Transitional Vertebra/ Having facet fusion

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Brian Mccarthy

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Hello Jen
I have been trying to find out more about the condition Sacrilization/Bertolotti Syndrome and came across your posting here. I have had a fair share of back problems over the years and had my first surgery, a microdiscectomy at L4/L5 in 1998. After 10 years of increasing problems and pain had a multi-level hy-brid surgery in April last year. I had Charite ADR at L3/L4, L4/L5 and an ALIF fusion at L5/S1. The fusion was supposed to finish off "what nature started" with this fused transverse process I have which, together with another condition "spina bifida occult", was the cause of the problem with L4/L5 years ago. Now, several injections and a second lot of denervation later, I am still in pain and on medication constantly. The last surgery has eased my leg pain but my back pain is as it was 18 months ago. My surgeon has told me I have this Bertolotti Syndrome and he is considering doing a "resection" which he describes as being an easy surgery in comparison to what I had last year. He wants to wait to see if the denervation will kick in before wanting to discuss going ahead.
Before I decide on this, I wanted to find out from other people who may have had this procedure to see first if it was successful and secondly what the recovery time was like as I have already had 3 months off work and still suffering. I just can't go through anything like that again.
Wondered if by now you had had your surgery?
Hope you can help me with your thoughts please.
Thanks
Brian McCarthy, London UK
 
Hi Brian, thanks for replying. One of my doctors had said that an easier surgery than fusion would be to remove the enlarged transverse process, but he said it would weaken my spine too much because it is used to having that support. He said if he was to do a surgery it would involve a bone graft, and putting hardware between l5/s1 and possibly from the sacrum to illium. In the research Ive done it sounRAB like a pretty tough surgery and he said it would be only about a 60/40 chance of it working. Is that the surgery that youve had? If so. would you recommend it? And I was wondering how you were diagnosed with Bertolotti's, did your doctor bring it up, or did you? I wish you luck with your surgery, I hope you get some relief. Thanks so much for the info.
- Sara
 
Hi, hoping someone might be able to help me.
Im 21 yrs old, and have had low back pain for about 7 years. It has gotten increasingly worse, and has been constant for about 5 years. I have done pt, accupuncture, chyropractor, pain management, pain pills, cortisone shots (one in my si joint, 3 facet injections, and a couple trigger point injections into my piraformis muscle) as well as using a brace and a tenz unit. nothing has helped. I have been to alot of doctors- one did mris and tests of my whole back, and the only place showing irritaions was an enlarged transverse process on my left side L5 , that rubs against my sacrum. he mentioned fusion surgery, but didnt recomend it. i proceded to get a few second opinions, and all those doctors said basically that the enlarged transverse process is fairly common and is unlikly to be causing my pain, and said i should NOT get surgery. But they were not able to give me alternitives or tell me what might be causing this pain. In the research I ve done, it sounRAB to me like i have bertolotti's syndrome, but not many doctors are familiar with it. Im really running out of steam and having a hard time not just giving up. if it gets any worse and i miss much more work im not going to be able to pay my rent.
Im sorry for rarabling on, but i was hoping somebody here might know a doctor on the east coast ( i live in ct) that knows about bertolotti's syndrome. or else any advice would be greatly appreciated.
 
Hi, I have had lower back pain for almost 2 years now. All my tests show minor this and minor that, but nothing real concrete. I have had mri, xray, discogram, bone scan, and several types of cortizone injections. My doctor has concluded that my transitional vertebra has caused damage to the level above it and is going to try to fuse the facet joints that are full of arthritis and bone spurs.

I am only 36, and am very concerned. What will this surgery be like? Will a transitional vertebra cause more problems down the road? I would love to talk to some people who have a transitional and what they have been through.

I have felt so alone the last 2 years, the doctors never believing I am in the pain that I am. It has got to the point of limping on the right side of my body. I have been through 2 years of agony, trying to find out whats wrong with me. I feel like the transitional vertebra might be my answer all along.

I would love to get some more info here. Thanks for listening!
My surgery is set for Sept 27th.

