Lumbosacral transitional vertebra in the young men population with low back pain: anatomical considerations and degenerations (transitional vertebra types in the young men population with low back pain)

A systematic review and bibliometric study of Bertolotti's syndrome: clinical characteristics and global trends

PURPOSE

Bertolotti's syndrome is a prevalent congenital deformity. However, many physicians fail to include it in their differential diagnosis for low back pain (LBP), which results in missed diagnosis or misdiagnosis. There is still a lack of standardized treatment and management strategies for Bertolotti's syndrome. This study aimed to review the clinical characteristics and management of Bertolotti's syndrome and reports bibliometric insights in advancements in Bertolotti's syndrome research.

METHODS

Studies published until 30 September 2022 were systematically reviewed according to the PRISMA guidelines. Three independent reviewers extracted the data and assessed the quality and risk of bias of the studies based on the methodological index of non-randomized studies (MINORS). SPSS, VOS viewer, and the Citespace software were used for the systematic review, visual analysis, data mining, mapping, and clustering of the retrieved articles, which presented clear and visual presentations of the structural patterns of published research in graphs.

RESULT

A total of 118 articles, describing a total of 419 patients with Bertolotti's syndrome, were included. There was an upward trend with a steady increase in the number of publications. The world map distribution showed that most publications were predominantly from North America and Asia. The most cited articles were published in the following journals: Spine, J Bone Joint Surg, and Radiology. The mean age of the patients was 47.7 years, and 49.6% of them were male. A total of 159 (96.4%) patients had LBP symptoms. The mean symptom duration was 41.4 months (74.8%), and most of the patients had Castellvi type II. Disc degeneration was the most reported comorbid spinal diseases. The mean methodological index of non-randomized studies score was 4.16±3.95 points (range, 1-21). A total of 265 (68.3%) patients underwent surgical treatments. Minimally invasive surgical techniques, prevalence, image classification, and disc degeneration were the current main research areas of Bertolotti's syndrome.

CONCLUSIONS

The steady increase in the number of publications demonstrated the increased attention of researchers on this topic. Our results showed a significant prevalence of Bertolotti's syndrome in patients with LBP and a long symptom duration before the initiation of treatment. Surgical treatments were commonly used to treat patients with Bertolotti's syndrome after a non-effective conservative treatment. Minimally invasive surgical techniques, prevalence, image classification, and disc degeneration are the major research areas of Bertolotti's syndrome.

Muscle mass ratio in male gastric cancer patients as an independent predictor of postoperative complications after minimally invasive distal gastrectomy

BACKGROUND

The current study aimed to investigate the relationship between muscle mass proportion and the incidence of total complications in male gastric cancer (GC) patients after minimally invasive distal gastrectomy (MIDG).

METHODS

Between March 2017 and March 2020, 152 male GC patients with clinical stage III or lower GC who underwent MIDG were enrolled in this study. The muscle mass ratio (MMR) was calculated by dividing the total muscle weight obtained from bioelectrical impedance analysis by the whole-body weight. Thereafter, the association between MMR and surgical outcomes was determined.

RESULTS

Based on the optimal MMR cutoff value of 0.712 obtained using the receiver operating characteristic (ROC) curve, patients were divided into two groups (69 and 83 patients in the MMR-L and MMR-H groups). The MMR-L group had a significantly higher total complication rate compared to the MMR-H group (MMR-L, 24.6% vs. MMR-H, 7.2%; P = 0.005). Multivariate analysis also identified MMR-L as a significant independent risk factor for total complications and intra-abdominal infectious complications after MIDG.

CONCLUSIONS

The MMR calculated using bioelectrical impedance analysis can be a useful predictor for postoperative complications after MIDG in male GC patients.

Lumbosacral transitional vertebrae: prevalence in a southern European population and its association with low back pain

PURPOSE

Lumbosacral transitional vertebra (LSTV) is a congenital anomaly of the lumbosacral junction. Its prevalence is variable in the literature such as its association with low back pain. The aim of this study was to identify the prevalence of LSTV in a southern European population, and its correlation with low back pain.

METHODS

A retrospective review of 639 thoraco-abdomino-pelvic consecutive CT-scans between January 2019 and November 2020 was performed. The presence of LSTV was classified into type II, III, IV based on Castellvi's classification. To investigate the association with low back pain, Oswestry Low Back Disability Questionnaire (ODI) and the EuroQol-5D-3L questionnaire was applied.

