Original Article
Redefining the Treatment of Lumbosacral Transitional Vertebrae for Bertolotti Syndrome:
Long-Term Outcomes Utilizing the Jenkins Classification to Determine Treatment
Arthur L. Jenkins III1-3, Richard J. Chung3, John O’Donnell3, Charlotte Hawks3, Sarah Jenkins1,3, Daniella Lazarus3,
Tara McCaffrey3, Hiromi Terai3, Camryn Harvie3, Stavros Matsoukas1
- OBJECTIVE: Using the Jenkins classification, we pro-
pose a strategy of shaving down hypertrophic bone, uni-
lateral fusion, or bilateral fusion procedures to achieve
pain reduction and improve quality of life for patients with
Bertolotti syndrome.
- METHODS: We reviewed 103 patients from 2012 through
2021 who had surgically treated Bertolotti syndrome. We
identified 56 patients with Bertolotti syndrome and at least
6 months of follow-up. Patients with iliac contact preop-
eratively were presumed to be more likely to have hip pain
that could respond to surgical treatment, and those patients
were tracked for those outcomes as well.
- RESULTS: Type 1 patients (n [ 13) underwent resection.
Eleven (85%) had improvement, 7 (54%) had good outcome,
1 (7%) had subsequent surgery, 1 (7%) was suggested
additional surgery, and 2 (14%) were lost to follow-up. In
Type 2 patients (n [ 36), 18 underwent decompressions
and 18 underwent fusions as a first line. Of the 18 patients
treated with resection an interim analysis saw 10 (55%)
with failure and needing subsequent procedures. With
subsequent procedure, 14 (78%) saw improvement. For
fusion surgical patients, 16 (88%) saw some improvement
and 13 (72%) had a good outcome. In Type 4 patients (n [
7), 6 (86%) did well with unilateral fusion, with durable
benefit at 2 years. In patients who had hip pain
Key words
- Bertolotti syndrome
- Castellvi classifications
- Lumbosacral transitional vertebrae
- Minimally invasive surgery
- Neurosurgery
- Spine
Abbreviations and Acronyms
CT: Computed tomography
LSTV: Lumbosacral transitional vertebrae
MIS: Minimally invasive surgery
MRI: Magnetic resonance imaging
PSIC: Posterior superior iliac crest
SI: Sacro-Iliac
WORLD NEUROSURGERY 175: e21-e29, JULY 2023
preoperatively (n [ 27), 21 (78%) had improvement of hip
pain postoperatively.
- CONCLUSIONS: The Jenkins classification system pro-
vides a strategy for patients with Bertolotti syndrome who
fail conservative therapy. Patients with Type 1 anatomy
respond well to resection procedures. Patients with Type 2
and Type 4 anatomy respond well to fusion procedures.
These patients respond well in regard to hip pain.
INTRODUCTION
L umbosacral transitional vertebra (LSTV) anatomy is defined
as a congenital anomaly with incomplete sacralization or
lumbarization of lumbosacral junction.1 In recent studies,
LSTVs have a prevalence of 15.8% to 35.6% within the general
population.2-5 Bertolotti syndrome is a clinical finding where an
LSTV is the source of one or more of: back pain, hip pain,
sacroiliac pain, groin pain, or radiating leg pain in a classically L5
distribution.6 We believe that having a full understanding of a
patient’s LSTV anatomy improves management. Currently, the
diagnosis of Bertolotti syndrome is inconsistent and
unclear—often a diagnosis of exclusion.7
Many studies utilize the Castellvi classification system estab-
lished in 1984 for LSTV identification and subsequent Bertolotti
TP: Transverse process
VAS: Visual analog scale
From the Departments of 1Neurosurgery, and 2Orthopedics, Icahn School of Medicine at
Mount Sinai; 3Jenkins NeuroSpine, Private Practice, New York, New York, USA
To whom correspondence should be addressed: Arthur L. Jenkins III, M.D.
[E-mail: alj@arthurjenkinsmd.com]
Citation: World Neurosurg. (2023) 175:e21-e29.
https://doi.org/10.1016/j.wneu.2023.03.012
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/ª 2023 The Authors. Published by Elsevier Inc. This is an open access article under
the CC BY license (http://creativecommons.org/licenses/by/4.0/).
www.journals.elsevier.com/world-neurosurgery e21

ARTHUR L. JENKINS ET AL.
syndrome diagnosis. Yet Castellvi’s hypothesis was that pain was
derived primarily from disk herniations at the transitional level,
instead of contact between elements of the transitional anatomy at
the L5-S1 level.8 However, the proximity of the transverse process
(TP) and ala, or the pseudoarticulation itself, as well as in some
cases bone spurs coming off the facet joints, may directly
irritate the exiting L5 nerve.2 Direct bone-on-bone contact may
induce inflammatory mediators that irritate the exiting L5 nerve,
in addition to nerves on the surfaces of the bones of the transverse
process, ala, and iliac wing.2 A significant number of patients have
also reported mechanical hip region pain, which may be alleviated
by treatment of the transitional anatomy in which the pain
mechanism may be from the contact or instability of the
sacroiliac (SI) joint caused by extra bones being nearby.6 Many
patients with Bertolotti syndrome also report groin pain, and
this may be partially related to contributions of the L5 nerve to
the genitofemoral nerve.9
Thus, we proposed the anatomic basis for our new classification
system in the parallel paper, which we will refer to as the Jenkins
classification (Figure 1, Table 1). This new description of LSTV
anatomy is based on the concept of a reduced gap between the
transverse process and sacral ala being the primary responsibility
for Bertolotti syndrome pain, rather than disk herniations (which
we consider to be at most an epiphenomenon of the LSTV, not
Bertolotti syndrome). This physical gap in symptomatic patients
with Bertolotti syndrome, which in normal patients is typically
greater than or equal to 20 mm, is almost always less than 10
mm.9 In addition, when the transverse process is less than 5 mm
from the iliac wing, this iliac contact can also be part of the
symptomatic LSTV anatomy as well.
