What is the management of Bertolotti syndrome?

Management of Bertolotti Syndrome

The management of Bertolotti syndrome should begin with conservative treatment including physical therapy, anti-inflammatory medications, and lifestyle modifications, followed by targeted injections at the pseudoarticulation if conservative measures fail, with surgical resection of the abnormal transverse process reserved for refractory cases. 1, 2

Diagnosis

• Bertolotti syndrome is defined as chronic low back pain caused by a lumbosacral transitional vertebra (LSTV), typically presenting with:

  • Pain in the sacroiliac joint, groin, and hip region
  • Possible radiculopathy
  • Symptoms similar to common degenerative spine diseases

• Diagnostic imaging:

  • X-rays to identify the transitional vertebra
  • CT scan to better visualize the pseudoarticulation
  • MRI to evaluate for associated nerve compression or disc degeneration

• Diagnostic injection:

  • Local anesthetic injection at the pseudoarticulation can confirm the diagnosis if it provides temporary pain relief

Treatment Algorithm

First-Line: Conservative Management

• Physical therapy focusing on core strengthening and lumbar stabilization
• Anti-inflammatory medications (NSAIDs)
• Activity modification and ergonomic adjustments
• Weight management if applicable

Second-Line: Injection Therapy

• Targeted injections at the pseudoarticulation between the transverse process and sacral ala
  • Local anesthetic with or without corticosteroids
  • Studies show these provide better symptomatic relief than other injection types 3
• Epidural steroid injections may be considered if radicular symptoms are present
• Patients responding well to pseudoarticulation injections are better candidates for surgical intervention if needed 3

Third-Line: Surgical Intervention

For patients with persistent symptoms despite conservative treatment and injections:

1. Pseudoarthrectomy (surgical resection of the abnormal articulation)

   • Most common surgical approach
   • Shown to provide significant pain relief in properly selected patients 4, 3

2. L5 Transverse Processectomy

   • Particularly effective when the L4 nerve root is compressed by the enlarged L5 transverse process
   • Studies show 86.89% satisfactory results with this approach 5

3. Spinal Fusion

   • Reserved for cases with significant instability or when other surgical approaches have failed

Special Considerations

• Early identification of Bertolotti syndrome is crucial as undiagnosed patients often undergo multiple ineffective injections 3
• Young patients with intractable pain should be considered for earlier surgical intervention to prevent years of chronic pain 4
• Radiofrequency ablation around the transitional segment may provide relief in some cases 1
• Post-surgical rehabilitation is essential for optimal outcomes

Outcomes and Prognosis

• Properly diagnosed and treated patients typically experience significant pain reduction
• Surgical outcomes are generally favorable in carefully selected patients
• Pain improvement is usually noted within 6 weeks of surgical intervention 4
• Long-term outcomes depend on proper patient selection and appropriate treatment targeting the specific pain generator

The evidence for Bertolotti syndrome management is primarily based on smaller cohort studies and case series, highlighting the need for larger clinical trials to establish stronger evidence-based guidelines 1.