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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 290-292

Extraordinary bilateral elongation of transverse processes of fifth lumbar vertebra causing severe pain: An unusual and rare variant of Bertolotti's syndrome


1 Department of Orthopaedics, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
2 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
3 Department of Anatomy, Government Medical College, Patiala, Punjab, India

Date of Web Publication27-Feb-2013

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.107898

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  Abstract 

A 53-year-old female presented with an intermittent low back pain above the sacroiliac joints to the orthopedic outpatient department. There was no history of trauma. Clinically, the straight-leg-raising test was negative. There was left paraspinal tenderness just above the sacroiliac joint and a nodular swelling in that area was felt. A plain radiograph was taken, which showed bilateral elongation and fusion of the fifth lumbar transverse process with the iliac crests and was diagnosed as a rare and unusual variant of Bertolotti's syndrome. There was also fusion of body of the fifth lumbar with first sacral vertebra. The patient was advised conservative treatment in the form of rest, medication, ergonomic advice, and local steroid injection in tender nodular area besides epidural administration of methylprednisolone with local anesthetic ropivacaine. The patient got therapeutic relief from the pain associated with lumbosacral pathology after epidural injection of local anesthetic and steroid. The patient was advised magnetic resonance imaging scan for further evaluation so as to plan surgical excision of fused transverse processes.

Keywords: Bertolotti′s syndrome, bilateral fused transverse processes, fifth lumbar vertebra, lumbosacral transition


How to cite this article:
Singh M, Bajwa SJ, Kaur H. Extraordinary bilateral elongation of transverse processes of fifth lumbar vertebra causing severe pain: An unusual and rare variant of Bertolotti's syndrome. Int J Health Allied Sci 2012;1:290-2

How to cite this URL:
Singh M, Bajwa SJ, Kaur H. Extraordinary bilateral elongation of transverse processes of fifth lumbar vertebra causing severe pain: An unusual and rare variant of Bertolotti's syndrome. Int J Health Allied Sci [serial online] 2012 [cited 2021 Sep 27];1:290-2. Available from: https://www.ijhas.in/text.asp?2012/1/4/290/107898


  Introduction Top


Anatomical variations in the lumbosacral spine have been rarely documented in the literature, which can have varied clinical presentations. The clinical implications of such anatomical variations can be unimaginable and may pose numerous diagnostic difficulties besides therapeutic challenges. Lumbosacral transitional vertebra (LSTV) is an anatomical variation of the fifth lumbar vertebra in which an enlarged transverse process can form a joint or fusion with the sacrum or ilium. [1],[2] The association of this variant with concomitant low back pain and alterations in the biomechanical characteristics of the lumbar spine is called Bertolotti's syndrome. This syndrome, which was first described in 1917 by Mario Bertolotti, an Italian physician, is characterized by a transitional fifth lumbar vertebra. The reported incidence is estimated at 4-21%. [1],[3] However, the nature of probable association between LSTV, low back pain, and disc degeneration has remained uncertain. [1],[4] We are reporting a 53-year-old female with an unusual variant of Bertolotti's syndrome who presented with intermittent low back pain just above the sacroiliac joints.


  Case Report Top


A 53-year-old female patient presented to the orthopedics outpatient department with intermittent low back pain just above the sacroiliac joints, which was excruciating at times. The etiology of pain could not be established during elicitation of history and the patient did not remember any past incidence of even trivial trauma. On clinical examination, no neurological deficit could be observed and the straight-leg-raising test was negative. However, there was localized tenderness on the left paraspinal region just above the sacroiliac joint with clear demonstration of nodular swelling in that area. The hematological and biochemical investigations were within normal limits. Radiographic investigations were also carried out, which revealed fusion of the body of fifth lumbar vertebra with the body of first sacral vertebra [Figure 1]. Surprisingly, there was bilateral anomalous enlargement of both the transverse processes of the fifth lumbar vertebra and their fusion to the corresponding iliac crests. The therapeutic planning was formulated after discussion with consultant anesthesiologist and a consultant who was vastly experienced in clinical anatomy. The therapeutic regimen included rest, symptomatic medications, local ultrasound therapy, and ergonomic advice besides an epidural injection of ropivacaine and methylprednisolone (depot preparation). The patient was administered injection ropivacaine (10 mL of 0.2%) admixed with 40 mg of methylprednisolone through the epidural route at lumbar 4 to 5 interspace in the anesthesia pre-op room. The patient was also administered a local steroid injection in nodular swelling near the left paraspinal region. The clinical efficacy of the therapeutic procedure was established within minutes as the patient got immense relief from pain, which remained suppressed even after two follow-ups 15 days apart. The clinical and anatomical variation of the disease process was clearly explained to the patient. Further, it was also advised to the patient to get magnetic resonance imaging (MRI) done for precise evaluation and possible surgical excision of long transverse processes which was, however, refused by the patient.
Figure 1: Lumbosacral transition with bilateral fusion of transverse processes of the fifth lumbar vertebra with iliac crest

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  Discussion Top


Anatomical variations pose numerous diagnostic and therapeutic challenges to the attending clinicians. One of the commonest anomalies seen in the fifth lumbar vertebra is the so-called "sacralization." [5],[6] This anomaly is characterized by an increase in the size of the transverse processes which is strikingly different from anatomical configuration of the ordinary lumbar transverse processes and somehow resembles the lateral masses of the sacral segments. Another anomaly of clinical interest related to the transverse process, which deserves a special mention here, includes its articulation or fusion with the ala or lateral portion of the sacrum. This articulation is frequent and distinct, and was named "lumbosacral transverse articulation" by Professor Dwight. Further, the articulation can occur even with the iliac crest, without having assumed sacral characteristics. This, however, is uncommon, and is highly unlikely to be congenital rather than acquired. [5],[6]

