PDF - Annals of Clinical Case Reports

Annals of Clinical Case Reports
Case Report
Published: 27 May, 2016
Individualizing Radiofrequency Ablation Therapy in Two
Patients with Bertolotti’s Syndrome
Philip A* and Modzelewska M
Department of Anesthesiology and Physical Medicine and Rehabilitation, University of Rochester Medical Center,
USA
Abstract
Objective: Describe the clinical presentation, diagnostic evaluation, and successful treatment of
two cases of Bertolotti's syndrome using radiofrequency ablation targeting levels based on the
distribution of each individual patient's pain and radiological findings.
Case: We describe two cases of young patients with Bertolotti’s syndrome resulting in axial low
back pain. In case 1 the patient had Lumbarization of S1 vertebra hence the diagnostic block was
performed with 0.5% bupivacaine along the pseudo-articulation and also we targeted the L5 medical
branch and S1 lateral branch this resulted in complete pain relief. Radiofrequency ablation was
performed of the same locations resulting in 100% pain relief for 10 months.
In case 2 the patient had partially sacralized L5 transitional vertebra hence the diagnostic block was
performed with 0.5% bupivacaine along the pseudo-articulation and also we targeted the L4 and L5
medical branch this resulted in 80% pain relief. Radiofrequency ablation was performed of the same
locations resulting in 80% pain relief which lasted for 7 months.
Conclusion: By describing these two cases of Bertolotti’s syndrome we want to highlight how
radiofrequency ablation therapy can be individualized depending on lumbarization or sacralization
of the transitional vertebrae.
OPEN ACCESS
*Correspondence:
Annie Philip, Department of
Anesthesiology and Physical Medicine
and Rehabilitation, University of
Rochester Medical Center, 601
Elmwood Avenue BOX 604 Rochester,
NY-14642, USA, Tel: 585-242-1300l;
Fax: 585-244-7271;
E-mail: [email protected].
edu
Received Date: 28 Apr 2016
Accepted Date: 20 May 2016
Published Date: 27 May 2016
Citation:
Philip A, Modzelewska M.
Individualizing Radiofrequency Ablation
Therapy in Two Patients with Bertolotti’s
Syndrome. Ann Clin Case Rep. 2016;
1: 1004.
Copyright © 2016 Philip A. This is an
open access article distributed under
the Creative Commons Attribution
License, which permits unrestricted
use, distribution, and reproduction in
any medium, provided the original work
is properly cited.
Keywords: Bertolotti’s Syndrome; Pseudo articulation; Radiofrequency ablation
Background
Bertolotti's syndrome is defined as axial low back pain in the presence of lumbosacral
transitional vertebrae, in which the enlarged transverse processes of the most caudal lumbar or the
first sacral vertebrae either articulate or fuse with the sacrum or ilium to varying degrees. Bertolotti's
syndrome is important to consider in the differential diagnosis of axial low back pain in young
patients. This anatomical variant affects approximately 4-8% [1] of the population with a prevalence
higher in males compared to females (28.1 vs 11.1%) [2]. Throughout literature the prevalence of
individuals with lumbosacral transitional vertebrae seeking care for low back pain ranges from
4.6-35.6% [3-5]. The diagnosis of Bertolotti's syndrome is based on radiological findings and their
clinical correlation [6]. Plain X-rays of the lumbosacral spine in the anteroposterior view are usually
sufficient. If patients present with radicular symptoms this may necessitate ordering of a lumbar
spine MRI to rule out other etiologies.
As discussed previously, anatomic variations of lumbosacral transitional vertebrae have been
described. The morphology can vary, from partial/complete L5 sacralization to partial/complete S1
lumbarization (Figure 1). Castellviet al. [7] classified LSTV into 4 types. Type I includes unilateral (Ia)
or bilateral (Ib) dysplastic transverse processes, measuring at least 19 mm in width (craniocaudad
dimension). Type II exhibits incomplete unilateral (IIa) or bilateral (IIb) lumbarization/
sacralizationwith an enlarged transverse process that has a diarthrodial joint between itself and
the sacrum. Type III describes unilateral (IIIa) or bilateral (IIIb) lumbarization/sacralization with
complete osseous fusion of the transverse process (es) to the sacrum. Type IV involves a unilateral
type II transition with a type III on the contralateral side. Type I and Type II was the most common,
accounting for 40% of the lumbosacral transitional vertebra. Type III accounted for 11.5% and Type
IV for 5.25% [2]. Case 1
Remedy Publications LLC., | http://anncaserep.com/
45 year old male with an eight year history of bilateral lumbar axial predominant low back pain.
