Int J Anat Res 2015, 3(3):1285-88. ISSN 2321-4287 1285

Case Report

A CASE REPORT OF A VARIANT OF LUMBO-SACRAL TRANSITIONVERTEBRAE: CASTELLVI TYPE IIA SACRALISATIONSubhendu Pandit *1, Monalisa 2, Samrat Sapkota 3, Sushil Kumar 4.

ABSTRACT

Address for Correspondence: Dr. Subhendu Pandit, Associate Professor, Dept of Anatomy, ArmedForces Medical College, Pune 411040, Maharastra, India. E-Mail: subhendupandit@yahoo.co.in

*1 Associate Professor, Dept of Anatomy, Armed Forces Medical College, Pune, Maharastra, India.2,3 Resident, Dept of Anatomy, Armed Forces Medical College, Pune, Maharastra, India.4 Professor and Head, Dept of Anatomy, Armed Forces Medical College, Pune, Maharastra, India.

Lumbosacral transitional vertebra (LSTV) are congenital anomalies of the lumbosacral spine causing sacralisationor lumbarisation. Sacralisation has been defined as an abnormality where one of the transverse processes ofL5 vertebra may articulate or fuse with the sacrum. The sacralisation has been studied for almost a century forits association with low back pain as “Bertolotti Syndrome”, but there are studies for and against its association.Castellvi in 1984 had propounded a radiographical classification identifying sacralisation in four sub types.Out of this, the Type IIA, is the least prevalent wherein there is a unilateral articulation of the L5 transverseprocess with the sacral ala. Inspite of the controversy, there is a high association of low back pain with discdegeneration, nerve root compression and degenerative facet joints observed with this condition. It is a widelyresearched vertebral anomaly for its anatomical, developmental and clinical ramifications.KEY WORDS : Lumbosacral vertebra, Sacralisation, Low back pain.

INTRODUCTION

International Journal of Anatomy and Research,Int J Anat Res 2015, Vol 3(3):1285-88. ISSN 2321- 4287

DOI: http://dx.doi.org/10.16965/ijar.2015.212

Access this Article online

Quick Response code Web site:

Received: 13 Jul 2015 Accepted: 01 Aug 2015Peer Review: 13 Jul 2015 Published (O): 31 Aug 2015Revised: None Published (P): 30 Sep 2015

International Journal of Anatomy and ResearchISSN 2321-4287

www.ijmhr.org/ijar.htm

DOI: 10.16965/ijar.2015.212

Lumbosacral transitional vertebrae (LSTV) arecongenital anomalies of the vertebrae where thefifth lumbar vertebra (L5) may articulate withthe sacrum producing sacralisation or thehighest sacral vertebra may show a transitionto a lumbar type causing lumbarisation [1,2]. Oneof the earliest to describe these anomalies wasT. Manners Smith in 1909 where he explainedthe articulation or fusion of the costal elementof the L5 transverse process (TP) with the sacrumproducing sacralisation. The etiology explainedreferred to a mechanical force in utero [3]. In1917, Bertolotti explained the relationship ofLSTV with low back pain, which subsequentlycame to be known as “Bertolotti Syndrome” [4].

Since then, this condition has been researchedover a century for its anatomical and clinicalimplications. Castellvi in 1984 [5], devised aradiographic classification system under whichthe sacralisation was identified into four types:Type IA: A unilateral dysplastic TP with craniocaudal dimension of 19 mmType IB: Both TPs cranio caudal height greaterthan or equal to 19 mmType IIA: Presence of unilateral articulationbetween the enlarged TP and the sacrum.Type IIB: Presence of bilateral articulationbetween the TP and the sacrum.Type IIIA: Unilateral osseous fusion of the TP andthe sacrum.

Int J Anat Res 2015, 3(3):1285-88. ISSN 2321-4287 1286

Subhendu Pandit et al. A CASE REPORT OF A VARIANT OF LUMBO-SACRAL TRANSITION VERTEBRAE: CASTELLVI TYPE IIA SACRALISATION.

MATERIALS AND METHODS

Type IIIB: Bilateral osseous fusion of the TP andthe sacrum.Type IV: Unilateral Type II transition (articulation)with a Type III (fusion) on the contralateral side.LSTV are common in the general population andits prevalence may vary from 4-30% [1,2] whileits association with low back pain ranges from6-37% [6,7,8]. Other studies have mentioned theoverall prevalence of sacralisation to be 1.7%-11.6% [2] with Castellvi type II prevalent in 2.7%of the population, especially amongst youngmales [9,10,11]. The wide variability in itsprevalence has been explained due to differentdiagnostic criteria, observer error and imagingtechniques utilized by various researchers in itsidentification [1,9]. There are studies whichsupport the association of low back pain withLSTVs [5,12,13] while others do not agree to anycorrelation [6,7,14]. This debate on low back painand LSTV with a diverse prevalence rate and adifficult diagnostic criteria has kept studies onLSTVs alive since Bertolotti explained it almosta century ago. The case report here is of a typeIIA Castellvi sacrum extracted from a cadaver inthe Department of Anatomy.

