552 - Successful Nonoperative Management of L5 Radiculopathy with Multilevel Butterfly Vertebrae

Case Diagnosis: Right L5 radiculopathy with L4 and S1 butterfly vertebrae

Case Description: We document the first successful non-operative management for lumbar radiculopathy with multilevel butterfly vertebrae. A 41-year-old male presented with low back pain, right sciatica symptoms, and evolving right lower extremity weakness (foot drop). Diagnosis of right L5 radiculopathy with L4 and S1 butterfly vertebra was established after comprehensive assessment (physical examination, CT, MRI, and electromyography). Treatment course began with NSAIDs, 6-day and 18-day oral prednisone taper, and physical therapy. Initially, symptoms were not improving with the course of treatment, and a surgical consultation was obtained. Surgical intervention was not recommended. After three lumbar epidurals and an additional course of physical therapy (five months total treatment). Treatment resulted in functional recovery resolution of radicular pain and weakness. Repeat EMG at 18 months showed resolution of fibrillations but persistent polyphasic motor units in the L5 muscles suggesting nerve sprouting and healing.

Discussions: A “butterfly” vertebra(e), also referred to as “anterior rachischisis”, is a congenital vertebral anomaly caused by failed fusion of two hemivertebrae. Multiple butterfly vertebrae can be associated with syndromes such as Alagille syndrome, spondylocostal dysostosis, ankylosing spondylitis, Fryns syndrome, and VATER syndrome. Literature review revealed three cases of single butterfly vertebrae with radiculopathy, one of which was managed conservatively, and two required surgical intervention.

Conclusions: We report a rare multilevel butterfly vertebrae case with EMG confirmed radiculopathy that improved with non-operative care. Based on the literature review and our case, there is emerging evidence of successful non-operative management of lumbar radiculopathy in the setting of butterfly vertebra. Increased awareness of this rare anatomical anomaly will improve identification and aid in the development of evidence-based treatment plans for associated symptoms.