Although an LSTV can be radiologically diagnosed, current
diagnostic and clinical treatment of symptomatic LSTVs, or Ber-
tolotti syndrome, is unclear.10 Often, the source of the pain can be
identified by targeted injections to the LSTV anatomy, confirmed
by positive responses to specific and sensitive relief. For
treatment options, the current literature recommends
conservative management with medical management, physical
therapy, and a combination of local and steroid injections into
the pseudoarticulation as non-surgical therapeutic measures.10
There have long been 2 primary surgical treatments for symp-
tomatic Bertolotti syndrome patients: decompressions or fusions
of the transitional articulation at the lumbosacral junction.10
Determining the appropriate treatment for a particular patient
depends upon matching the clinical presentation with the
radiologic findings to optimize the treatment plan for each
patient. However, there has been no large-scale study that estab-
lishes a consensus of decompressions or fusions procedures based
on LSTV presentation or other diagnostic measures. In our sur-
gical outcomes analysis of 56 patients with Bertolotti syndrome,
we proposed the following treatment strategies based on the pa-
tient’s specific type.
For patients with Type 1 LSTVs who had favorable responses to
injections between the transverse process and ala at the closest
point of proximity, we proposed to perform decompressions
(resection of a portion of the hypertrophic or prominent transverse
process, ala, or in some cases, both) as we hypothesize that it is
the proximity (less than 10 mm separation between the transverse
processes and the ala, as seen on multiplanar computed axial
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ORIGINAL ARTICLE
SURGICAL OUTCOMES OF BERTOLOTTI’S SYNDROME
tomography [CT] reconstructions) that causes the pain, and that
separating these surgically to a minimum of 10 mm separation
would be adequate distance to mitigate bone-on-bone rubbing
without potential regrowth. This was based on the observation
that no patients (without a hypermobility diagnosis) were found to
be symptomatic at this anomaly if the transverseeala gap was
larger than 10 mm.
By the same logic, we initially anticipated that for patients with
Type 2 anatomy and favorable response to injections into the
pseudoarticulations, they would also respond to shaving down the
bone on the painful side(s), but also considered that this strategy
may require re-evaluation over time. We also considered that Type
2 anatomy might benefit from a fusion procedure, as patients who
had decompression-type procedures might eventually develop
bone regrowth or have an inadequate resection that results in
recurrence of symptoms and potential reoperation, or instability
from “releasing” a relatively unstable level (given the prevalance of
LSTV hypoplastic disks, lack of muscle development at the LSTV
level, and other associated findings).11,12 Our initial hypothesis
was that we could try the shaving first, a much smaller
“minimally invasive” procedure, and if that failed, proceed to a
fusion as a second stage procedure.
Type 3 anatomy is predicted to have no symptoms referable to
the LSTV level itself, and therefore no need for surgical manage-
ment at that level, given the bilateral stability of the sacroiliac
junction. For these patients, we proposed looking at alternate
levels or locations for their primary pain generator, and not calling
it “Bertolotti syndrome”, even if they have associated adjacent level
disease known to be associated with LSTV anatomy.
And finally, we proposed that patients with Type 4 anatomy and
favorable response to injections targeting the painful side of the
LSTV will benefit most from fusion surgery of the non-fused side,
given the existing unilateral stability.
The concept of whether an LSTV is already a “fusion”, or that a
partial fusion within an LSTV can even generate any pain, has
caused considerable discussion and dissent among providers and
researchers, and many patients report hearing from their other
clinicians that a unilateral fusion (a Type 4 LSTV) “cannot cause
pain”. We hypothesize that given the presence of hypoplastic but
partially functional disks, bilateral mobile facet joints, and only a
unilateral fusion on one side, and either a gap or a “pseudoarti-
culation” on the other side, pain can be generated in these pa-
tients either from flexing of the “fused” side and bone contact or
irritation of the nerve causing pain on the “open” side, or from
flexing of the “fused” side and stress on that flexing side leading
to pain on the “fused” side.
The purpose of this study is to establish a preliminary guideline
based on our collective experience with these patients who only
have Bertolotti syndrome and not any other confounding or
coincident spinal conditions. Heretofore, there has been little
consensus regarding the surgical management of Bertolotti syn-
drome. Of note, in discussions with many surgeons who have
attempted to treat this syndrome, a pattern of doing resections for
all classifications as the treatment has been noticed among sur-
geons who have treated fewer than 5 patients (unpublished data).
With our proposed surgical recommendations, we hope to in-
crease inter-surgeon reliability, and in return, improve care in
patients presenting with Bertolotti syndrome.

ARTHUR L. JENKINS ET AL.
Figure 1. Schematic presentation of the classification of unilateral and bilateral LSTV according to the proposed Jenkins classification.
METHODS
Patient Selection
We performed a retrospective cohort study, under the exemption
of the Center for IRB Intelligence review board, of patients
operated on from 2012 through 2021 with clinically verified
Bertolotti syndrome, who all met the following criteria: Symp-
tomatic patients (1) with 1 or more of back pain, L5 radiculop-
athy, SI pain, hip pain, groin pain; (2) having transitional
anatomy as described by the Jenkins classification; (3) having
favorable injection results targeting the LSTV, and in many cases,
also with no response to targeting other spinal and non-spinal
anatomy including epdidural injections, hip injections, facet or
medial branch block injections (with no or minimal response to
these latter types); (4) who failed other forms of conservative
treatment; and (5) who subsequently underwent a surgical pro-
cedure to address their LSTV by the senior author.
