Bertolotti’s syndrome is a congenital spinal variation in which the lowest lumbar vertebra (L5) forms an incomplete or complete articulation—or fusion—with the sacrum or ilium, referred to as a lumbosacral transitional vertebra. Though present in around 4–8% of people, only a subset develops symptoms, often emerging in the late 20s to early 30s.

Clinical Presentation

Patients typically report deep, persistent lower back pain worsened by prolonged sitting or activity, with possible radiation into the hip or leg, mimicking sciatica. Radiculopathy is seen in over 70% of symptomatic cases due to nerve root compression from the pseudoarticulation or bony outgrowths.

Diagnostic Work-up

A thorough clinical history and imaging are essential:

• X‑raysreveal transitional anatomy.
• MRI assesses disc degeneration and nerve compression.
• CTmay better define stenosis or osteophytic changes.
• Diagnostic steroid or anesthetic injection* at the pseudo‑joint serves both diagnostic and therapeutic roles.

Response to an injection is especially useful in confirming the painful segment before considering surgery.

Non‑Surgical Management

Initial treatment follows a tiered, conservative approach:

• NSAIDs, muscle relaxants, and activity modification
• Physical therapy, focusing on core strengthening, neural mobilization, and addressing pelvic alignment
• Diagnostic and therapeutic injections, including steroids and lidocaine, which offer short-term pain relief
• Radiofrequency ablation (RFA) of the pseudoarthrosis or medial branches, which may last approximately six months and provide relief in selected patients.

While many find sufficient relief with these methods, most enduring symptomatic improvement comes from surgical intervention when non-surgical treatment fails

Surgical Options: Decompression vs. Fusion

When conservative therapies fail and diagnostic work-up confirms the transitional joint as the pain source, surgery is considered. Two primary surgical strategies are in use:

1. Pseudo‑Articulation Resection (Decompression)

This involves removing the abnormal bony connection between L5 and the sacrum/ilium:

Pros & cons :

- Good short-term symptom relief (>75%) in appropriate Castellvi types (e.g. Type II) if confirmed by diagnostic injection. - Risk of recurrence or later onset of adjacent-segment degeneration if excessive motion is induced.

2. Spinal Fusion

This stabilizes the transitional segment and adjacent vertebrae: Commonly performed at L5–S1 or L4–S1.

Pros & cons :

- Offers higher long-term rates of pain relief: ~78% at >12 months versus ~28% for resection.

- Greater surgical morbidity, longer recovery, and risk of adjacent-level degeneration or nonunion.

Conclusion

For patients with symptomatic Bertolotti’s syndrome, especially younger individuals, surgical options can offer substantial relief if conservative therapies are exhausted. A nuanced approach—guided by detailed imaging, diagnostic injections, and patient-specific factors—can optimize outcomes.

Dr. Callewart’s practice can play a key role in helping patients navigate these decisions—ensuring accurate diagnosis, conservative treatment optimization, selecting the most appropriate surgical strategy, and supporting recovery through tailored rehabilitation.