-Objective: Bertolotti's syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain. Method: We analyzed the cases of Bertolotti's syndrome that failed clinical treatment and reviewed the literature concerning this subject. Results: Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm. Conclusion: There is still no consensus about the most appropriate therapy for Bertolotti's syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.Key WorDs: low back pain, lumbosacral region, spine.dor lombar associada à vértebra de transição lombossacra: dificuldades no diagnóstico e manejo da síndrome de bertolotti resumo -Objetivo: A síndrome de Bertolotti é uma desordem congênita da coluna vertebral caracterizada pela ocorrência de uma mega-apófise transversa lombar em uma vértebra de aspecto transicional, que geralmente se articula com o sacro ou com o osso ilíaco. Tal síndrome tem sido considerada possível causa de dor lombar. Método: Análise dos casos de síndrome de Bertolotti que apresentavam dor lombar sem melhora com tratamento conservador e revisão dos artigos publicados. Resultados: Foram revisados cinco pacientes que não apresentaram melhora com o tratamento clínico, sendo que dois foram submetidos à ressecção cirúrgica da mega-apófise transversa. Considerando a experiência adquirida com estes casos, os autores propõem um algoritmo para diagnóstico e tratamento da síndrome de Bertolotti. Conclusão: Ainda não há consenso sobre qual é a terapia mais apropriada para a síndrome de Bertolotti. em pacientes em que a mega-apófise parece ser a origem da lombalgia, a ressecção cirúrgica parece ser um procedimento seguro e efetivo.PAlAvrAs-ChAve: dor lombar, região lombossacral, coluna vertebral.

Chronic paroxysmal hemicrania (CPH) is an unusual cause of headache, affecting predominantly women in the third to fourth decade. It is characterized by multiple attacks of unilateral pain, mostly located in fronto-orbito-temporal region, often associated with autonomic symptoms, such as lacrymation, conjunctival hyperaemia and nasal obstruction or rhinorrhea. Each attack usually lasts from 2 to 45 min and as diagnostic criteria it should be absolutely responsive to indomethacin in varying doses (1).Since the first description and definition of diagnostic criteria, few cases of CPH have been described in children. We report a 10 years-old girl with symptoms beginning since early childhood. Case reportA 10-year-old girl complained of attacks of left unilateral headache. Their parents explain that since she was a baby (1 year old), she had sudden periods of apparently unmotivated crying lasting about five minutes, approximately once a week, when she took her hands to the left ear region. As she started communication, on numerous occasions she said that she had pain or cold sensation in the periauricular region. At age 4, these attacks became more severe, lasting about 40 min, many times a day. She had a normal neurological, clinical and otological examination and CT scan, head MRI (three times since then), skull X-ray, auditory evoked-potentials, audiometry and blood tests were all normal. Thermography showed a cold-patch image in left frontal area, characteristic of hemiparoxystic headaches.Since the first attacks, she tried different medication, including NSAIDs, amitryptilin, imipramine, propranolol and carbamazepine, all without pain relief. The only effective medication was indomethacin, with a good efficacy since the first use at age 6, at doses of 25 mg 2-4 times a day it kept her free of headache if taken at least twice per day or with partial relief in lower doses. A psychological evaluation did not show any major affective disorders except coping strategies to avoid pain.At the time of consultation, the attacks varied in intensity and frequency. When she refrained from taking indomethacin, the attacks lasted from 15 to 40 min, followed by a brief relief of symptoms and posterior return after about 40 min. During severe attacks, lacrymation and conjunctival hyperaemia in the left eye could be seen. Rarely, her parents observed ipsilateral eyelid eodema but no nasal congestion or rhinorrhea. Some attacks have been videotaped and her behaviour was stereotyped in all of them, when she remained seated and crying, with her hand over the left side of her head and face, especially in left fronto-temporo-orbital region, sometimes including periauricular region. She markedly closed her left eye. Most of the time she remained seated but with occasional standing.After the diagnosis of possible chronic paroxysmal hemicrania was made, she was prescribed verapamil at increasing doses up to 240 mg, with a partial relief of symptoms, but still required indomethacin at lower doses (about 25 mg) 1-2 times a day.

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The authors found no correlation between excessive fibrosis with lumbar and leg pain, disability or straight leg resistance. The role of fibrosis in the generation of symptoms in patients who have had lumbar disc surgery should be reevaluated.