Of the original 103 surgical patients reviewed in the parallel
article, only 56 had only Bertolotti syndrome as their initial and
sole surgical diagnosis and therefore underwent only surgical
treatment of their transitional lumbosacral anatomy. That means
that 47 patients were excluded from this analysis because they
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underwent surgical treatment that included surgical treatment for
their Bertolotti syndrome on their LSTV plus 1 or more surgical
procedures at a different level/location, including suprajacent
lumbar fusions, diskectomies, laminectomies, or removal of
hardware and exploration of fusion at 1 or more levels above the
target level. This resulted in almost half of patients with Bertolotti
syndrome having a second significant diagnosis at a different
lumbar level that required simultaneous treatment. In addition to
those, a small population had insufficient follow-up data to be
used for outcome result, such as being lost to follow-up, providing
incomplete pain information, and death of the patient.
Collection of Patient-Reported Pain
Patient-reported pain data were collected utliizing the visual
analog scale (VAS) pain scale (0e10), and pain was recorded when
it was present in their back or legs or hips, and specifically re-
ported as to location in the upper lumbar, lower midline lumbar,
and SI regions, as well as specific dermatomal distribution, hip
pain, groin pain, or other regions.
Patients were screened for a combination of symptoms, ranging
from myelopathy, radiculopathy, mechanical back pain, hip pain,
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Table 1. Description of the Classification of Unilateral and Bilateral LSTV According to the Proposed Jenkins Classification
Laterality (More
Classification Abnormal Side) Anatomic Description

Primary Classification
1A (L)/(R) Unilateral dysplastic transverse process [<10 mm between TP and ala; e.g., Type 1A(L) gap is >2 mm, <10 mm, only on left,
>10 mm on right]
1B (L)/(R) Bilateral dysplastic transverse process [both sides <10 mm gap; e.g., Type 1B(R) closer on right than left]
2A (L)/(R) Incomplete unilateral lumbarization/sacralization with enlarged transverse process that has a diarthrodial joint between
itself and the sacrum [<2 mm separation, with planar surface on transverse process parallel to the opposite surface of the
ala, but >10 mm gap on the opposite side; e.g.: Type 2A(L) is Type 2 on the left, with >10 mm on the right]
2B (L)/(R) Incomplete bilateral lumbarization/sacralization with enlarged transverse process that has a pseudo-joint between itself and
the sacrum [<2 mm of separation on both sides, with planar surfaces on transverse process parallel to the opposite side of
the ala; e.g., Type 2B is symmetrical while 2B(R) has a bigger interface on right]
2C (L)/(R) Dysplastic transverse process on one side and incomplete lumbarization/sacralization on the other side [<10 mm but >2 mm
on one side, and <2 mm on the other side; e.g., Type 2C(L), Type 1 on right, Type 2 on left]
3 (L)/(R) Bilateral lumbarization/sacralization with complete osseous fusion of the transverse process to the sacrum [no radiographic
fusion plane viable on MRI, CT, or Ferguson views of roentogram, either side]
4A (L)/(R) Lumbarization/sacralization with complete osseous fusion on one side dysplastic transverse process on the other side [Type 1
on one side, Type 3 on the other side; e.g., Type 4A(L) Type 1 is open on right, Type 3 on left]
4B (L)/(R) Lumbarization/sacralization with complete osseous fusion on one side and incomplete lumbarization/sacralization on the
other side [Type 3 on one side Type 2 on other side; e.g., Type 4B(R), Type 2 side is open on right, Type 3 on left]
4C (L)/(R) Lumbarization/sacralization with complete osseous fusion on one side, >10 mm gap on other side [Type 3 on one side, Type
1 on other side; e.g., Type 4C(L) is open on left, Type 3 on right]
Secondary Classification
þL/R/B þL/R/B Denotes which side has contact between transverse process and iliac crest [e.g., Type 2C(L)þL]

CT, computed tomography; L, Left side more prominent; MRI, magnetic resonance imaging;R, Right side more prominent; TP, transverse process;þ, transverse process touches (within 2 mm of)
the iliac bone; C, Type 1 LSTV on one side and Type 2 LSTV on the other side.

and were screened for other spinal, orthopedic, or medical con-
ditions that might be contributing to their pain. Only those with
both transitional anatomy and the fact that the transitional anat-
omy was the primary pain generator were considered to have
“Bertolotti syndrome”.
We identified a “good” outcome to be either a reduction of the
original VAS pain level from their preoperative level to 50% of that
level, or to a 3 out of 10 or less; an “acceptable” outcome was any
reduction in that pain that was sustained, even if not a the “good”
level. Patient outcomes for this analysis were appraised at 6 month,
1 year, 2 years, and time of last follow-up. Presence of additional
surgical treatments was noted, and whether this surgical treatment
was for return of the original symptoms (a failure of treatment) or
for new and unrelated treatments (like a new L2-L3 disk herniation).
Particular notice was made as to whether those “unrelated” surgical
treatments were at the suprajacent level.
Surgical Treament Strategies
Our initial treatment paradigm consisted only surgical resection or
decompression procedures, and only on the symptomatic sides, of
all patients with Type 1 or Type 2 anatomic findings (Type 1A,
Type 1B, Type 2A, Type 2B, Type 2C).
While we offered a choice of instrumented fusion or “simple”
decompression procedures to the Type 2 patients, we left the
choice to the individual patients; in all cases the patients elected to
undergo a resection instead of a fusion as the first-line treatment.