RESULTS

The prevalence of LSTV was 24.9% (142 of 571). 37,3% were type IIb, 31,0% were type IIa, 13,4% were type IIIa, 9.9% were type IIIb and 8.5% were type IV. Individuals with LSTV were more likely to report low back pain and have a higher ODI score (OR:0.392, 95% CI:0.192-0.802, p = 0.010), (OR: 1050, 95% CI: 1029-1072, p < 0.01). Castellvi's type IV showed a significantly higher ODI when compared to type II (OR:1059, 95% CI:1019-1100, p = 0,04). There was no statistical difference in the EuroQol-5D-3L score between two groups (OR:1085, 95% CI: 0.459-2.560, p = 0.852).

CONCLUSION

This population-based study adds to the literature the prevalence of LSTV in a southern European population. LSTV was associated with low back pain. However, this difference did not translate into a loss of quality life. Type IV was associated with higher functional disability when compared with type II.

Is lumbosacral transitional vertebra associated with lumbar disc herniation in patients with low back pain?

PURPOSE

To evaluate lumbosacral transitional vertebrae (LSTV) frequency in patients with low back pain and lumbar disc herniation (LDH) and to analyze correlations between LSTV presence and intervertebral disc degeneration.

METHODS

This retrospective study included patients with low back pain applying between January 2021 and August 2021. Inclusion criteria were age of 18-65, presence of a standing lumbosacral Xray and a lumbar MRI taken within 2 weeks of the indexed symptoms. Patients with a history of spondylolisthesis, spondylodiscitis, scoliosis and vertebral neoplasia were excluded. A total of 1821 patients met the inclusion criteria. Radiographs and MRIs were evaluated by 2 radiologists.

RESULTS

Of all patients, 61.4% were female and the mean age was 43.2 ± 12.2. LDH was detected in 57.7% of patients while a LSTV was present in 43.3%. Sacralization and LSTV were significantly different between the patients with and without an LDH. Patients with LSTV had a higher incidence of a LDH affecting 3 or more intervertebral disc levels (p < 0.001). There was a significant difference in-between LSTV and non-LSTV groups regarding the M1 and M2 intervertebral disc degeneration levels.

CONCLUSION

A LDH is more common in the presence of a LSTV. Female sex is highly correlated with herniation. Three or more intervertebral disc levels are affected in the presence of an LSTV. Significantly higher degeneration incurs at the M1 and M2 intervertebral levels. Sacralization is a risk factors for a lumbar disc herniation.

Imaging of Structural Abnormalities of the Sacrum: The Old Faithful and Newly Emerging Techniques

The sacrum and sacroiliac joints pose a long-standing challenge for adequate imaging because of their complex anatomical form, oblique orientation, and posterior location in the pelvis, making them subject to superimposition. The sacrum and sacroiliac joints are composed of multiple diverse tissues, further complicating their imaging. Varying imaging techniques are suited to evaluate the sacrum, each with its specific clinical indications, benefits, and drawbacks. New techniques continue to be developed and validated, such as dual-energy computed tomography (CT) and new magnetic resonance imaging (MRI) sequences, for example susceptibility-weighted imaging. Ongoing development of artificial intelligence, such as algorithms allowing reconstruction of MRI-based synthetic CT images, promises even more clinical imaging options.

Lumbosacral Transitional Vertebra Contributed to Lumbar Spine Degeneration: An MR Study of Clinical Patients

We aimed to comprehensively characterize degenerative findings associated with various types of lumbosacral transitional vertebra (LSTV) on magnetic resonance images. Three hundred and fifty patients with LSTV (52.3 ± 10.9 years), including 182 Castellvi type I, 107 type II, 43 type III, and 18 type IV, and 179 controls without LSTV (50.6 ± 13.1 years), were studied. Discs, endplates, and posterior vertebral structures were assessed and compared to those of controls for the most caudal three discs on MRIs. There were no differences in degenerative findings between patients with type I LSTV and controls. For types III and IV, the transitional discs had smaller sizes, lower Pfirrmann scores, and lower rates of disc bulging (2.3% and 5.6% vs. 39.1%), osteophytes (2.3% vs. 15.1%), disc herniation (2.3% and 5.6% vs. 31.8%), and Modic changes (2.3% and 5.6% vs. 16.8%) than controls. However, the cranial discs had more severe Pfirrmann scores, disc narrowing and spinal canal narrowing, and greater rates of disc herniation (41.9% and 50.0% vs. 25.7%), endplate defects (27.9% and 33.3% vs. 14.4%) and spondylolisthesis (18.6% vs. 7.3%) than controls. Type II LSTV was associated with degenerative findings in the cranial segments but to a lesser degree, as compared with type III/IV LSTV. Thus, Castellvi type III/IV LSTV predisposed the adjacent spinal components to degeneration and protected the transitional discs. Type II LSTV had significant effects in promoting transitional and adjacent disc degeneration. Type I LSTV was not related to spinal degeneration.