Jen
 
Jen, thank you thank you! I did a quick search and with your post found out this information because of the finding on my MRI report i may even print it out although i am worried about the dr. thinking i'm crazy on my first appt. what do you think? And pepper please any suggestions to this? Sorry so long love, Monkey


Transitional Vertebrae:

A transitional vertebrae is either a sacralized lurabar vertebrae or a lurabarized sacral vertebrae. In the present study, a transitional vertebrae is defined as a vertebrae that presents with a distinctive enlargement of the transverse processes with or without fusion of the processes to the sacrum. Vertebrae that were bilaterally sacralized or lurabarized were not considered a transitional vertebrae. The reported prevalence of transitional type of vertebrae at the lurabosacral junc- tion has varied from 0.6 to 25% of persons (10,11).

Sacralization, and the presence of lurabosacral transitional vertebrae are anomalies in which an increased incidence of backache have been established in some reports, while other studies have revealed no apparent association.

Those who report a correlation between transitional vertebrae and backache feel that the etiology of the production of pain is due to the alteration in the symmetrical supportive bony architecture of the spinal vertebral column. With an asymmetrical condition the center of spinal rotation moves from the midline and is located nearer to the side of sacral articulation/fusion. The facet articulations and related structures on the side with a free transverse process will move through a greater arc of motion and be subjected to a greater amount of torsional stresses. This greater degree of stress predisposes to facet degeneration, disc deterioration, and possible disc protrusions(10,11).

Tiley, in a study of 7,236 pre-employment radiographs demonstrated 1,103 (14%) with sacralization of the fifth lurabar vertebrae. He noted a significant relationship between unilateral sacralization and variation in the articulating mechanism of the facets. Individuals with sacralization showed a greater occurrence of low back pain and more time lost from work than those workers without the condition(12).

Paillas, Winniger and Louis studies 1,000 individuals with lurabar pain and sciatica and 500 with proven disc protrusions, and they demonstrated a strong association between transitional vertebrae and back pain. The occurrence of pain and sciatica was nearly twice that of patients without transitional vertebrae (15.5% vs. 7.78%). They also demonstrated that the average age of patients with lurabar pain and congenital anomalies was 10 years younger than for individuals with a normal lurabar spine(13).

Hodges and Peck studies 447 individuals with back pain and 538 controls (as was previously mentioned). With respect to transitional vertebrae, the study showed a significant association with back pain(6).

Transitional vertebrae have been linked by some doctors to a clinical entity consisting of low back pain, with or with-out sciatica, which is associated with a disc herniation at the vertebral level craniad to the sacral articulation (Bertolotti's syndrome). This syndrome may be another cause of pain associated with the condition of a transitional vertebrae. Keim, has presented a series of 12 patients with this clinical presentation(14).

There are also several studies that did not establish any association between transitional vertebrae and the presence of back pain. It is postulated that a transitional vertebrae, by virtue of its enlarged process, is more stable and better protected from stresses, than a "free" vertebrae." The large transverse process is believed to add to the rotational stability of the vertebral column. LaRocca and Macnab, in their study of 150 men with back pain vs. a control group of 150 men, did not demonstrate a difference due to the presence of a transitional vertebrae(4). These findings were duplicated in the reports of Fischer, Friedman, and Van Demark(3), as well as in the study of Splithoff(5).

In the present study, no correlation was established for the occurrence of a transitional vertebrae and the presence of back pain. Also, just as for facet asymmetry, the rate of agreement between the three physicians in diagnosing transitional vertebrae was poor.

Conclusion

In considering the presence of facet asymmetry, spina bifida occulta and transitional vertebrae in relation to low backache, in this study, only spina bifida occulta showed any statistical association with low back pain. Even for this anomaly, the statistical correlation was slight. This was also the only condition in which the doctors showed a similar rate of diagnosis (agreement in the diagnosis of the condition). In analyzing various corabinations of the anomalies and the predisposition to back pain, the presence of all three anomalies showed some association, however, the agreement of the physicians in delineating such individuals was quite poor. As stated in this report, a review of the medical literature reveals considerable variances in relating congenital anomalies of the lurabar spine to backache/pain. As demonstrated in this study, this could be due to the considerable rate of difference among observers in diagnosing an anomaly as present. If one were to attempt to remedy this problem, perhaps an application of more stringent criteria in defining these conditions could help to provide more answers as the etiology of low back pain.
 