After an initial internal analysis, we determined that there was a
high rate of recurrent surgery for Type 2 patients (n ¼ 18 in this
group) undergoing resection/decompression procedures. The
majority of these patients, after undergoing instrumented fusion
of the LSTV level, had resolution or improvement in symptoms
that was sustained. As a result, we then changed our algorithm to
instead recommend resection/decompression only for Type 1
anatomy, and instrumented fusion for Type 2 anatomy of all
subtypes. This recommendation and strategy has been maintained
for the rest of the cohort.
No patients with Type 3 anatomy were identified with injections
to have pain coming from the LSTV level, and therefore no sur-
gical procedures were offered to treat this level.
Patients with Type 4 anatomy were offered surgical instru-
mented fusions of the unfused side only, except where a stress
fracture in the “fused” side was identified (n ¼ 1), for that patient
an instrumentation of the fractured side and an instrumentation
and fusion of the open side was performed.

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ARTHUR L. JENKINS ET AL.
Surgical Technique
Decompression procedures, whether unilateral or bilateral, were
performed using an operating microscope and the METRx dilators
(Medtronic, Memphis, TN), drilling out the bone of the inferior
half or so of the transverse process, the superior portion of the
sacral ala, or both, so that the gap between the 2 measured at least
10 mm at all points from tip to foramen. The intertransverse
membrane, the attached periosteum, and any scar in the area,
were removed completely from pars interarticularis and facet
medially to the end of the transverse process laterally, and the
bleeding surfaces of the bone edges so exposed were covered first
with bone wax, and then a layer of fibrin glue sprayed on top of
that to prevent bone regrowth.
Instrumented fusion procedures (unilateral or bilateral) in this
series were performed utilizing a Wiltse approach, utilizing
microsurgical dissection, and a dorsal fusion performed by
decorticating the surfaces of the sacral ala, the transverse process,
and the facet joint from the LSTV level, as follows: an incision 2e3
cm was utilized, parallel to but just medial to the posterior su-
perior iliac crest (PSIC) in line with the angles of the pedicles of
the lowest lumbar and highest sacral levels.13 The fascia and
muscle were split, exposing the ala and transverse process.
If instrumentation was to be placed, pedicle screws were placed at
the bottom lumbar (usually L5, but could be either L4 or L6) as well as
either pedicle screw or alar screw placed at S1, and a rod placed be-
tween them, and locked into place. In cases where there was a sig-
nificant focal scoliosis, distraction or compression was performed on
1 side to attempt to level the L5 body against the S1 body, or to
compensate for any other asymmetry that might have been present.
Bone grafting was performed with either locally harvested
autogenous iliac crest, or Infuse rhBMP-2 product (Medtronic),
and then allograft cancellous bone chips being placed over the
decorticated surfaces. All patients were informed that, if the
Infuse was utilized, this was considered an “off-label” indication.
The choice of allograft iliac crest or rhBMP-2 product was based
on several factors including price and insurance coverage issues,
or potential side effects of the rhBMP-2, but was left to the indi-
vidual patient; in most cases the patients elected to use the
rhBMP-2 instead of harvesting bone from their PSIC.
All patient who had hardware placed had intraoperative re-
constructions to verify final positioning of the screws prior to the
fusion part of the procedure, utilizing 1 of 3 systems, including
Ziehm Vision 3D (Ziehm Imaging, Orlando FL), Siemens C-ios or
Siemens ISO-C (Siemens, Erlangen, Germany).
Jenkins Classification
When discussing patient types, we use the Jenkins classification
Type 1, 2, 3, and 4 (Figure 1), with subclassifications of:
- L (left) or R (right) prominence
- A (unilateral), B (bilateral), or C (Type 2 with Type 1 and
contralateral 2 anatomy or Type 4 with a gap > 10 mm and
contralateral Type 3 anatomy)
- þ L (left) or R (right) iliac contact
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Type 1 anatomy is described as a dysplastic transverse process
that shows a gap of less than 10mm, but greater than 2mm across
the lumbosacral junction.
Type 2 anatomy is identified as pseudo-articulation between
adjacent transverse processes with a gap of less than 2 mm.
Type 3 anatomy is the complete fusion lateral to the facet at the
ala, without spontaneous fusion of the disk or facet joints, of the
lumbosacral junction.
Type 4 anatomy is the presence of unilaterally fused side with
varying pseudoarticulation on the contralateral side (Type 4A, 4B,
or 4C).
RESULTS
The 56 patients had an average age of 46.8  17.4 years with an
average body mass index of 25.1 4.8. There were 29 female and
27 male patients. Using the Jenkins classification, 13 patients with
Type 1 anatomy (all with Type 1B), 36 patients with 1 or more
subsets of Type 2 anatomy (Type 2A, n ¼ 2; Type 2B, n ¼ 14; Type
2C, n ¼ 20), no patients with Type 3, and 7 patients with Type 4
anatomy (Type 4A, n ¼ 3, and Type 4B, n ¼ 4).
In each subtype, surgical outcomes were defined as “good”,
“adequate”, and “no” improvement. Good improvement was
defined as patients with a 50% reduction in postoperative VAS
score compared with preoperative or a VAS score  3. Adequate
improvement was defined as patients displaying clinical
improvement but less than a 50% reduction in their VAS score. No
improvement was defined as patients with no change or even
worsening of their symptoms postoperatively.
Type 1
The 13 total patients with Type I anatomy generally did well with
decompression surgery by resection of the inferior portions of the
transverse process, the superior sacral ala protrusions, or both to
create at least 1 cm gap between the 2. A total of 13 patients un-
derwent decompression procedures, with 6 initial bilateral and 7
unilateral decompression surgeries (7 left).