A sacrum of Indian origin of an unknown agewas retrieved from the departmental burialground. It was washed with soap water andexposed to 6% hydrogen peroxide in 50:50concentration for 72 hours. The specimen wassubsequently dried and studied for its anatomi-cal presentation. The TP dimension in its cranio-caudal axis was measured by a digital verniercaliper. It was documented by photographs atvarious angles to exhibit its features.

OBSERVATIONS

On examination, the L5 transverse process ofthe right side presented an articulation with theala of the sacrum, while the transverse processof the left side presented a cranio-caudal lengthof 9.38mm with no abnormal broadening orelongation (Fig. 1,2,3 & 4). The sacral hiatus wasnormal (Fig.5). There was no other bonyabnormality observed.The sacrum presented here is of Type IIA as perCastellvi’s classification on sacralisation. Itdescribes a sacrum of type IIA as having a

unilateral articulation of the L5 transverseprocess with the sacral ala with a normal TP onthe contralateral side.Fig. 1: Anterior View of L5 and sacrum. The Lumbosacraltransition vertebra showing Castellvi IIA type ofSacralisation with unilateral articulation of L5 trans-verse process with the sacral ala. The sacrum dose notexhibit any another abnormal presentation.

Fig. 2: Superior view of L5 and sacrum. The Lumbosacraltransition vertebra showing the articulation of the L5right transverse process with sacral ala. The transverseprocess of the left side is normal.

Fig. 3: The cranio caudal height of the transverse pro-cess of L5 on the left side is 9.38 mm. This suggests thatthere is no abnormal broadening or elongation of thetransverse process. A cranio caudal dimension of morethan 19mm is abnormal.

Fig. 4: Lateral view of L5 and sacrum. The nerve rootsmay get compressed between the transverse process andthe sacral ala.

Int J Anat Res 2015, 3(3):1285-88. ISSN 2321-4287 1287

Subhendu Pandit et al. A CASE REPORT OF A VARIANT OF LUMBO-SACRAL TRANSITION VERTEBRAE: CASTELLVI TYPE IIA SACRALISATION.

DISCUSSION

Fig. 5: The posterior view of L5 and sacrum. The Lum-bosacral transition vertebra showing the articulationof the L5 transverse process to sacral ala on the rightside while there is no such articulation with the sacrumin the left side. The transverse process on the left side isnormal.

Among sub types of sacralisation, Castellvi’sType IIA is least prevalent at 1.6% [6] while thehighest prevalence of 5.5-14.7% is seen inCastellvi type IA [6,10]. The Type II sacrum hasbeen studied for association with back pain asa part of Bertolotti syndrome [4,11] howevermany authors do not see any correlation. Thiscontroversy is due to an incompleteunderstanding of the variations in thelumbosacral anatomy and an absence of acomprehensive classification system[6]. Thedysplastic transverse processes in the Type I isgenerally considered to be of no clinicalsignificance, but the etiologies behind the lowback pain associated with type II sacralisationmaybe due to nerve root compression betweenthe hypertrophic TP of L5 and the sacral ala, mayarise from an abnormal articulation between theTP and the sacral ala or may present in theopposite side of the lower back as a facetogenicpain due degenerative changes in the joint [2].Type IIA sacralisation exhibits an accelerateddisc degeneration and disc protrusion above thetransitional vertebra due to an abnormal torqueand hypermobility, with a protective action onthe disc below due to restriction in the rotationaland bending movements as a result ofstabilization provided by the anomalousarticulation [1,2,5,14,15,16]. Castellvi in hisobservations had associated the Type II withpresence of disc herniation at the level oftransition with a greater incidence at a level justabove the transition vertebra [5]. Extraforaminalstenosis is more often observed in type I.

Vergauven [16] has observed that the abnormalvertebra is in itself not a risk factor for spinaldegenerative changes but if it does occur, it isat the suprajacent level of the transitionvertebra. Significant association have also beenfound with presence of cervical ribs in thepresence of sacralisation suggesting developm-ental anomalies [17]. Recent studies havehypothesized presence of mutations in the HOXgenes which are involved with the normalpatterning of the lumbosacral vertebrae to beone of the factors for LSTVs [2].As LSTV with associated low back pain is stillunder debate, the presence of the abnormalvertebral morphology is diagnosed as acoincidental finding in many instances. Thecorrect diagnosis of the condition is importantfor spinal surgeries [2]. Reliable diagnosis isdone by imaging in Ferguson position usinganteroposterior view angled cranially at 30degrees collated with the Castellvi’s radio-graphic classification. CT and sagittal MRIimages study the height and morphology of thedisc for various sub types of LSTVs but type IIAsacralisation is best diagnosed by radiographsand coronal MR images [1]. The treatment isconservative in nature with local injection ofcorticosteroids at the abnormal articulation andat the contralateral facet joint. Surgery isenvisaged for cases with failed conservativetreatment involving radiculopathies, degenera-ted discs and intransigent facetogenic pain [1].

