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Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention.

ABSTRACT: Bertolotti's syndrome (BS) refers to the possible association between the congenital malformation lumbosacral transitional vertebra (LSTV), and low back pain (LBP). Several treatments have been proposed including steroid injections, resections of the LSTV, laminectomy, and lumbar spinal fusion. The aim of this review was to compare the clinical outcomes in previous trials and case reports for these treatments in patients with LBP and LSTV. A PubMed search was conducted. We included English studies of patients diagnosed with LSTV treated with steroid injection, laminectomy, spinal fusion or resection of the transitional articulation. Of 272 articles reviewed 20 articles met the inclusion criteria. Their level of evidence were graded I-V and the clinical outcomes were evaluated. Only 1 study had high evidence level (II). The remainders were case series (level IV). Only 5 studies used validated clinical outcome measures. A total of 79 patients were reported: 31 received treatment with steroid injections, 33 were treated with surgical resection of the LSTV, 8 received lumbar spinal fusion, and 7 cases were treated with laminectomy. Surgical management seems to improve the patient's symptoms, especially patients diagnosed with "far out syndrome" treated with laminectomy. Clinical outcomes were more heterogenetic for patient's treated with steroid injections. The literature regarding BS is sparse and generally with low evidence. Non-surgical management (e.g., steroid injections) and surgical intervention could not directly be compared due to lack of standardization in clinical outcome. Generally, surgical management seems to improve patient's clinical outcome over time, whereas steroid injection only improves the patient's symptoms temporarily. Further studies with larger sample size and higher evidence are warranted for the clinical guidance in the treatment of BS.

SUBMITTER: Holm EK

PROVIDER: S-EPMC5731823 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention.

Holm Emil Kongsted EK Bünger Cody C Foldager Casper Bindzus CB

SICOT-J 20171212

Bertolotti's syndrome (BS) refers to the possible association between the congenital malformation lumbosacral transitional vertebra (LSTV), and low back pain (LBP). Several treatments have been proposed including steroid injections, resections of the LSTV, laminectomy, and lumbar spinal fusion. The aim of this review was to compare the clinical outcomes in previous trials and case reports for these treatments in patients with LBP and LSTV. A PubMed search was conducted. We included English studi ...[more]

PMID: 29243586

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Project description:Background ?Advancements in radiological imaging and diagnostic criteria enable doctors to more accurately identify lumbosacral transitional vertebrae (LSTV) and their association with back and L5 distribution leg pain. It is considered the most common congenital anomaly of the lumbosacral spine with an incidence between 4 and 35%, 3 although many practitioners describe 10 to 12% overall incidence. LSTVs include sacralization of the L5 vertebral body and lumbarization of the S1 segment while demonstrating varying morphology, ranging from broadened transverse processes to complete fusion. 5 The most common types of LSTV that present with symptomatic Bertolotti's syndrome are the Castellvi type I and type II; type III and type IV variants rarely present with symptoms referable with confirmatory and provocative testing to the transitional vertebra itself, and therefore there is limited experience and no case reports of treatment toward this particular entity. Case Description ?We illustrated a case of a 37 years old female in which a computed tomography scan demonstrated type III LSTV on the left and a type I anomaly on the right. The patient presented with right-sided leg pain and left-sided sacroiliac (SI) region low back pain, worse with rotation and standing, for several years, and had been on daily narcotic pain medications for more than 2 years. The patient had temporary relief of her leg pain with a transverse/ALA injection on the right, but no improvement in her back pain, whereas a left-sided injection into the region around the type III interface on the left did transiently alleviate her SI pain without improvement in her leg pain. We proposed that this particular anomaly induced mechanical back pain on the left side by flexion of the bone bridge (a form of stress-fracture, with associated sclerotic changes in the interface in the transverse/ALA junction) with associated irritation of the right L5 nerve from the type I anomaly on the right in conjunction with her typical radiating leg pain on the right. A patent, but somewhat hypoplastic L5/S1 disk space was also present. Nonsegmental pedicle screw instrumentation with low-profile screws was implanted on the right side with fusion induced using allograft and off label use of infuse rh-BMP2 bone graft substitute, and the patient was discharged the same day. The patient noted immediate improvement in her preoperative symptoms, and by 2 weeks after her surgery noted complete resolution of the preoperative symptoms, and required no narcotic medications to control her incisional pain. Conclusion ?Patients who present with symptoms consistent with Bertolotti's syndrome, even if they have a type III or type IV LSTV, should be considered for surgical treatment of their LSTV. These patients can respond well, even if symptoms have been present for years. Given the prevalence of these anatomic variants in the general population (10-12% in most series), Bertolotti's syndrome should be considered in the differential diagnosis of any patient with a presentation of L5 radiculopathy and/or back pain.