Of these patients, 11 of 13 (85%) improved from their decom-
pression procedure. Within these 13 patients, 7 (54%) patients had
good improvement, 5 (38%) patients reported adequate improve-
ment, and 1 (8%) showed no improvement. The patient with no
improvement developed supra-adjacent issues and underwent an
L4-S1 decompression and L5-S1 fusion to manage her recurrent
Bertolotti type pain, followed by an L4-L5 discectomy. She still
reported residual pain but was lost to follow-up at the 6-month
mark.
None of the other Type I patients underwent subsequent
resection/decompression surgery. Three patients considered to be
a successful outcome with regard to their Bertolotti related surgery
subsequently developed pain that was different from their pre-
operative Bertolotti pain, and are being managed by injections, or,
in 1 case, being managed for her endometriosis pain. Notably, of
the 7 patients with good improvements (54%), 4 patients (31%)
had no back or leg pain at the last follow-up ranging from 4 to 10
years after surgery.
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ARTHUR L. JENKINS ET AL.
Type 2
Of 36 patients who underwent surgical procedures, 18 underwent
decompressions and 18 underwent fusions as their first treatment.
MIS Decompression/Reduction Procedures
Our initial surgical management of Type 2 patients (n ¼ 18) was
similar to Type 1 patients, with the performance of a decom-
pression/reduction of the transverse process and/or ala with a goal
of 1 cm gap between the ala and the transverse process, only on
the symptomatic side (right ¼ 9, left ¼ 7) or bilaterally (n ¼ 2).
Around 2017, at the time of the initial evaluation of efficacy of
this technique, we noticed that many of these initial cohort of 18
patients had undergone a subsequent re-operation for recurrent
Bertolotti’s Syndrome symptoms (contralateral decompression
(n ¼ 2), ipsilateral revision decompression (n ¼ 1), diskectomy at
L5/S1 (n ¼ 1), and revision with fusion (n ¼ 4)) within the first 2
years after their index procedure. Therefore, we performed an
initial subgroup analysis and determined that in the first 2 years,
12/18 (67%) patients who underwent initial resections for Type 2
anatomy failed to have durable relief and recurrence of their initial
pain, with 7 of the 12 patients undergoing another procedure at
the index level (3 repeat decompressions and 4 fusions).
Of the 3 patients who underwent repeat decompression/reduc-
tion Bertolotti’s procedures, 1 was successful in keeping pain 2/10
or less, 1 was still a treatment failure but refused further surgical
intervention, and 1 showed some improvement in pain but did not
fall under the criteria for good improvement.
Of the 4 patients who subsequently underwent fusion at the
lumbosacral junction, all 4 had good improvement based on the
earlier criteria of reduction in pre-operative Bertolotti’s pain.
However, 1 patient developed a new pain from the proximity of the
S1 pedicle screw to the iliac wing but refused removal of that screw
despite a solid fusion. 1 went on to develop L4/5 spondylolisthesis
but refused surgical treatment of that level despite 6/10 pain that
was 80% reduced with L4/5 medial branch blocks. The remaining
2 patients had adequate improvement in their pain following
surgery at 2 years after surgery.
Of the 5 remaining decompression for Type 2 patients who
refused either “Bertolotti’s” reoperation procedure, all had some
persistent pain, refractory to conservative treatments. 1 patient
underwent subsequent laminotomies and diskectomy at the L5/S1
level due to a delayed new disk herniation at the index level, and
after that procedure was noted to have 1/10 pain (a “good”
outcome eventually) at the last follow-up; this patient was pain-
free initially after the Bertolotti’s decompression until a sudden
onset of leg pain 5 months after surgery, and a new MRI
demonstrated a new L5/S1 disk herniation that was not present
prior to their decompression procedure; this was considered a
treatment failure at the index level of the initial decompression
procedure because it was believed a fusion would have prevented
this disk herniation. 1 patient developed a delayed fracture in their
remaining L5 transverse process tip, but refused surgical resection
of the fractured portion despite their 8/10 VAS pain level; it was
also believed that a fusion at this level would have prevented the
fracture. 1 patient had a hip replacement after their decompres-
sion but still had the same pre-operative pain afterward and was
lost to follow-up. The remaining 2 patients were recommended
fusions at the index level but refused surgical treatment.
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SURGICAL OUTCOMES OF BERTOLOTTI’S SYNDROME
All subsequent patients with Type 2 anatomy were then rec-
ommended to undergo fusion bilaterally instead of decompres-
sion. An option was given to them to undergo decompression
first, with the caveat that there was a high likelihood for revision
procedure based on our analysis, and no patient subsequently
opted for that option given the high likelihood of failure.
Overall, the pain reduction for all patients in the initial MIS
resection/decompression treatment group for Type 2 anatomy with
any improvement was 15/18 (83%), yet the good improvement
(50% pre-op pain or VAS  3) was limited to 6/18 (33%) patients.
Patients with the initial treatment failures tended to do well with a
second procedure if they had one.
MIS Fusion Procedures
MIS bilateral fusion procedures as described above in Methods
were then performed on the next 18 patients with Type 2 anatomy
of any subtype.
Bilateral fusion surgery helped 16/18 (89%) patients. 13/18 (72%)
showed good improvement (more than 50% pre-op pain or VAS 
3), 3/18 (17%) reported adequate improvement (less than 50% pre-
op reduction), and only 2/18 (11%) had no improvement at the last
follow-up.
All 3 patients with only “adequate” improvement had one or
more surgical complications from their initial fusion procedure,
and none of them had surgical hardware (screws and rods) placed.
2 of the 3 patients had pseudoarthroses, and then subsequent
revision fusion surgeries with the senior author, and proved suc-
cessful with good reduction in their pain. The last patient had a
non-union and was recommended a revision fusion, but declined
any further surgical treatment, given their advanced age and
“adequate” improvement. All three of these patients had under-
gone un-instrumented fusions (using rhBMP-2 and allograft, but
without screws). After this third failure of uninstrumented fu-
sions, no further patients were offered uninstrumented fusions as
an options for Type 2 anatomy.