Quantitative measurements at the lumbosacral junction are more reliable parameters for identifying and numbering lumbosacral transitional vertebrae

OBJECTIVES

To evaluate quantitative parameters to identify the anatomic variation lumbosacral transitional vertebrae (LSTV) and compare them with the landmarks commonly used at present.

METHODS

A total of 2,845 PET/CT scans were reviewed, and the patients with 23 and 25 presacral vertebrae were included. The quantitative parameters, including the anterior-edge vertebral angle (AVA) of the lowest lumbar-type vertebra, the ratio of the length of the inferior endplate to that of the superior endplate (RISE) of the uppermost sacral-type vertebra and the lumbosacral intervertebral disc angle (LSIVDA), and the anatomical landmarks, including the iliac crest tangent (ICT) level, the iliolumbar ligament (ILL) origin level and psoas proximal insertion, were all evaluated to determine their ability to identify LSTV.

RESULTS

The values of AVA and RISE were significantly different between the LSTV group and the control group, and between subgroups of LSTV. The cutoff value for AVA was 73.0°, with an accuracy, sensitivity, and specificity of 91.1%, 77.5%, and 88.3%, and that for RISE was 0.79, with an accuracy, sensitivity, and specificity of 90.3%, 77.5%, and 94.2%, while that for LSIVDA was 14.15°, with an accuracy, sensitivity, and specificity of 75.9%, 65.7%, and 78.3%, to differentiate L5 sacralization from S1 lumbarization. For differentiating the controls from LSTV, the accuracy, sensitivity, and specificity of the ICT level and proximal psoas insertion were 78.0%, 70.2%, and 95.0%, versus 71.7%, 61.7%, and 94.0%.

CONCLUSIONS

Compared with the anatomical landmarks, the quantitative measurements at the lumbosacral junction, including AVA and RISE, may be more helpful for differentiating subgroups of LSTV especially if only lumbar spine imaging is available.

KEY POINTS

• The quantitative parameters, the anterior-edge vertebral angle (AVA) of the lowest lumbar-type vertebra and the ratio of the length of the inferior endplate to that of the superior endplate (RISE) of the uppermost sacral-type vertebra, are more helpful for distinguishing L5 sacralization from S1 lumbarization than the previously proposed anatomic landmarks. • AVA and RISE represent relevant changes in the curvature at the lumbosacral region and the shape of the transitional vertebral body, respectively. • AVA and RISE are easily assessed, with high intra- and inter-reader reliability.

Role of the Lumbosacral Transition Vertebra and Vertebral Lamina in the Pathogenesis of Lumbar Disc Herniation

OBJECTIVE

To investigate the prevalence of lumbosacral transition vertebrae (LSTVs) in both the normal population and the lumbar disc herniation (LDH) population and to determine the risk factors for LDH.

METHODS

Between January 2019 and September 2020, all patients aged 18-39 years and underwent an anteroposterior (AP) X-ray of the lumbar vertebrae were retrospective reviewed in our institution. Those patients who were diagnosed with LDH were eligible for inclusion in the LDH group. During the same period, those patients admitted to our hospital who underwent an anteroposterior X-ray of the lumbar spine and had not been diagnosed with LDH were included in the control group. Those patients with disease that might affect the lumbar anatomy were excluded from both groups. The type of LSTV was classified according to the Castellvi classification. The height of the lumbar vertebral lamina was evaluated through the h/H index. The inter- and intra-observer reliability was evaluated by one senior radiologist and one senior orthopedist using intraclass correlation coefficient (ICC). The association between the LSTV and the herniation level was also investigated. Binary logistic regression was used to explore the association of different factors between the LDH group and the control group.

RESULTS

Two hundred LDH patients (115 male and 85 female) and 200 individuals (108 male and 92 female) were investigated retrospectively. The prevalence of LSTVs was 71.5% (n = 143) in the LDH group and 34.0% (n = 68) in the control group. The most frequent LSTV types were type Ib and type IIa. The inter- and intra-observer ICCs of the measurement of "h/H" index and the classification of LSTV were all "excellent" (ICC > 0.90). The median h/H index in the control group was significantly higher than that in the LDH group (0.28 (0.26, 0.31) vs 0.34 (0.31, 0.37), P = 0.000). The distribution of the Castellvi classification in the L4/5 and L5/S1 herniation patients was significantly different (P = 0.048). LSTVs, BMI and the h/H index were closely associated with LDH, with odds ratios of 3.06 (95% CI: 2.12-4.43), 1.23 (95% CI: 1.13-1.33) and 0.09 (95% CI: 0.05-0.15), respectively. The incidence of L4/5 disc herniation in patients with an LSTV was significantly more common than that in patients with L5/S1 disc herniation (P = 0.048).

