The Spine Journal 21 (2021) 1286−1296

Narrative Review
Clinical assessment and management of Bertolotti
Syndrome: a review of the literature
Kyle McGrath, BSa,*, Eric Schmidt, MDa, Nicholas Rabah, BSb,
Mohammad Abubakrc, Michael Steinmetz, MDa
a
Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation,
Cleveland, OH, USA
b
Case Western Reserve College of Medicine, Cleveland, OH, USA
c
The Ohio State University, Columbus, OH, USA
Received 6 November 2020; revised 10 February 2021; accepted 27 February 2021

Abstract Bertolotti Syndrome is a diagnosis given to patients experiencing pain caused by the presence of a
lumbosacral transitional vertebra (LSTV), which is characterized by enlargement of the L5 trans-
verse process(es), with potential pseudoarticulation or fusion with the sacrum. The Castellvi classi-
fication system is commonly utilized to grade LSTVs based on the degree of contact between the
L5 transverse process(es) and the sacrum. LSTVs present a diagnostic dilemma to the treating clini-
cian, as they may remain unidentified on plain x-rays and even advanced imaging; additionally,
even if the malformation is identified, patients with a LSTV may be asymptomatic or have nonspe-
cific symptoms, such as low back pain with or without radicular symptoms. With low back pain
being extremely prevalent in the general population; it can be difficult to implicate the LSTV as the
source of this pain. Care should be taken however, to exclude Bertolotti Syndrome in patients under
30 years old presenting with persisting low back pain given its congenital origin. If a LSTV is iden-
tified, typically with acquisition of a MRI or CT scan of the lumbosacral spine, and there is an
absence of a more compelling or obvious source for the patient’s symptoms, a conservative, step-
wise management plan is recommended. This may include assessing for improvement in symptoms
with injections prior to proceeding with surgical intervention. Additional concerns arise from the
biomechanical alterations that a LSTV induces in adjacent spinal levels, predisposing this patient
population to a more rapid-onset of adjacent segment disease, raising the question as to the most
appropriate surgery (resection of LSTV pseudoarticulation with or without fusion). Postoperative
outcome data for patients undergoing surgical treatment is limited in the literature with promising,
but variable, results. More large-scale, controlled studies must be performed to gain further insight
into the ideal work-up and management of this pathology. © 2021 Elsevier Inc. All rights
reserved.

Keywords: Bertolotti Syndrome; Lumbosacral Transitional Vertebra; Pseudoarticulation; Lumbarization; Sacralization

FDA device/drug status: Not applicable.
Author disclosures: KMG: Nothing to disclose. ES: Nothing to disclose.
NR: Nothing to disclose. MA: Nothing to disclose. MS: Royalties: Zimmer
(B), Elsevier (B); Consulting: Globus (A); Speaking and/or teaching
arrangements: Stryker (B), Globus (B).
Funding disclosures: No financial support of any kind was received for
this study.
*Corresponding author. Center for Spine Health, Department of Neuro-
surgery, Neurologic Institute, Cleveland Clinic Foundation, 9500 Euclid
Ave, Suite S40 Cleveland, OH. Tel.: (419) 310-9755.
E-mail address: kb725416@ohio.edu (K. McGrath).
Introduction
Bertolotti Syndrome (BS) is a clinical diagnosis given to
patients who experience pain due to a lumbosacral transi-
tional vertebra (LSTV). LSTVs are congenital vertebral
anomalies in which elongated fifth lumbar (L5) transverse
process(es) (TP) articulate or fuse to the first sacral segment
(S1). This transitional vertebra is described as forming
through either the process of sacralization of the L5 verte-
bra or a lumbarization of the S1 segment [1]. The literature
surrounding this condition is relatively limited. There are
numerous studies discussing the prevalence, diagnosis, and

