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Case report
Bertolotti syndrome: Report of a case
Síndrome de Bertolotti: a propósito de un caso
Marina Soledad Moreno Garcíaa,
Corresponding author
, Pilar S. del Río-Martíneza, Pablo Baltanás Rubiob, Pedro Cía Blascob
a Servicio de Reumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Servicio de Anestesia y Reanimación, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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more pronounced in the right side&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The nuclear magnetic resonance &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; reveals some degree of disk dehydration&#44; with moderate diffuse bulging of the annulus fibrosus of the intervertebral discs L4-L5 and L5-S1&#44; with a small posterior annular tear at the L5-S1 level&#46; It also shows interapophyseal degenerative phenomena that cause decrease of the caliber of foramina at the L4-L5 and L5-S1 levels&#44; of greater connotation at the right L4-L5 level&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">With a diagnosis of alteration of the lumbosacral transitional vertebra or Bertolotti syndrome&#44; we intensified the analgesic treatment along with rehabilitation&#44; but given the poor response&#44; she was referred to the unit of pain management of our hospital&#44; where a block of the medial branch of the dorsal branch of the spinal nerve &#40;facet block&#41; at the L3-4&#44; L4-L5 and L5-S1 levels was carried out&#44; with local anesthetic and corticoid&#44; with a positive but transient outcome&#46; This block served for the localization of the structure that caused the low back pain&#46; For this reason it was decided&#44; subsequently&#44; to perform a conventional radiofrequency &#40;rhizolysis&#41; of the medial branches&#44; of the dorsal branches of the spinal nerves&#44; at the L3-L4&#44; L4-L5 and L5-S1 levels&#44; in the right side&#46; This radiofrequency&#44; by using temperatures of 80 degrees&#44; is ablative because it denervates the innervated joints&#46; In this case the neo-articulation formed between the transverse mega-apophysis of L5 and the iliac blade&#44; receives the innervation from these branches&#44; and therefore&#44; its denervation can produce relief of the low back pain&#44; if this is the cause of this pain&#46; In this patient there was a significant pain relief after performing the rhizolysis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Bertolotti syndrome was described in 1917 by Mario Bertolotti&#44; as already mentioned&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> It is a congenital anatomical abnormality&#44; present&#44; according to the literature&#44; in 7&#8211;20&#37; of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> It is defined by the presence of a transverse mega-apophysis that articulates with the sacrum or the ilium&#44; which leads to an alteration in the lumbosacral transition&#44; and therefore&#44; to a change in the biomechanics of the axial skeleton&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This alteration can be bilateral or unilateral&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> producing a low back pain clinic usually after the second decade of life&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Most patients are asymptomatic&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> although when it is assymetric<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> it can generate pain&#44; originated in different structures&#58; a neo-articulation in the affected side&#44; arthrosis in the posterior interapophyseal joints&#44; facet arthrosis in the contralateral side&#44; pain in the sacroiliac joint&#44; and even discogenic pain and lumboscyatic pain&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is characterized by low back pain&#44; because there is an abnormal mechanical tension which leads to an affectation of the facet joint&#44; overstrain of the psoas and quadrate lumborum muscles&#44; a compression of the nerve root due to the narrowing of the intervertebral foramina and the increased prevalence of protrusion or extrusion of the disk above the transitional vertebra L5&#46; This would explain the lumbosciatic pain experienced by some of these patients&#46; We should not forget that in almost 30&#37; of patients who have undergone a surgery of herniated disc<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> there is an alteration of the lumbosacral transition&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">For its diagnosis we should be based on the clinic of low back pain and the radiological findings &#40;lumbosacral radiograph&#44; nuclear magnetic resonance&#44; CT scan&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The lumbosacral transitional vertebra&#44; anatomically defined as a vertebra that shares similar characteristics with both the upper and lower vertebral segments&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> has been classified into 4 types according to the method of Castellvi<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Type I&#58; dysplastic transverse process&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Type