The 2 patients that did not see any initial improvement post-
operatively had subsequent surgeries with different providers and
were lost to follow-up in spite of repeated attempts to reach them.
Patients in this group, even with good outcomes, were not
without subsequent adject level back pain “generators” in future
follow-up data. Confirmed or suspected adjacent level diagnoses
developed in 8/16 patients: 4 L4/5 spondylolistheses; 1 confirmed
and 1 possible cluneal nerve entrapment; 1 confirmed and 1 sus-
pected possible SI Joint aggravation; 1 additional patient under-
went a removal of previously placed SI fusion screw with excellent
resolution of those symptoms; 1 solid fusion but new L4/5 spon-
dylolisthesis, refusing intervention as pain improved from 8/10 to
4.5/10; 1 patient developed both target level pseudoarthrosis and
suprajacent L4/5 spondylolisthesis; 1 patient had a solid fusion at
L5/S1 but developed L4/5 spondylolisthesis and did well after
fusion L4/5; and 1 patient developed an unclear combination of
L4/5 and possible cluneal nerve or SI joint symptoms and declined
further follow-up with us after 2 years.
Minimally Invasive Surgery Decompression versus Fusion
Analysis
A total of 36 patients with Type 2 anatomy underwent minimally
invasive surgery (MIS) decompressions (n ¼ 18) or fusion (n ¼ 18)

ARTHUR L. JENKINS ET AL.
Table 2. Breakdown of Patients With or Without Iliac Contact
Patients with Hip Pain and Patients with Hip Pain
Status No Iliac Contact and Iliac Contact
Improved 9 (33%) 12 (44%)
Did not improve 2 (7%) 4 (15%)
procedures as their initial treatment. From the initial treatment,
the Type 2 decompression group had good improvement in 6 of 18
(33%) patients, while the fusion group had good improvement in
13 of 18 (72%) patients, showing a significant difference between
the procedures (P ¼ 0.044).
Type 3
No Type 3 patients were identified as having pain from the tran-
sitional level itself, so none were operated upon.
Type 4
Seven patients underwent surgery for their symptomatic Type 4
LSTV anatomy (right open ¼ 4, left open ¼ 3) with a unilateral
instrumented fusion, although 1 patient also underwent instru-
mentation without fusion for possible fracture developing on the
“fused” side. Six patients did well with unilateral fusion of the
“open” (or Type 1/Type 2 side) as treatment of the pain that was
improved by the injection. One patient did not have satisfactory
response to surgery (even though he did well with preoperative
injections into the open side), was found on CT scan to have a
solid fusion on the operated side, underwent exploration of the
(solid) fusion and removal of the hardware, still with no
improvement in any of his symptoms. All Type 4 patients had
solid fusion of the operated sides of these procedures which
resulted in the equivalent of Type 3 anatomy.
Three of 7 of these Type 4 patients developed 1 or more adjacent
level pathology. One (whose index procedure was an L6-S1 tran-
sitional level) developed Baastrup syndrome 2 levels above the
fusion as well as having pain in his SI fusion screw sites; this
patient did well with subsequent removal of the SI fusion screws
as well as removal of the L4 and L5 (of 6) spinus processes. One
was found to have cluneal nerve and other peripheral nerve
entrapment syndromes, although that workup is still ongoing.
One had persistent but slowly improving (and different location)
low back pain, which coincided with the radiographic subsidence
of his previously placed suprajacent (L5-L6) artificial lumbar disk.
This pain was not present prior to his Bertolotti surgery.
Iliac Contact
Patients with contact between their transverse process and iliac
wing and hip pain preoperatively were very likely to have
improvement or resolution of that hip pain postoperatively. In
some cases, patients who had undergone hip surgery for this “hip
pain” had resolution of symptoms that were not improved by that
prior hip surgery.
Of 56 surgical patients, 27 (48%) presented with some
component of hip pain. Of 56 patients, 50% (n ¼ 28) had some
WORLD NEUROSURGERY 175: e21-e29, JULY 2023
ORIGINAL ARTICLE
SURGICAL OUTCOMES OF BERTOLOTTI’S SYNDROME
form of iliac contact between the transverse process. Of those with
hip pain, 59% (16 of 27) had iliac contact with the transverse
process. Of those patients with hip pain preoperatively, 78% (n ¼
21) had their hip pain improve after surgery for Bertolotti syn-
drome. The breakdown of those with or without iliac contact is
shown in Table 2.
Thus, patients with hip pain and iliac contact had a 75% chance
of improving, while those with hip pain and no iliac contact had
an 82% chance of improving with surgery treating just the
lumbosacral transitional anatomical variation (P ¼ not signifi-
cant). Of the patients with hip pain, 11 had severe hip pain (pain of
at least 8 on VAS scale). All 11 with severe pain had at least
adequate improvement in this hip pain, with the average being a
5.6-point improvement. A “good” outcome occurred in 6 (55%)
patients with regard to hip pain.
DISCUSSION
From the original cohort of 103 surgical patients with Bertolotti
syndrome with or without other spinal comorbidities, 47 (or
45.6%) had more than 1 surgical diagnosis and underwent a more
complex procedure than isolated Bertolotti syndrome treatments
and were excluded from this analysis, to focus exclusively on pa-
tients with isolated Bertolotti syndrome requiring treatment of the
lumbosacral transitional level. These other patients will be
analyzed separately. However, this incidence is consistent with
other authors, who identified about a 40% incidence of clinically
significant issues at adjacent levels in patients with LSTVs.5 This
does not include those patients who were found to also have
distant neurologic issues including cervical myelopathy, thoracic
outlet syndrome, and who underwent treatments for those
entities. An analysis of other associated congenital and
degenerative anomalies in this patient population (symptomatic
LSTV) is ongoing.
