Bertolotti’s syndrome

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A 23-year-old, female, recreational player presents with a two year history of left-sided lumbar region pain. She had previously been noted to have transitional lumbosacral anatomy and has attempted a coordinated rehabilitation program. This had involved regular physiotherapy treatments, a progressive core stability program and a guided local anaesthetic/steroid injection. Despite this she has continued to have activity related pain and has been unable to continue to play football. She has also required regular analgesics.

On examination she had a near-normal lumbar assessment. The only finding of note was of localised tenderness over the left low-lumbar region in the vicinity of the pseudoarthrosis.

X-ray images of the lumbar spine show a transitional lumbosacral vertebrae at L5. There is sacralisation of the left transverse process with articulation to the sacrum via a pseudoarthrosis. The transverse process on the right, as well as the remainder of the lumbar spine, is normal. An MRI scan, from her original presentation, shows increased signal related to the pseudoarthrosis. A SPECT scan, conducted at the time of her repeat assessment, shows that there is markedly increased uptake related to the pseudoarthrosis. A post-operative x-ray image shows a fusion of the L5-S1 level with pedicle screws and posterior interconnecting rods.

This player was very keen to pursue surgical treatment given her lack of response to a prolonged period of non-surgical treatment. Prior to considering surgery a SPECT scan was completed. This showed markedly increased signal related to the pseudoarthrosis. It should also be noted that she had experienced a very good response from a guided injection into this articulation. She elected to undergo a posterior instrumented spinal fusion L5-S1. Following surgery she was in hospital for four nights to help control her pain and to ensure she could safely mobilise. For six weeks she was limited to a progressive walking program. During this time she also had some physiotherapy treatments and started some body-weight exercises. She was unable to play football for a period of six months however during this time she started with a limited running-based program. From six months following surgery she was able to progressively return to running and football activities. At nine months following surgery she was able to return to football training. At this point her left sided low back pain had largely resolved. She did have some persisting, more generalised lumbar discomfort after activity.

It is important to highlight that the majority of players who are found to have transitional lumbosacral anatomy have this as an incidental finding, rather than the primary cause of their symptoms. As this case illustrates, MRI scanning, SPECT imaging and diagnostic injections can all help to determine whether a pseudoarthrosis is contributing to the player’s symptoms. Bertolotti’s syndrome (BS) refers to the association between transitional lumbosacral vertebrae and low back pain. The literature regarding BS is very limited and is generally of low quality. In most cases rehabilitation is an effective treatment. This may include physiotherapy treatments, analgesia, load management and guided injections. Surgical treatment should only be considered when a player fails non-surgical treatment. Laminectomy, spinal fusion or resection of the transitional articulation have all been described in the literature.

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