CONCLUSION

Castellvi’s type IIA is a type of LSTV prevalent in1.6% of the population. The condition has beenstudied by various authors over the years andno concrete explanation has been given for itsrelationship with low back pain. However, thecondition has been associated with nervecompression, degenerative joint or presence ofdisc pathology which is postulated as thereasons for the pain or as a coincidentalfinding. The treatment is conservative withsurgery indicated only for the most intractablepain.

LSTV : Lumbo Sacral transition vertebraTP: Transverse process

List of Abbreviations:

Int J Anat Res 2015, 3(3):1285-88. ISSN 2321-4287 1288

Subhendu Pandit et al. A CASE REPORT OF A VARIANT OF LUMBO-SACRAL TRANSITION VERTEBRAE: CASTELLVI TYPE IIA SACRALISATION.

Acknowledgement:The study had not utilized any grants/funds fromany source. The study acknowledges the staffof the dissection hall, Dept of Anatomy, forextracting and cleaning the specimen from theburial ground.

Conflicts of Interests: None

REFERENCES

[9]. French HD, Somasundaram AJ, Schaefer NR, LahertyRW. Lumbosacral transitional vertebrae and itsprevalence in the Australian population. Globalspine journal 2014;4(4):229-32.

[10]. Ucar D, Ucar BY, Cosar Y, Emrem K, Gumussuyu G,Mutlu S, et al. Retrospective cohort study of theprevalence of lumbosacral transitional vertebrain a wide and well-represented population. Arthritis2013;(2013).

[11]. Paraskevas G, Tzaveas A, Koutras G, Natsis K.Lumbosacral transitional vertebra causingBertolotti’s syndrome: a case report and review ofthe literature. Cases journal 2009;2:8320.

[12]. Chang HS, Nakagawa H. Altered function of lumbarnerve roots in patients with transitionallumbosacral vertebrae. Spine 2004;29(15):1632–1635.

[13]. Magora A, Schwartz A. Relation between the lowback pain syndrome and X-ray findings. II .Transitional vertebra (mainly sacralisation).Scandinavian Journal of Rehabilitation Medicine1978;10(3):135–145.

[14]. Luoma K, Vehmas T, Raininko R, Luukkonen R,Riihimäki H. Lumbosacral transitional vertebra :relation to disc degeneration and low back pain.Spine 2004; 29:200-205.

[15]. Van Tulder MW, Assendelft WJ, Koes BW, Bouter LM.Spinal radiographic findings and nonspecific lowback pain. A systematic review of observationalstudies. Spine 1997;22:427-434.

[16]. Vergauwen S, Parizel PM, Van Breusegem L et al.Distribution and incidence of degenerative spinechanges in patients with a lumbo-sacraltransitional vertebra. Eur Spine J 1997;6:168-172.

[17]. Erken E, Ozer HTE, Gulek B, Durgun B. The AssociationBetween Cervical Rib and Sacralization. Spine2002;27(15):1659-64.

[1]. Konin GP, Walz DM. Lumbosacral transitionalvertebrae: classification, imaging findings, andclinical relevance. AJNR American journal ofNeuroradiology 2010;31(10):1778-86.

[2]. Bron JL, Van Royen BJ, Wuisman PI. The clinicalsignificance of lumbosacral transitionalanomalies. Acta orthopaedica Belgica 2007;73(6):687-95.

[3]. Manners Smith T. The variability of last lumbarvertebra. University of Cambridge Jan 1909;Vol.XLIII(Third Ser Vol IV):146-159.

[4]. Bertolotti M. Contribute alla conoscenza dei vizi didifferenzazione del rachide con speciale reguardoall assimilazione sacrale della v lombare. LaRadiologia Medica 1917;4:113–44.

[5]. Castellvi AE, Goldstein LA, Chan DP. Lumbosacraltransitional vertebrae and their relationship withlumbar extradural defects. Spine 1984;9:493–95.

[6]. Bulut M, Uçar BY, Uçar D, Azboy Ý, Demirtaþ A,Alemdar C etal. Is sacralisation really a cause oflow back pain?. ISRN orthopedics 2013.

[7]. Otani K, Konno S, Kikuchi S. Lumbosacral transitionalvertebrae and nerve-root symptoms. The Journal ofBone and Joint Surgery 2001;83(8):1137–1140.

[8]. Elster AD. Bertolotti’s syndrome revisited:transitional vertebrae of the lumbar spine. Spine1989;14:1373–177.

How to cite this article:Subhendu Pandit , Monalisa, Samrat Sapkota, Sushil Kumar. A CASEREPORT OF A VARIANT OF LUMBO-SACRAL TRANSITIONVERTEBRAE: CASTELLVI TYPE IIA SACRALISATION. Int J Anat Res2015;3(3):1285-1288. DOI: 10.16965/ijar.2015.212