Sir,
I read this paper with interest. 'Bertolotti's syndrome' is a term given to a possible causal association
of transitional lumbo-sacral vertebrae and back pain. This paper reviews
the lumbar MRI scans of 769 patients with low back pain and the authors report an
overall incidence of transitional vertebrae in 4.6% of all scans, but 11.4
% in the under 30 age group. They conclude that "Bertolotti's syndrome
must form part of a list of differential diagnoses in the investigation of
low back pain in young people".
I am far from certain that the results of their investigation warrant
such a conclusion. Tini,1 in an extensive review of lumbar spine
radiographs in symptomatic and asymptomatic patients, found no significant
difference in the incidence of transitional vertebrae in the two groups.
In addition, while I would agree that existing evidence2,3 would point
to an increased risk of degenerative change occurring in the level above
the transitional vertebrae, the link between radiological degenerative
changes and symptoms of pain is tenuous to say the least. Their finding of
a higher incidence of Bertolotti's syndrome in the under 30 age group is
not convincing evidence of a causal link, and certainly not sufficient to
warrant adding this diagnosis to the list of possible causes of low back
pain in young people, particularly as it would seem that the clinical
features, natural history and treatment of this condition are no different
from those of other patients with more typical mechanical low back pain.
I am also concerned about the use of the term 'Bertolotti's
syndrome', highlighted by its inclusion in the title of the paper.
Eponymously named diseases can possess immense power and influence the
patient's understanding and approach to their condition. Such names may
give some degree of comfort to patients and doctors alike, but they give
simply "an illusion of clarity"4 where none exists. Clinicians too can
be confused by the precise meaning of such diagnoses and are more likely
now to pass on any named disease to their patient. My colleagues and I
recently presented a paper5 indicating that 90% of general
practitioners, on receiving a radiology report which included the words
'Scheuermann's disease', would tell their patients that they suffered such
a conditon using that term, although only half understood the nature of
the diagnosis they were passing on. Vulnerable patients with chronic low
back pain may have their own catastrophic and negative beliefs reinforced
by having their symptoms attributed to a spuriously named disease of
doubtful relevance. Whoever heard of a syndrome being cured by
lifestyle changes, exercise and activity, and positive mental attitudes?
B.N. Summers,
Consultant Orthopaedic Surgeon,
The Princess Royal Hospital,
Telford, Shropshire, UK.
1. Tini PG, Wieser C, Zinn WM. The transitional vertebra of the lumbosacral spine: its radiological classification, incidence, prevalence, and
clinical significance. Rheumatol rehabil 1977;16:180-5.
2. Elster AD. Berlotti's syndrome revisited. Transitional vertebrae of
the lumbar spine. Spine 1989;14:1373-7.
3. Aihara T, Takahashi K, Ogasawara A, et al. Intervertebral disc
degeneration asociated with lumbosacral transitional vertebrae: a clinical
and anatomical study. J Bone Joint Surg [Br] 2005;87-B:687-91.
4. Asher R. Talking Sense. Tunbridge Wells:Pitman Medical, 1972:26.
5. Summers BN, Manns R, Singh JP. Lumbar/type two Scheuermann's
disease, a radiologically based condition commonly reported by
radiologists and which might be better ignored. Britspine, 2006.
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