New SURGICAL STRATEGIES in the management of patients with BERTOLOTTI’S SYNDROME
Channel: Nicandro Figueiredo
Date: 2021-02-20

ABSTRACT  
RATIONALE: Lumbosacral transitional vertebrae (LSTV) are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes. Due to possible other comorbidities present in the spine, the diagnosis of Bertolotti's syndrome (BS) is not straightforward thus making it a diagnosis of exclusion. BS consists of low-back pain caused by LSTVs and associated biomechanical spinal changes and associated spinal disorders like: lumbar disc degeneration or disc herniation; degeneration of the anomalous joint between the LSTV-TP and the sacrum; facet arthrosis ipsi-or contralateral to an unilateral fused or articulating LSTV; hypertrophy or broadened of the enlarged TP compressing the nerve root (far out syndrome); secondary lumbar scoliosis, more in asymmetric pseudo-joint. There is a lack of consensus regarding the cause, clinical significance, and treatment of this condition. 
OBJECTIVE: The authors aim to review the most important aspects for the management of this syndrome, associated spinal abnormalities and discuss the most important features, including their own experience on the treatment of this syndrome. 
METHODS: A literature review related to surgical treatment of BS was performed and the main aspects were presented. An author’s series of consecutive patients who had the diagnosis of symptomatic BS underwent minimally invasive (MIS) paramedian tubular-based resection of the LSTV for BS were identified and also described. The authors used MIS-tubular transverse processectomy, checked by IONM (intraoperative neuromonitoring) and image guided, initially only fluoroscopy, and at the last 4 cases, it was used fluoroscopy plus O-arm (advanced 3D intraoperative image system) during the procedure. 
RESULTS: A series of 12 consecutive patients with chronic low-back pain associated with LSTV and BS, who had transient pain relief on pseudo-joint image-guided injection with steroid and anesthetics, were submitted to the MIS-tubular microsurgical transverse processectomy, 6 patients had associated lumbar disc disease treated simultaneously, and 6 had only BS. Medical records were reviewed to identify demographics, operative data, and outcome. The vast majority of the patients had very good result regarding the relieve of the pain related to the BS. There was 1 case of incomplete resection of the bone, when it was used only fluoroscopy, being the patient submitted to another surgery to remove the bone bridge 3 days after the index surgery; and 1 case of wound dehiscence treated with debridement with good result.  
CONCLUSIONS: Majority of the selected patients submitted to the minimally invasive-tubular microsurgical transverse processectomy experienced a good relief of their chronic pain.