1
2016 | Volume 1 | Article 1004
Annie Philip, et al.
Annals of Clinical Case Reports - Pain Management Case Reports
Figure 1: Lumbarization of S1 vertebra.
The patient described this as a burning pain, which was exacerbated
with sitting or twisting while golfing. He rated his pain as 7-10/10.
He denied any radiation of pain to his lower extremities and also
denied any numbness or tingling in his lower extremities. The
patient had participated in physical therapy and had been on antiinflammatory medication with minimal pain relief. Examination
revealed reproduction of pain in the lower lumbar paravertebral
region and in the upper sacral region. This pain was exacerbated by
lateral rotation and extension. The patient’s neurological exam did
not reveal any deficits. Lumbar X-ray revealed lumbarization of
the 1st sacral vertebrae. Lumbar MRI did not reveal any significant
pathology.
Figure 2: Partially sacralized L5 transitional vertebra.
period to time. She rated her pain 3-7/10. The patient had tried opioid
medications, anti- inflammatory medications and physical therapy
with minimal pain relief. On physical exam the pain was reproduced
by palpation in the lumbar paravertebral region bilaterally. The pain
was exacerbated by lumbar lateral rotation and extension bilaterally.
Neurological exam did not reveal any deficits. Plain radiographs of
her lumbar spine were obtained demonstrating a partially sacralized
L5 transitional vertebra (Figure 2). Lumbar MRI showed minimal
disc protrusion at L5-S1.
Based on his physical exam and radiographic findings, the
diagnosis of Berolottti’s syndrome (Lumbosacraltransitional vertebra
type IIb) was made. The decision was made to target the pseudoarticulation of the S1 transverse process and the sacral alae.
Her physical exam and review of the radiographic findings led
to the diagnosis of Bertolotti’s syndrome (lumbosacral transitional
vertebrae type IIb). As the aforementioned case had provided positive
results, the decision was made to target the pseudo-articulation of the
L5 transverse process and the L4 and L5 medical branch.
The first diagnostic block was performed under fluoroscopy using
a 22 gauge 3.5 inch needle with 1cc each of 0.5% bupivacaine targeting
the pseudo-articulation in the upper, middle and lower border of S1
transverse process and sacral alae bilaterally. Follow up phone call
the next day revealed that patient had only 50% pain relief for 4
hours. A second diagnostic block was performed with 1cc of 0.5%
bupivacaine at the L5 medical branch, 1cc of 0.5 % Bupivacaine at the
S1 lateral branch and 1cc each of 0.5% bupivacaine along the pseudoarticulations in the upper, middle and lower border of S1 transverse
process and sacral alae bilaterally. Follow up phone call after this
procedure revealed that this provided him with 100% pain relief for
4 hours. Since he reported significant pain relief from the second
diagnostic intervention, radiofrequency ablation was performed
using a 20 gauge 10cm, 10mm RF needle at 80 degree centigrade for 80
seconds at the L5 medical branch, S1 lateral branch and three lesions
along the upper, middle and lower border of the pseudo-articulations
of the S1 transverse process and sacral alae bilaterally.
The first diagnostic block was performed under fluoroscopy using
a 22 gauge 3.5 inch needle with 1cc of 0.5% bupivacaine at L4 and L5
medial branches and also with 1cc each along the pseudo-articulation
in the upper, middle and lower border bilaterally. Phone call after
the procedure revealed that she had reported 80% pain relief after
this intervention. Radiofrequency ablation was offered to provide
sustained relief. Radiofrequency ablation was performed using 20
gauge 10cm, 10mm RF needle at 80 degrees centigrade for 80 seconds
at the L4 and L5 medial branches and three lesions were performed
along the upper, middle and lower border bilaterally at the pseudoarticulation.
When the patient was seen for her 2 month follow up, she
continued to report 80% pain relief in the lower lumbar region which
lasted for 7 months after the radiofrequency ablation. Medication
usewas no longer necessary and the patient were able to return to full
functionin school.
When the patient was seen for follow up 2 months after the
procedure, he reported 100% pain relief lasting 10 months after
the radiofrequency ablation, during which time patient was able to
resume golfing.
Discussion
Lumbosacral transitional vertebrae are increasingly recognized
as common anatomical variants associated with altered patterns of
degenerative spine changes. The causes of back pain in Bertolotti's
syndrome are multifactorial. Pseudo articulations between the
transverse process and the sacrum create a "false joint" susceptible
to arthritic changes and osteophyte formation potentially leading to
nerve root entrapment. Abnormal mechanical stress can lead to facet
arthropathy as a contributing factor [8]. Other causes include iliopsoas
and quadratus lumborum strain, nerve root compression due to
Case 2
A 19 year old female presented to our clinic with axial predominant
low back pain of three years duration. The patient described the pain
as a burning, pressure like sensation in the lower lumbar region.