The 56 patients in this cohort underwent a total of 66 proced-
ures, which were performed by the senior author over this same
10-year period and resulted in an overall improvement in the pa-
tients functioning. The treatment paradigm for Type 1, Type 3, and
Type 4 LSTVs with only Bertolotti syndrome as their pain gener-
ator did not vary over the time of collection of this data (2012 to
the beginning of 2022).
The treatment paradigm for symptomatic Type 2 LSTVs shifted.
Initially, treatment was effectively limited to MIS partial resections
(also known as “reduction” or “decompression”) of the transverse
process and/or ala of the transitional levels, but after a high rate of
clinical failures of the resections for the Type 2 patients, we moved
to a minimally invasive fusion paradigm for all 3 of the Type 2
anatomic variants (Type 2A, Type 2B, Type 2C), based on the
surgical outcomes from those initial 20 patients with that
anatomic finding; additionally, after 3 patients failed to fuse with
un-instrumented procedures, all fusions were performed with at
least 1-sided instrumentation.
Initially, in this series, the first 31 patients all underwent
minimally invasive or open decompressions for Type 1 and Type 2
anatomy, regardless of symptomatic subtype (Type 3 patients were
excluded from surgery as none were found to have the LSTV level
be the pain generator, and no Type 4 patients had presented for
surgery by then), but after the first 18 patients with Type 2
www.journals.elsevier.com/world-neurosurgery e27

ARTHUR L. JENKINS ET AL.
anatomy were operated on, we performed an interim subgroup
analysis, which suggested a high rate of failure and subsequent re-
operation. Three patients with Type 2 anatomy underwent
attempted fusion without instrumentation, and all 3 failed to fuse.
After this, all patients with favorable medical conditions and Type
2 anatomy were recommended to undergo the minimally invasive
fusion and instrumentation procedure.
Six patients underwent unilateral surgery for symptomatic Type
4 anatomy, 1 of those patients was previously reported in a case
report.14 One additional Type 4 patient presented with a fracture
of her Type 3 anatomy and the Type 2 “pseudoarticulation” on the
other side (Type 4B with fracture) and underwent bilateral
instrumentation but only unilateral bone grafting on the Type 2
side, with good outcome of this pain.
CONCLUSIONS
Bertolotti syndrome is much more common than previously
thought, and many patients may go misdiagnosed for years, but in
others the diagnosis and treatment can proceed in less than 6
months from initial suspicion to surgical treatment and resolution
of symptoms. Using the new Jenkins nomenclature system for
LSTVs, we feel this both helps to identify patients who might be
missed in the diagnosis (compared with the older Castellvi sys-
tem), as well as directing the treatment strategy based on both
anatomy type and the above evidence-based guidelines.
Bertolotti syndromeecaused sciatica can be differentiated from
herniated disk or foraminal stenosisecaused sciatica by the dif-
ferential response to epidural steroids and Bertolotti targeted in-
jections. For those who fail conservative management of their
Bertolotti syndrome symptoms, surgery to correct or address the
anatomic and biomechanical anomalies was highly successful,
although following a variable time course in recovery. Surgical
treatments (56 patients, 66 surgeries) fell into 2 categories: re-
sections (of the transverse process and/or alar prominence) and
fusions. In some cases, patients who underwent resections and
then failed to have durable relief underwent subsequent fusions at
those levels, and in those cases most did well with the fusions.
Within the surgical subgroup, we found after an evolution of
our treatment paradigm that patients with Type 1 anatomy did
better with resection surgery, while patients with Type 2 or Type 4
anatomy did better with instrumented fusions (unilateral for Type
4, bilateral for Type 2). Type 3 patients (bilateral fusions of the
transverse-ala junctions) were not found in this series to have pain
derived from the LSTV anatomy directly, but that their pain
generator was from another level or location and were never
identified as having pain from the LSTV itself.
Over the course of our treatments in the last 10 years, we
noticed not only that hip pain was a component of Bertolotti
syndrome, but that patients with contact between their trans-
verse process and iliac wing were more likely to have hip pain
preoperatively, and more likely to have resolution of that hip
pain postoperatively, so that aspect of the anatomy was added
to the classification system. Severe hip pain also showed a
larger improvement postoperatively than more mild cases,
suggesting that patients diagnosed with Bertolotti syndrome
and severe hip pain could see durable relief with treatment
aimed at their transitional anatomy alone, rather than opting
e28 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2023.03.012
ORIGINAL ARTICLE
SURGICAL OUTCOMES OF BERTOLOTTI’S SYNDROME
for hip surgery for (what might be incidental) findings in the
hip joint first.
Patients who underwent successful treatment of their Bertolotti
syndrome are still subject to adjacent level or joint degeneration,
and should be observed over time for SI, lumbar, and hip pa-
thology developing over time. More longitudinal and larger patient
series will be necessary to look at what impact the surgical
treatment of Bertolotti’s Syndrome patients has on these joints,
compared to their natural untreated history, and to patients
without these congenital anomalies.
By further describing the additional clinical presentations of
Bertolotti syndrome, which may overlap with other potential pain-
generating joints (such as sciatica, referred hip and SI pain
potentially coming from the facets or disks of the spine, hip pa-
thology, or SI instability), we hope to avoid misdiagnoses that
result in inappropriate nonsurgical and surgical treatments (such
as SI fusions, hip replacements, and diskectomies, all of which
were noted in our series to have preceded the diagnosis and
treatment of some Bertolotti syndrome patients, and to have not
benefited the patients’ symptoms).