CONCLUSION

The prevalence of LSTVs was 34.0% in the control group and 71.5% in the LDH group; LSTVs and BMI were positively correlated with LDH, and h/H was negatively correlated with LDH.

O2-O3 chemodiscolysis: How much, how long? Retrospective outcome evaluation of different treatment sessions in partially-responder patients

PURPOSE

To retrospectively evaluate the clinical and instrumental outcome of different treatment sessions of oxygen-ozone (O₂-O₃) chemodiscolysis in patients with lumbar disc herniation.

METHODS

We evaluated 73 patients partially responders to a single session of oxygen-ozone (O₂-O₃) chemodiscolysis and submitted to multiple injections sessions. All patients completed a pre- and post-treatment clinical (VAS and modified McNab score) and instrumental MRI follow-up. Imaging evaluation included assessment of intervertebral disc area (IDA). Pre- and post-treatment differences were compared to evaluate differences in variation between groups. Correlation analysis was used to evaluate the relationship between morphological and clinical parameters.

RESULTS

Based on the type and number of treatments performed, patients were divided into three groups: Group A) patients submitted to an additional periradicular anaesthetic/steroid injection; Group B) patients submitted to an additional session of intradiscal O₂-O₃ injection; Group C) patients submitted to two further sessions of intradiscal O₂-O₃ injection.The results showed an improvement of pain scores in all groups, and a smaller disc area change in group B. Comparing the differences between pre- and post-treatment features among the three different groups of patients, we did not find any statistically significant difference. Correlation analysis did not show any statistically significant correlation between the morphological changes of the intervertebral disc and the clinical output scores.

CONCLUSIONS

In our retrospective observation of partially responder patients, multiple intradiscal ozone injections were not associated with a higher disc shrinkage nor superior clinical outcome compared to a single intradiscal O₂-O₃ application with an additional periradicular injection session.

Lumbosacral Transitional Vertebrae in Adolescents: Effects on the Short-Term Outcomes of Percutaneous Endoscopic Lumbar Discectomy

Objective

To investigate whether lumbosacral transitional vertebrae (LSTV) affects the clinical outcomes of percutaneous endoscopic lumbar discectomy (PELD) in adolescent patients with lumbar disc herniation (LDH).

Methods

This was a retrospective study with two groups. Group A was made up of 22 adolescent LDH patients with LSTV (18 males and 4 females). Group B was made up of 44 adolescent LDH patients without LSTV (36 males and 4 females), who were matched to group A for age, sex, and body mass index. All patients underwent PELD at the L4/5 or L5/S1 single level and were followed up at 18 months after surgery. We identified LSTV on radiographs and computed tomography and assessed the imaging characteristics of all patients. Outcomes were evaluated through a numerical rating scale (NRS), the Oswestry Disability Index (ODI), the modified MacNab grading system, and the incidence of additional lumbar surgery.

Results

At 18 months after PELD, both groups had significant improvements in the mean NRS scores of low back pain (LBP) or leg pain and the ODI scores. In terms of the MacNab criteria, 90.9% in group A and 93.2% in group B showed excellent or good outcomes. The mean NRS scores of LBP or leg pain, ODI score, and MacNab grade after surgery were not significantly different between the 2 groups. Two patients (one patient had a recurrence; one patient had a new lumbar disc herniation) in group A and 3 patients (one patient had a recurrence; two patients had new lumbar disc herniations) in group B underwent additional lumbar surgery.

Conclusions

Our study suggests that in terms of pain relief, life function improvement, and the incidence of additional lumbar surgery, LSTV has no effect on the short-term clinical outcomes of PELD in adolescents. A new lumbar disc herniation is an important reason for additional surgery in adolescents, regardless of the LSTV status.

Lumbosacral transitional vertebrae are associated with lumbar degeneration: retrospective evaluation of 3855 consecutive abdominal CT scans

Objectives

To assess the prevalence of lumbosacral transitional vertebra (LSTV) and associated spinal degenerative changes on abdominal CT scans in Caucasian population.

Material and methods

A total of 3855 abdominal CT scans of the year 2017 from a single hospital were retrospectively assessed for LSTV, disc degeneration (DD), and facet joint degeneration (FD). An age- and sex-matched 150-subject control group without LSTV was picked at random. Multivariable logistic regression was used for the analysis.