The fifth lumbar vertebra has massive transverse processes that are continuous with the pedicle and encroaches upon the body of the vertebra. These processes are mainly meant for the attachment of the iliolumbar ligament. With increasing age, the iliolumbar ligament can undergo secondary degenerative changes such as calcification, hyalinization, and myxoid degeneration. [7]

As per the radiographic classification given by Castellvi, there are four types of LSTV [1] -Type-I: Dysplastic transverse process with height >90 mm; Type-II: Incomplete lumbarization/sacralization; Type-III: complete lumbarization/sacralization with complete fusion with the neighboring sacral basis, and Type-IV: Mixed.

However, in this case there was type III lumbosacral transition associated with bilateral enlargement of the transverse processes of the fifth lumbar vertebra and there was fusion with the corresponding iliac crests. This rare anomaly that involved bilateral variation has hardly been reported in the accessible literature. The possible cause seems unlikely to be congenital, rather clinical postulates point toward an acquired etiology. Possibly, it could be due to the secondary degenerative changes in the iliolumbar ligaments attached to transverse processes on one end and the iliac crests on the other. [8],[9]

The association between LSTV and low back pain has been debated since it was first described by Bertolotti almost a century ago. Furthermore, several conflicting studies have been published regarding the association of LSTV with other spinal pathologies. There seems to be a possible relation with early disc degeneration above the LSTV in young patients. However, these differences fade with age as they are masked by other degenerative changes of the spine. From a clinical viewpoint, failure to recognize and failure to recognize LSTV exactly during spine surgery may have serious clinical consequences. [10]

The initial treatment of Bertolotti's syndrome, as with other causes of low back pain, is symptomatic which includes a combination of non-steroidal anti-inflammatory drugs and rehabilitative physical therapy. [4],[5],[8] The performance of anesthetic blocks at the articulation level between the mega-apophysis and the sacrum or iliac bone may be effective in temporarily relieving pain in some cases. In this case, administration of lumbar epidural block at L4-5 interspace with ropivacaine and methylprednisolone was quite effective. The selection of ropivacaine over bupivacaine and lignocaine was solely on the basis of its safe cardiovascular and neurological profile when used through the epidural route in various surgical procedures. [11],[12]


  Conclusion Top


The exact diagnosis of low back pain may be challenging at times, and in cases with anatomical variations, the diagnostic and therapeutic difficulties can increase tremendously. In patients with low back pain especially the young, the possibility of Bertolotti's syndrome should always be taken into account, if other common causes are easily ruled out.

 
  References Top

1.Paraskevas G, Tzaveas A, Koutras G, Natsis K. Lumbosacral transitional vertebra causing Bertolotti's syndrome: A case report and review of the literature. Cases J 2009;2:8320.  Back to cited text no. 1
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2.Luoma K, Vehmas T, Raininko R, Luukkonen R, Riihimaki H. Lumbosacral transitional vertebra: Relation to disc degeneration and low back pain. Spine (Phila Pa 1976) 2004;29:200-5.  Back to cited text no. 2
    
3.Quinlan JF, Duke D, Eustace S. Bertolotti's syndrome. A cause of back pain in young people. J Bone Joint Surg Br 2006;88:1183-6.  Back to cited text no. 3
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4.Dai L. Lumbosacral transitional vertebrae and low back pain. Bull Hosp J Dis 1999;58:191-3.  Back to cited text no. 4
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5.Aihara T, Takahashi K, Ogasawara A, Itadera E, Ono Y, Moriya H. Intervertebral disc degeneration associated with lumbosacral transitional vertebrae: A clinical and anatomical study. J Bone Joint Surg Br 2005;87:687-91.  Back to cited text no. 5
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6.Elster AD. Bertolotti's syndrome revisited. Transitional vertebrae of the lumbar spine. Spine (Phila Pa 1976) 1989;14:1373-7.  Back to cited text no. 6
    
7.Eom KS, Kim TY, Moon SK. Extreme elongation of the transverse processes of the fifth lumbar vertebra: An unusual variant. Turk Neurosurg 2011;21:648-50.  Back to cited text no. 7
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8.Otani K, Konno S, Kikuchi S. Lumbosacral transitional vertebrae and nerve-root symptoms. J Bone Joint Surg Br 2001;83:1137-40.  Back to cited text no. 8
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9.Brault JS, Smith J, Currier BL. Partial lumbosacral transitional vertebra resection for contralateral facetogenic pain. Spine (Phila Pa 1976) 2001;26:226-9.  Back to cited text no. 9
    
10.Bron JL, van Royen BJ, Wuisman PI. The clinical significance of lumbosacral transitional anomalies. Acta Orthop Belg 2007;73:687-95.  Back to cited text no. 10
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11.Bajwa SJ, Bajwa SK, Kaur J, Singh G, Arora V, Gupta S, et al. Dexmedetomidine and clonidine in epidural anaesthesia: A comparative evaluation. Indian J Anaesth 2011;55:116-21.  Back to cited text no. 11
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12.Bajwa SJ, Kaur J, Bajwa SK, Bakshi G, Singh K, Panda A. Caudal ropivacaine-clonidine: A better post-operative analgesic approach. Indian J Anaesth 2010;54:226-30.  Back to cited text no. 12
[PUBMED]  Medknow Journal  


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