Pepper i am so sorry, i get confused thats why usually don't sign my name as to not confuse others ithier, but i thought i had it right lol. Anyway, i didn't get much sleep last night you know how that goes!
Love, Monkey
 
Monkey-
Ive had some similar things done as you. I also have a transitional vertabrae thats rubbing against my sacrum. I had a shot in my SI joint last August, and could hardly walk for about 2 weeks afterwarRAB. I have been going to pain managment for a few weeks now- she also gave me an injection in my piraformis muscle which did not help at all. She is really pushing for me to try the SI joint shot again but I am really scared to go through that again- I can barely deal with the pain I have now. I told her I wasnt ready to do it yet and she said she didnt have anything else to offer me and is reffering me to yet another doctor. I wish you lots of luck, and please let me know if you find something that works.

- Sara
 
Hello Sarah
I have Bertolotti Syndrome along with Spina Bifida Occult - see my previous post to yours for the problems it has caused me.
Since then I have had more surgery on 7th April and still recovering. I had revision fusion with instrumentation at L5/S1 along with a complete sacroiliac fusion which was in a really bad state. I was having hypermobility leading to scoliosis. All of this stemming from the two anomolies. My surgeon told me he may have to remove part of the sacrilized transverse process to gain access to the pedicle but I'm told it was not necessary. The two fusions have hopefully stabilised the micro movement that was causing the pain on the facet joints.
Hope this is of some help to you and that your pain eases.
I'm still on lots of meRAB but hope to start coming off soon.
RegarRAB
Brian McCarthy, London UK
 
Monkey
I am unclear on what type of doc you are going to. is it neurosurgeon? I went to a neurologist and he was no help at all, told me to do some exercises.

I went the orthopedic route and they were not any help either.

The guy I am seeing now is at a place called the back center, and he is strictly a back surgeon. He is a teaching doctor, so he is more open to things like this. He is willing to use me as a teaching case, which is awesome because no one else would help me.

Hope that helps.
Jen
 
Jen, my first fusion in 1982 was for a transitional vertebrae. I had it fused and lived a pain free life until 2004. Then I hurt the level above it and required a fusion in 2007 and now I am facing a 3rd fusion on the one above it.

I am telling you not to scare you but let you know once you have a fusion you risk having the ones above them going out and needing to be fused. As you can see between my first and second fusion there was a huge time span and between the 2nd fusion and 3rd fusion looks like it will be one year.

Do I regret going thru the fusions? Absolutely not!! After each one I felt better; however, between my latest fusion and the upcoming one is a bit shorter than I would like. I suspect that the newest level should have been fused last year.

I hope I have not scared you and if you have any specific questions ask away.
 
pepper, i know you are not a dr. like you said and you have to be careful whats posted but what is your thought on this? Could this be why i have less hip rotation ect.?
I'm asking you because you replied to what i posted about my MRI findings!



Bertolotti's syndrome is a form of lurabago in the lurabosacral transitional vertebrae. The syndrome is not usually treated, as not much is known yet about these spinal segments. It is named for Mario Bertolotti, an Italian physician [1]

Bertolotti's syndrome is defined by a transitional 5th lurabar vertebra resulting in partial sacralization. Of importance is that this syndrome will result in a pain generating 4th lurabar disc resulting in a "sciatic" type of a pain correlating to the 5th lurabar nerve root. Usually the transitional vertebra will have a "spatulated" transverse process on one side resulting in articulation or partial articulation with the sacrum or at time the illium and in some cases with both. This results in limited / altered motion at the lurabo-sacral articulation. This loss of motion will then be compensated for at segments superior to the transitional vertebra resulting in accelerated degeneration and strain through the L4 disc level which can become symptomatic and inflame the adjacent L5 nerve root resulting in "sciatic" or radicular pain patterns. This is a congenital condition and is usually not symptomatic until one's later twenties or early thirties, yet there are cases found where Bertolotti's is symptomatic at a much earlier age.
 
Thank you for your quick reply! I have a ton of questions for you. The doc says he is only fusing the facet joints. Did you have your actual vertebra fused? I have a lurabarized S1. Is this what you have also? Have you heard of Bertolotti's syndrome? Did you have trouble getting your doc to do the surgeries? My doc was terrible about trying absolutely everything before doing surgery and saying there really wasnt a whole lot on the tests but a transitional vertebra. He said he was going by my pain, not the tests. I am in lots of pain and nothing I have tried in 2 years has helped.