Results

LSTV was found in 1101 (29%) scans: Castellvi type I in 68%, type II in 16%, type III in 13%, and type IV in 3% of scans. Age- and sex-adjusted prevalence of DD was significantly higher in Castellvi type II and III groups at multiple lumbar levels, and in IV group at L4/5 than in control group (p < 0.001–0.034). At L5/S1, the prevalence of DD was significantly higher in the control group than in type II, III, or IV groups (p < 0.001–0.017). After combining Castellvi types II, III, and IV into one group, significant differences were found at all lumbar levels except L2/3 (p < 0.001–0.016). Prevalence of FD was significantly higher at L4/5 in Castellvi groups I, II, and III than in the control group (p < 0.001–0.002). When Castellvi types II, III, and IV were combined into one group, significant differences were found at lumbar levels L2/3, L3/4, and L4/5 (p < 0.001–0.021).

Conclusion

Lumbosacral vertebrae of Castellvi types II, III, and IV are associated with greater lumbar degeneration, warranting meticulous evaluation of spinal anatomy, even on CT.

Key Points

• Lumbosacral transitional vertebra is a common incidental finding on abdominal CT scans with a high prevalence of 29%.

• When assessing whole lumbar spine, lumbosacral vertebrae of Castellvi types II, III, and IV were associated with greater lumbar degeneration, warranting careful evaluation of the lumbar spine on abdominal CT scans.

The prevalence and clinical significance of transitional vertebrae: a radiologic investigation using whole spine spiral three-dimensional computed tomographic images

Background

Errors in counting spinal segments are common during interventional procedures when there are transitional vertebrae. In this study, we investigated the prevalence of the transitional vertebrae including thoracolumbar transitional vertebra (TLTV) and lumbosacral transitional vertebrae (LSTV). The relationship between the existence of TLTV and abnormal rib count or the existence of LSTV were also evaluated.

Methods

The vertebral levels were counted craniocaudally, starting from C1, based on the assumption of 7 cervical, 12 thoracic, and 5 lumbar vertebrae, using whole spine spiral three-dimensional computed tomographic images. The 20th and 25th vertebrae were defined as L1 and S1, respectively.

Results

In total, 150 patients had TLTV, with a prevalence of 11.2% (150/1,340). LSTV was observed in 111 of 1,340 cases (8.3%). Sacralization was observed in 68 of 1,340 cases (5.1%) and lumbarization in 43 of 1,340 cases (3.2%). There was a significant relationship between the existence of TLTV and the abnormal rib count (odds ratio [OR]: 117.26, 95% confidence interval [95% CI]: 60.77-226.27; P < 0.001) and LSTV (OR: 7.38, 95% CI: 3.99-13.63; P < 0.001).

Conclusions

Our study results suggest that patients with TLTV are more likely to have an abnormal rib count or LSTV. If a TLTV or LSTV is seen on the fluoroscopic image, a whole spine image is necessary to permit accurate numbering of the lumbar vertebra.

Tethered cord syndrome and transitional vertebrae

PURPOSE

Tethered cord syndrome (TCS) usually presents with low-lying conus medullaris and thickened filum terminale. Spinal cord anomalies usually accompany congenital malformations and variations of the vertebral column. Transitional vertebrae (TV) are common variant, especially in the lumbosacral region. Accurate definition of the spine level is essential for proper radiological diagnosis and treatment. In this study, congenital spinal cord and vertebral anomalies and the relation with TV groups and types were evaluated in TCS patients.

METHODS

The study was performed in 97 patients. Radiological imaging findings [computed tomography (CT), magnetic resonance imaging (MRI), and radiography] and medical records were evaluated. Spine bony malformation, spinal cord malformation, and spinal level of malformation were compared with TV and non-TV groups in TCS patients. In addition, TV groups and types were compared with each other for these anomalies.

RESULTS

There was no statistically significant difference between TV and non-TV group in terms of the presence of vertebral bone and spinal cord anomalies. There were some significant differences in some of the spine bone and spinal cord anomalies among the groups and types of TV.

CONCLUSION

Sixty-two point nine percent TCS patients had TV. Although these findings indicate that TV is common in patients with TCS, no significant difference is observed in most of the studied anomalies. However, there were some differences among the TV groups and TV types in relation to congenital malformations. It can be concluded that TV anomaly could be a distinct malformation apart from all the other anomalies that were studied. Transitional vertebrae may cause pain due to biomechanical changes in addition to progressive neurological symptoms which are usually seen with TCS.