Keeping an open mind among pain management, physiatric,
orthopedic, and neurosurgery colleagues to the possibility of
Bertolotti syndrome causing these overlapping symptoms will
be the key to reducing the likelihood of failures of those sur-
gical procedures, and direct surgical treatments to the causative
etiology for these patients—the LSTV itself. The use of differ-
ential injections for patients with possible overlap can be used
to their advantage with a high degree of success, if the in-
jections are done properly. Although not all patients with an
LSTV have pain from it, when noticed and when the condition
could also cause the symptoms the patient is suffering from, it
should be eliminated from the diagnosis prior to proceeding
with any other surgical procedures that do not address the
LSTV directly.
Fortunately, surgical treatment of their Bertolotti syndrome
resulted in improvement or resolution of the same symptoms the
patients had, even if previously “unsuccessfully” treated, even
when the symptoms persisted for years. We hope these data
provide guidance for those early in their Bertolotti syndrome
treatment experience to consider instrumented fusions for all but
Type 1 patients who fail conservative management.
CRediT AUTHORSHIP CONTRIBUTION STATEMENT
Arthur L. Jenkins: Conceptualization, Methodology, Validation,
Investigation, Data curation, Resources, Writing e original draft,
Writing e review & editing, Visualization, Supervision, Project
administration. Richard J. Chung: Validation, Formal analysis,
Investigation, Data curation, Writing e original draft, Writing e
review & editing, Visualization. John O’Donnell: Validation,
Formal analysis, Investigation, Data curation, Writing e original
draft, Writing e review & editing, Visualization, Project admin-
istration. Charlotte Hawks: Validation, Formal analysis, Investi-
gation, Data curation, Writing e original draft, Writing e review
& editing, Visualization, Project administration. Sarah Jenkins:
Conceptualization, Methodology, Validation, Investigation, Data
curation, Resources, Writing e original draft, Writing e review &
editing, Visualization, Supervision, Project administration.
 ORIGINAL ARTICLE
ARTHUR L. JENKINS ET AL. SURGICAL OUTCOMES OF BERTOLOTTI’S SYNDROME

Daniella Lazarus: Validation, Formal analysis, Investigation, Data
curation, Writing e original draft, Writing e review & editing,
Visualization. Tara McCaffrey: Validation, Formal analysis,
Investigation, Data curation, Writing e original draft, Writing e
review & editing, Visualization. Hiromi Terai: Validation, Formal
analysis, Investigation, Data curation, Writing e original draft,
Writing e review & editing, Visualization. Camryn Harvie: Vali-
dation, Formal analysis, Investigation, Data curation, Writing e
original draft, Writing e review & editing, Visualization. Stavros
Matsoukas: Writing e review & editing.

REFERENCES
1. Jancuska JM, Spivak JM, Bendo JA. A review of
symptomatic lumbosacral transitional vertebrae:
Bertolotti’s syndrome. Int J Spine Surg. 2015;9:42.
2. Connolly LP, d’Hemecourt PA, Connolly SA,
Drubach LA, Micheli LJ, Treves ST. Skeletal
scintigraphy of young patients with low-back pain
and a lumbosacral transitional vertebra. J Nucl
Med. 2003;44:909-914.
3. Cohen J. Statistical power analysis for the behavioral
sciences. xxi. 2nd ed. Hillsdale, NJ: L. Erlbaum
Associates; 1988:567.
4. Hughes RJ, Saifuddin A. Numbering of lumbo-
sacral transitional vertebrae on MRI: role of the
iliolumbar ligaments. AJR Am J Roentgenol. 2006;
187:W59-65.
5. Luo CA, Kaliya-Perumal AK, Lu ML, Chen LH,
Chen WJ, Niu CC. Staged surgery for tandem
cervical and lumbar spinal stenosis: which should
be treated first? Eur Spine J. 2019;28:61-68.
6. Mahato NK. Redefining lumbosacral transitional
vertebrae (LSTV) classification: integrating the full
spectrum of morphological alterations in a
biomechanical continuum. Med Hypotheses. 2013;
81:76-81.
7. Meucci RD, Fassa AG, Faria NM. Prevalence of
chronic low back pain: systematic review. Rev
Saude Publica. 2015;49:1.
8. Castellvi AE, Goldstein LA, Chan DP. Lumbosa-
cral transitional vertebrae and their relationship
with lumbar extradural defects. Spine. 1984;9:
493-495.
9. MacGregor AJ, Andrew T, Sambrook PN,
Spector TD. Structural, psychological, and genetic
influences on low back and neck pain: a study of
adult female twins. Arthritis Rheum. 2004;51:
160-167.
10. Crane J, Cragon R, O’Neill J, et al.
A comprehensive update of the treatment and
management of Bertolotti’s syndrome: a best
practices review. Orthop Rev. 2021;13:24980.
11. Becker L, Ziegeler K, Diekhoff T, Palmowski Y,
Pumberger M, Schömig F. Musculature adaption
in patients with lumbosacral transitional verte-
brae: a matched-pair analysis of 46 patients. Skel-
etal Radiol. 2021;50:1697-1704.
12. Bahadir Ulger FE, Illeez OG. The effect of
lumbosacral transitional vertebrae (LSTV) on Par-
aspinal muscle Volume in patients with low back
pain. Acad Radiol. 2020;27:944-950.
13. Guiroy A, Sícoli A, Masanés NG, Ciancio AM,
Gagliardi M, Falavigna A. How to perform the
Wiltse posterolateral spinal approach: Technical
note. Surg Neurol Int. 2018;9:38.
Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 5 January 2023; accepted 2 March 2023
Citation: World Neurosurg. (2023) 175:e21-e29.
https://doi.org/10.1016/j.wneu.2023.03.012
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/ª 2023 The Authors. Published by Elsevier Inc.
This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

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