I am hopeful that you had such a success with your first surgery! However, he is going very minimal and wont be fusing my transitional vertebra, only the facets I think, and I have no idea what the recovery time on this is or anything. I will find out more on pre op on the 20th.

Thank you so much for your reply. I appreciate it!
Jen
 
Hello Sarah
mine was diagnosed along with Spina Bifida Occulta after several MRI/CAT Scans which together are thought to be the source of the irabalance and scoliosis affecting the mechanics of my spine. This was at the root of the problems first encountered about 11 years ago which caused the problem I had at L4/L5 which ended up with me having a microdiscectomy. That then put pressure on the levels above and below which result with surgery in April last year (Charite ADR L3/L4, L4/L5 and ALIF Fusion at L5/S1) That in effect repaired the damage but did not really address the cause. The surgery I had April 7th was a revision with instrumentation at L5/S1 but also needed my sacroiliac joint completely fused due to hypermobility which was causing pain at the SI joint and at the facet joints. This surgery is to stop the micro movement. It was explained that I may need to have part of the sacrilized transverse process removed if it was restricting access to the pedicle where the screws needed to go, but I understand this was not necessary. The odd thing about all of this is that a resection of the STP was considerded an option some months ago, but then the surgeon decided it was not the best way to go for some reason. I have my 6 week follow up on the 15th, so I'll find out more then. Perhaps it was for the same reason your surgeon decided against it??
I'm still slowly recovering so hard to say if it has worked yet. My foot pain has certainly healed and my back does feel different but still quite sore and very fragile and tense so I'll need to get over it a bit more to know - and besides, I'm still on lots of medication which will probably be masking things still. Ihope you find a solution to your pain very soon. PM me if you think I may be able to answer any questions you might have.
Best wishes Brian
 
Melissa, how old are your twins? Girls/Boys? I have identical girls age 11. I doubt the neurologist will help you any. I hate to be negative but dont get your hopes up. There are a few things you can do. Research you area to find a leading edge doc, or ask a few other docs who is the best doc in town. You need to find a doc who will go by your pain rather than your test results. That is what I have finally found after almost 2 years. There is findings on your report, the docs just dont want to get involved because treatment is controversial for transitional vertebra. But you need to find some help before you get worse.

My doc sent me to the nearest big city to see a doc. Try a specific doc who works on spines. My doc actually said to me, most surgeons wont touch this case. It is probably similar for you. What do you mean the spine center wouldnt see you? Does it have to do with your insurance? Do you have a teaching hospital in your area? These are good places to see a doc who is willing to go the extra mile for someone who is in pain.
My doc told me not to be mad at him if it didnt work and I promised.
I would love to hear more about your case!
Jen
 
How did they determine that this was happening while you were walking, a certain type of xray? I have done xrays straight and bent, but not anything that simulates walking. My biggest pain is after I have walked a distance or walked on a concrete floor, or even standing for longer than 15 minutes. Did you ever try Lyrica for pain? I just started on it yesterday. It helps a little. It is supposed to be for nerve pain.
Jen
 
Brian, i totally sympathize with you. I feel as though this is what i'm heading towarRAB as all my pain is in this area as well. It;s getting harder and harder to function as time goes by. I just recent;y had an injection in my SI joint again and this week is the Piriformis muscle. I think there they are going to find alot out but the SI joint one felt like i was going to die as it was very irritating to that area i could hardly walk and i was in tremendous pain but i got through this! I am worried what the next one is going to do and this is the last of injection for hope to a solution to all this pain. Whenever i have injections to this area is is very painful. i feel that this is because of the transitional vertabrea thats partially fused with my sacrum but they are pushing that out of the way it seems! My main problem is when i wake up i like laid straight for too long and i'm stuck because it hurts to bad to move and my poor foot is painful as well.Please keep me updated as to what happens with you! I am going to ask and push for another MRI of my back and leftside with contrast when i go as it has been two years now since any tests i had done in 2007 and i am goin to ask for a referral to a surgeon i recent;y found out about! Wish me luck i need it!
Take care, Monkey
 
Sara, i will keep you posted. I had the piriformis injection today, no change. I was worried about that, at least there was no nurabness or reduced pain yet. I will give it a few days. And I am going to have a lower Lurabar MRI again on Saturday due to he said i havent had one since 2007 and go from there! And then he is refering me to a eval from a different surgeon than before. maybe i will get somewhere, i can only hope! Take care, Melissa
 
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