Bertolotti’s Syndrome is the clinical presentation of back pain, sciatica (electrical pain that shoots down the leg), or both, associated with the congenital anomaly of a bone in the spine rubbing against part of the pelvis, also known as a lumbosacral transitional vertebra (LSTV). Because of the overlap of the symptoms with other more common conditions (herniated disks, spondylolisthesis, SI joint instability, hip pathology, and other regional conditions), it is often overlooked as a cause of patient’s pain. In fact, it is one of the more difficult to identify because it often sounds like something else, and the imaging (CT, X-ray, MRI) is not always done in a way that shows the anomaly well. It is also not well understood by many spine surgeons, so it is often missed.
Early in spine development, there comes a time when the bottom 4 vertebrae of the spine (also known as the sacrum, the black bone in the first image) fuses (or becomes one bone) and then sits in the middle of the two halves of the pelvis known as the iliac wings (white bones in first image). These three bones make up the pelvis, and the other 24 vertebral bodies of the spine (blue bones, first image) sit on top of the sacrum.
In about 10% of people, the junction between the 5 mobile lumbar vertebrae and the single block vertebra of the sacrum … becomes a bit blurred. Image 2 shows a model of a patient with one variant of the congenital anomaly. The bottom lumbar vertebra (L5) seems to “try” to fuse into the sacrum, by having a much larger transverse process (TP) that is much closer to the sacrum (red line, second image) than it is to the L4 transverse process (green line) and the outside top of the sacrum seems to reach up to meet this larger transverse process (blue arrow; blue lines are where “normal” bone margins would be located on the sacrum and L5 TP, see second image)
When a patient has other findings on MRI or X-ray that could also contribute to the symptoms, it is useful to have diagnostic tools to help separate the symptoms from Bertolotti’s syndrome from those of other spinal conditions: herniated disks, stenosis, facet arthritis, sacroiliac instability, fractures, slipped discs (“spondylolisthesis”), hip problems, a hernia, and other lesions in this area. The use of direct injections into the region of the bone interface, similar to epidural steroid injections but targeting the specific anatomy of the anomaly can be very helpful. Response to this particular injection seems to be fairly specific and sensitive to the diagnosis of Bertolotti’s. In Bertolotti’s syndrome, we believe that the back pain is due to the direct contact between the bone of the L5 transverse process with either the ala or the iliac bone, which because the anomaly is not a normal joint, does not have the proper articular cartilage to protect it. This bone-on-bone contact can be caused by normal movement bringing them into contact with each other. It can also cause leg pain because the nerve root runs just in front of the bones. In other cases, the bones are so close they make a false joint, and movement of that false joint causes pain because it doesn’t have the normal cartilage lining that protects the bone.
Traditional conservative management of Bertolotti’s Syndrome consists of injections for pain management, and physical therapy. If that doesn’t work, surgical treatments have historically consisted of big open surgeries, either to open up the space, or to fuse the two bones together so they don’t move any more, or putting a probe next to one of the nerves in the area to burn it and make the area numb. We have developed a procedure, done minimally invasively and that is usually done as an outpatient procedure (go home same day) where we trim down the two bones so they don’t come into contact with each other anymore. We have presented our results at international meetings, and continue to study the treatments to determine the best approach for each patient.
If you or your doctor thinks you may have Bertolotti’s Syndrome, please feel free to have them contact our office at 212-241-8175 for an evaluation. One of our trained doctors may be able to consult on your case to determine what the next steps should be for you. To read more, click here.