Project description:Background and Objectives: This pilot study aimed to evaluate the clinical effectiveness, cost-effectiveness, and safety of acupotomy combined with epidural steroid injection (ESI) in lumbosacral radiculopathy and examine its feasibility for the main study. Materials and Methods: This randomized, controlled, two-arm, parallel, assessor-blinded, pragmatic study included 50 patients with severe lumbosacral radiculopathy who had insufficient improvement after an ESI. Patients were randomized (1:1 ratio) into a combined treatment (acupotomy + ESI, experimental) and an ESI single treatment (control) group. Both groups underwent a total of two ESIs once every 2 weeks; the experimental group received eight additional acupotomy treatments twice a week for 4 weeks. Types of ESI included interlaminar, transforaminal, and caudal approaches. Drugs used in ESI comprised a 5-10 mL mixture of dexamethasone sodium phosphate (2.5 mg), mepivacaine (0.3%), and hyaluronidase (1500 IU). The primary outcome was the difference in changes from baseline in the Oswestry Disability Index (ODI) scores between the groups at weeks 4 and 8. The incremental cost-utility ratio (ICUR) was calculated to evaluate the cost-effectiveness between the groups. Adverse events (AEs) were assessed at all visits. Results: Mean ODI scores for the experimental and control groups were -9.44 (95% confidence interval [CI]: -12.71, -6.17) and -2.16 (95% CI: -5.01, 0.69) at week 4, and -9.04 (95% CI: -12.09, -5.99) and -4.76 (95% CI: -7.68, -1.84) at week 8, respectively. The difference in ODI score changes was significant between the groups at week 4 (p = 0.0021). The ICUR of the experimental group versus the control group was as economical as 18,267,754 won/quality-adjusted life years. No serious AEs were observed. Conclusions: These results demonstrate the potential clinical effectiveness and cost-effectiveness of acupotomy combined with ESI for lumbosacral radiculopathy and its feasibility for a full-scale study. Larger, long-term follow-up clinical trials are needed to confirm these findings.

Project description:BackgroundPrevious systemic reviews have examined the efficacy of individual therapeutic agents, but which type of treatment is superior to another has not been pooled or analyzed. The objective of the current study was to compare the clinical effectiveness of epidural steroid injection (ESI) versus conservative treatment for patients with lumbosacral radicular pain.MethodsA systematic search was conducted with MEDLINE, EMBASE, and CENTRAL databases with a double-extraction technique for relevant studies published between 2000 and January 10, 2019. The randomized controlled trials which directly compared the efficacy of ESI with conservative treatment in patients with lumbosacral radicular pain were included. Outcomes included visual analog scale, numeric rating scale, Oswetry disability index, or successful events. Two reviewers extracted data and evaluated the methodological quality of papers using the Cochrane Collaboration Handbook. A meta-analysis was performed using Revman 5.2 software. The heterogeneity of the meta-analysis was also assessed.ResultsOf 1071 titles initially identified, 6 randomized controlled trials (249 patients with ESI and 241 patients with conservative treatment) were identified and included in this meta-analysis. The outcome of the pooled analysis showed that ESI was beneficial for pain relief at short-term and intermediate-term follow-up when compared with conservative treatment, but this effect was not maintained at long-term follow-up. Successful event rates were significantly higher in patients who received ESI than in patients who received conservative treatment. There were no statistically significant differences in functional improvement after ESI and conservative treatment at short-term and intermediate-term follow-up. The limitations of this meta-analysis resulted from the variation in types of interventions and small sample size.ConclusionsAccording to the results of this meta-analysis, the use of ESI is more effective for alleviating lumbosacral radicular pain than conservative treatments in terms of short-term and intermediate-term. Patients also reported more successful outcomes after receiving ESI when compared to conservative treatment. However, this effect was not maintained at long-term follow-up. This meta-analysis will help guide clinicians in making decisions for the treatment of patients with lumbosacral radicular pain, including the use of ESI, particularly in the management of pain at short-term.

Project description:BACKGROUND: A rapidly growing knowledge base has evolved describing recently developed diagnostic and therapeutic techniques in the management of hepatic-pancreatic-biliary (HPB) disease. As such, it is expected that the current literature should reflect these trends in the emerging specialty of HPB surgery. METHODS: The content of 10 leading surgical journals was assessed for the separate years 1998 and 2002 using a combination of hand searching and Medline searching using the Pubmed search engine. Data retrieved for each journal included: total number/type of publication, specialty category, disease focus and comment on surgical technique. RESULTS: A total of 817 HPB articles were reviewed (386 in 1998,431 in 2002). Half of the journals showed an absolute increase in the number of HPB articles published; the largest increase was for Surgery (12%; 2002: 64/431; 1998: 10/386, p<0.0001), while the British Journal of Surgery displayed the greatest decrease (11%; 2002: 56/431; 1998: 94/386, p<0.0001). Publication by the nature of disease revealed that overall, there was a trend towards a greater volume of publications on malignant disease over the 4-year period (1998: 41%; 2002: 56%). Furthermore, 91% (10/11) of articles published by the Canadian Journal of Surgery related to benign disease; while almost all (97%) of the articles published by the Annals of Surgical Oncology were on malignant disease. There was a difference in the pathology focus for each sub-category of HPB topics. Fifty percent (150/302) of the articles on hepatic disease focused on malignancy, as compared with 46% (124/272) of those on pancreatic disease and 21% (44/213) of those on biliary disease. A comment on surgical technique was uniform across all categories (47% hepatic, 48% pancreatic and 44% biliary). DISCUSSION: Articles dealing with HPB topics are published widely across all reviewed journals. Although the absolute number of HPB articles published increased over a 4-year period, there is significant variability in overall topics and focus of publication between journals. Overall, there was a uniform paucity of basic science articles, evidence-based reviews and/or meta-analyses, indicating an opportunity for growth in the future.

Project description:BackgroundTo examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis.MethodsFollowing the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria.ResultsAll 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228).PresentationHeadache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9).OutcomesImprovement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1).ConclusionsAlthough the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

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Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention.

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Symptomatic lumbosacral transitional vertebra: a review of the current literature and clinical outcomes following steroid injection or surgical intervention.

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