertolotti's syndrome: case report and review of unsatisfactory cases in the literature. BMC Surg. 2022;22(1):36:1-8.