II&#58; lumbarization&#47;sacralization with enlargement of the transverse process which forms a diarthrosis with the sacrum&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Type III&#58; fusion of the transverse process with the sacrum&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Type IV&#58; mixed &#40;it includes a unilateral type II with a type III in the contralateral side&#41;&#46;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Each type is subdivided into a or b&#44; according to whether they are unilateral or bilateral&#44; respectively&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The initial treatment should be conservative &#40;NSAIDs &#8211; muscle relaxants and rehabilitation&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> while there are interventionist alternatives<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;9</span></a> such as infiltration of the lumbosacral neo-articulation<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> with local anesthetics or steroids&#44; the infiltration of facet joints and the radiofrequency sensitive ablation&#44; also called rhizolysis&#44; and even a more aggressive intervention such as the resection of the transverse mega-apophysis&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> with controversial outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The block at the level of the nerves that supply the joint &#40;facet or lumbosacral neo-articulation&#41; is temporarily effective and it help us to identify the origin of the pain&#46; In the case that we present&#44; it was carried out a block with anesthetic and corticoid in the facet joints at different levels and&#44; given the positive response&#44; it was decided the radiofrequency ablation &#40;rhizolysis&#41; of the sensory branches which are responsible for the facet innervation and hypothetically for the neo-articulation formed between the mega-transverse and the iliac blade&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">This interventional technique seeks the percutaneous radiofrequency lumbar facet denervation&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11&#44;12</span></a> It is based on the application of an electrode in the proximity of the posterior branch of the spinal nerve in its emergence between the facet and the transverse process&#44; with the aid of fluoroscopy by AP or lateral projection&#44; to verify the exact location of the electrode&#44; which transmits heat generated by radiofrequency&#44; causing damage in a controlled manner&#44; which produces the cessation of the transmission of the pain originated in its innervation territory&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> A sensorimotor stimulation should be conducted before producing the lesion&#44; in order to check the proper placement of the electrode and&#44; therefore&#44; it should be verified that the motor stimulation does not generate a muscle contraction in the territory of the stimulated root&#44; thus ensuring there is no damage to the anterior branch of the spinal nerve&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Bertolotti syndrome has a high incidence and occurs in a high percentage in young people&#46; The treatment should be initially conservative&#46; However&#44; in refractory cases and with an intense level of pain&#44; interventional treatment can be an alternative in these patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bertolotti&#39;s syndrome was first described in 1917&#46; It is due to a congenital anatomical abnormality&#44; and is defined by the presence of a transverse mega-apophysis&#44; which entails an alteration in the lumbosacral transition&#46; It can cause pain due to involvement of various structures&#58; lumbosacral neo-articulation&#44; contralateral facet arthrosis&#44; sciatica&#44; discogenic&#44; or sacroiliac pain&#46; It is characterized by low back pain&#44; with a normal physical examination&#46; According to some studies&#44; the incidence is high &#40;between 7&#37; and 20&#37;&#41;&#46; Initial treatment should be conservative&#44; while there are interventionist alternatives&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Bertolotti fue descrito en 1917&#46; Se debe a una anormalidad anat&#243;mica cong&#233;nita y se define por la presencia de una megaap&#243;fisis transversa&#44; que conlleva una alteraci&#243;n en la transici&#243;n lumbosacra&#46; Puede generar dolor por afectaci&#243;n de diversas estructuras&#58; neoarticulaci&#243;n lumbosacra&#44; artrosis facetaria del lado contralateral&#44; lumbociatalgia&#44; dolor discog&#233;nico o dolor sacroil&#237;aco&#46; Se caracteriza por un dolor lumbar bajo&#44; con una exploraci&#243;n f&#237;sica normal&#46; Seg&#250;n algunos estudios la incidencia es elevada &#40;entre 7 y 20&#37;&#41;&#46; El tratamiento inicial debe ser conservador&#44; si bien existen alternativas intervencionistas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Moreno Garc&#237;a MS&#44; del R&#237;o-Mart&#237;nez PS&#44; Baltan&#225;s Rubio P&#44; C&#237;a Blasco P&#46; S&#237;ndrome de Bertolotti&#58; a prop&#243;sito de un caso&#46; Rev Colomb Reumatol&#46; 2016&#59;23&#58;200&#8211;203&#46;</p>"
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