She denied any radiation of pain down to her lower extremities. The
pain was exacerbated by twisting, bending and sitting for prolonged
Remedy Publications LLC., | http://anncaserep.com/
2
2016 | Volume 1 | Article 1004
Annie Philip, et al.
Annals of Clinical Case Reports - Pain Management Case Reports
the narrowing of the intervertebral foramen,and disc protrusion or
extrusion in the disc above the transitional L5 vertebra.
2. Nardo L, Alizai H, Virayavanich W, Liu F, Hernandez A, Lynch JA, et
al. Lumbosacral transitional vertebrae: association with low back pain.
Radiology. 2012; 265: 497-503.
The other common differential diagnosis to be considered for
axial predominant low back pain are muscle strain or ligamentous
injury, degenerative disc disease, spondylolysis, facet mediated pain,
primary or secondary neoplastic disease, infection and Baastrup’s
disease.
3. Paik NC, Lim CS, Jang HS. Numeric and morphological verification of
lumbosacral segments in 8280 consecutive patients. Spine 2013; 38: E573578.
4. Apazidis A, Ricart PA, Diefenbach CM, Spivak JM. The prevalence of
transitional vertebrae in the lumbar spine. The spine journal: official
journal of the North American Spine Society. 2011; 11: 858-862.
As the study by Bogduk and Long [9] indicated that medial
branches transmit pain sensation from the capsule of the facet joints
from the level above and same level, there has been numerous studies
published about the efficacy of radiofrequency ablation for treatment
of facet mediated low back pain. A systematic review of randomized
controlled trials of radiofrequency ablation for lumbar facet joint
pain [10] revealed 6studies. All six studies assessed pain reduction
using a visual analogue scale. Five of the studies found evidence of
statistically significant pain relief when compared to sham RFA. One
of studies did not show any evidence of statistically significant benefit.
5. Tang M, Yang XF, Yang SW, Han P, Ma YM, Yu H, et al. Lumbosacral
transitional vertebra in a population based study of 5860 individuals:
Prevalence and relationship to low back pain. European journal of
radiology. 2014; 83: 1679-1682.
6. Jain A, Agarwal A, Jain S, Shamshery C. Bertolotti syndrome: a diagnostic
and management dilemma for pain physicians. Korean J Pain. 2013; 26:
368-373.
7. Castellvi AE, Goldstein LA, Chan DP. Lumbosacral transitional vertebrae
and their relationship with lumbar extradural defects. Spine (Phila Pa
1976). 1984; 9: 493-495.
Although there have been multiple studies in the literature about
radiofrequency ablation for lumbar facet pain, there has been only
one case report by Burnham [11] in the literature describing the
benefit of radiofrequency ablation for Berolotti’s syndrome.
8. Mahato NK. Facet dimensions, orientation, and symmetry at L5-S1
junction in lumbosacral transitional States. Spine (Phila Pa 1976). 2011;
36: E569-573.
9. Bogduk N, Long DM. The anatomy of the so-called “articular nerves” and
their relationship to facet denervation in the treatment of low-back pain. J
Neursourg. 1979; 51: 172-177.
Conclusion
Bertolotti’s syndrome should be considered in the differential
diagnosis of young patients presenting with axial predominant low
back pain. To date, there has been no consensus about the best method
for the treatment of Bertolotti's syndrome. Radiofrequency ablation
can be a successful option for management of pain in patients with
Bertolotti’s syndrome. The above mentioned cases demonstrate how
this therapy can be individualized depending on lumbarization or
sacralization of the transitional vertebrae.
10.Leggett L, Soril L, Lorenzetti D, Noseworthy T,Steadman R, Tiwana S, et al.
Radiofrequency ablation for chronic low back pain : A systematic review of
randomized controlled trial. Pain Res Manag. 2014; 19: e146-e153.
11.Burmham R. Radiofrequency sensory ablation as a treatment for
symptomatic unilateral lumbosacral junction Pseudo articulation
(Bertolotti’s Syndrome): A case report. Pain Medicine. 2010; 11: 853-855.
References
1. Aihara T, Takahashi K, Ogasawara A, Itadera E, Ono Y, Mariya H.
Intervertebral disc degeneration associated with lumbosacral Transitional
vertebrae: a clinical and anatomical study. J Bone Joint Surg Br. 2005; 87:
687-691.
Remedy Publications LLC., | http://anncaserep.com/
3
2016 | Volume 1 | Article 1004