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Sarah Key - Beat That Back Pain

Back Pain Exercises

Treatment Options for Partial sacralisation (Bertolotti's Syndrome)

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There are several treatment options for Partial sacralisation, or Bertolotti's Syndrome, ranging from hands on mobilisation of the pseudarthrosis to surgical resection (osteotomy) of the oversized transverse process of L5.

 

 

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Therapist Administered Non-Surgical Treatment of Bertolotti's Syndrome

As the intervertebral disc at the L5 level loses height the 'propping' trauma of the transverse process against the side of the pelvis increases . Although the disc degeneration is unlikely to be painful, mobilisation of the L5 vertebra centrally (PA pressures) helps the disc to absorb water, raises the roof of L5 centrally off the sacrum and thus lessens the lateral pressure of the transverse process on the pelvis.

With Bertolotti's syndrome, mobilisation pressures have a dual focus: centrally on the L5 spinous process and out wide on the pseudarthrosis to get this developmental joint working better.  Treatment ideally involves manual mobilisation of the false joint with the hands (or in my case, the heel) but it is easy to 'overdo' treatment here.

Bear in mind that the pseudarthrosis has developed as a functional necessity but it is far from an ideal joint. Although the hard pinpoint of pain craves pressure, it can be overwhelmed and inflamed by too much drilling and stretching treatment. Gentle progressive mobilsation administered at the right rate is spectacularly effective when combined with appropriate self treatment (see below). 

 

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Self-Mobilisation Treatment of Sacralisation


You will see in the video 'Lumbar Facet Syndrome' how you can perfectly mobilise a facet joint yourself using a soft squashy mass directly underneath joint. A pair of kid gloves is ideal for this but a tennis ball is too much. The gloves folded back upon themselves creates the perfect tool, with the suede leather surface creating drag against the skin that keeps the gloves in place. You can do the same to mobilise a pseudarthrosis of Bertolotti's syndrome, taking care to place the glove-mass locally, right under the false joint. 

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With the glove-mass in place you then perform small oscillatory flexion-extension movements of the lower back and pelvis that open and close the false joint. The soft, squashy mass of the gloves kneads the soft tissues surrounding the joint, dissipating toxic inflammatory products and  and helping make them more compliant.  With each session it takes perseverance to get the gloves in exactly the right place and the pressure well-directed. See the video for real-time application of this exercise. 

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Self-Treatment of Sacralisation with Decompression Exercises

All the usual appeasing, self-mobilisation and strengthening exercises described in exercises for back pain can be put into action here. Spinal decompression using a BackBlock is an important part of treatment as this decompresses the pseudarthrosis along with the intervertebral discs at L5 and L4. 

Using the BackBlock is an important part of self-treatment for any back problem. The pressure changes induced by the end-of-range movement of the lumbar spinal segments act like a physical pump. The local pumping concertina-action shunts a better fluid exchange through both the intervertebral disc and the pseudarthrosis and helps to dissipate inflammatory products from both structures. The enhanced fluid flow in and out of the lower discs also helps  to stimulate proteoglycans synthesis, which improves the disc's capacity to retain water. A more bulky water-filled disc at the affected level reduces the grinding contact of the transverse process against the pelvis. You can read more about How to Use the BackBlock here. 

 

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Generalised spinal mobilising techniques also target neighbouring 'normal' spinal joints, upping their performance and thereby reducing the forces on the problematic L5 level.  The 'banana stretch' is an important sideways stretch for unilateral sacralisation. 

While the 'banana stretch' opens the pseudarthrosis through a side-flexion stretch of the trunk, the 'floor twists' open the joint through a twisting or rotatory action. You will see in the short video attached that the important leg straightening at the knee helps to wrest the lower lumbar nerve roots free of adhesions and thus reduces chronic sciatica that is often associated with Bertolotti's syndrome. 

 

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Surgical Options For Bertolotti's Syndrome

After using local anaesthetic to confirm that the sacrailsation is the seat of pain, the first surgical intervention is usually an injection of steroids, possibly followed by cautery of the nerve supply to the joint. If the effect is positive but not long-lasting (and assuming that exhaustive conservative treatment has not been helpful) there is the option of resecting the enlarged transverse process and the pseudarthrosis, or fusing it. 

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There are only a few studies to go by, but it appears that fusion is marginally more successful than osteotomy (removal of bone) although the post-operative recovery period is longer. The removal of bone is carried out through the use of a high-speed burr.  Bear in mind that the pseudarthrosis often develops an enhanced nerve supply during the period it has steadily become more inflamed. For this reason, the pain may be slow to settle during the post-operative period.

 

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