https://doi.org/10.1016/j.spinee.2021.02.023
1529-9430/© 2021 Elsevier Inc. All rights reserved.
 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
management of LSTVs, however many of these studies
present inconclusive results emphasizing the need for fur-
ther research across the board to aid in the understanding of
LSTVs and how they affect patients. Herein we will discuss
the literature as it pertains to LSTVs, specifically focusing
on how patients with Bertolotti Syndrome are diagnosed
and managed.
Methods
PubMed, Google Scholar, and the Journal of Neurosur-
gery were searched using the key words: Bertolotti, LSTV,
Lumbosacral Transitional Vertebra. References of the
resulting papers were scanned for additional literature that
was not found in the initial literature search.
Classifying LSTVs
The modern classification of LSTVs was introduced in
1984 by Castellvi et al. Each Type (I − IV) is additionally
labeled with an “a” (unilateral) or “b” (bilateral). Type I
refers to either unilateral (Ia) or bilateral (Ib) enlargement
of the L5 TP(s), measuring >19 mm in width. Type II refers
to incomplete sacralization (of L5) or incomplete lumbari-
zation (of S1) in addition to an enlarged TP that forms a
“pseudoarticulation” with the sacral ala (IIa or IIb). (Fig. 1)
A Type III classification indicates complete fusion between
the TP and ala (as compared the pseudoarticulation seen in
type II), with complete sacralization of L5 or lumbarization
of S1. Type IV refers to having a Type IIa on one side, and
a Type IIIa on the contralateral side (Table 1) [2].
Among Castellvi classifications, Type Ia is the most
common, with Types I and II each accounting for approxi-
mately 40% of all LSTVs occurrence. Type Ia, while pres-
ent in as much as 14% of the general population, rarely
requires clinical intervention. Types II, III, and IV are less
common than type I albeit more likely to cause pain war-
ranting intervention (Table 2) [3].
Further subclassification of LSTVs based on S1-S2 disc
morphology and the extent of lumbarization of the S1 seg-
ment was described by O’Driscoll et al. This classification
system is described as such: Type I refers to an absence of
any disc material present, as seen in normal sacral spines.
Type II refers to the presence of a small residual disc not
extending full AP diameter of the sacrum, which is also
seen more commonly seen in those without an LSTV. Type
III describes a well-formed disc extending the full AP diam-
eter of the sacrum. Type IV describes a Type III class with
an abnormal upper sacral outline referred to as “squaring”
seen on sagittal imaging. Among these classifications, there
has been an identified correlation between Type IV S1-S2
discs and high (III, VI) Castellvi classification types [4].
Biomechanical considerations
There is a paucity of data regarding the biomechanical
implications of LSTVs on overall spine health. It has been
1287
Fig. 1. Castellvi Type II: L5 TP forming a pseudoarticulation with
the sacral ala. A) Castellvi Type IIa (unilateral), B) Castellvi Type IIb
(bilateral).
proposed that the anatomic development of the sacrum and
lumbosacral spine may be greatly influenced by mechanical
loading at the sacroiliac (SI) junction. Cadaveric studies
have demonstrated distinct anatomic variants in patients
with LSTVs apart from the LSTV itself. These include
sacra that are significantly shorter in height (excluding the
height of the L5 body) than normal [5] and a reduction in
the caliber of the iliolumbar ligaments in these patients [6].
A reduction in sacral height can significantly decrease the
contact surface area between the sacrum and ilium. This
can be problematic due to the role that the SI joint has in
ambulatory load transmission. It is suggested that L5 sacral-
ization may occur in some cases to compensate for this
decrease in SI joint surface area seen in some LSTVs. The
reduction in iliolumbar ligament caliber seen in these
patients may occur developmentally as a result of decreased
lumbosacral motion caused by the pseudoarticulation or
fusion at the LSTV. A reduction in motion at the LSTV
with the concomitant weakening of the iliolumbar liga-
ments can both contribute to adjacent segment instability
that these patients are predisposed to experience.
Unilateral LSTVs cause the most notable discrepancies
in loading throughout the spine, resulting in an oblique pel-
vic alignment and scoliosis. This perpetuates further load-
ing discrepancies resulting in unilateral degenerative
changes of the facet and disc, increased intradiscal pres-
sures, and hypermobility and abnormal torque moments
above the transitional segment [6−11]. This asymmetric
loading and adjacent segment hypermobility has been
implicated in the increased incidence of adjacent segment
disease in Bertolotti patients, which has been demonstrated
in numerous studies. Overall, LSTVs are less likely to show
degenerative changes than control patients at L5-S1; how-
ever, degenerative changes in the superjacent segments to
the LSTV occur at significantly higher rates than the same
level in patients without an LSTV. These findings were best
documented by Vergauwen et al. who studied 350 patients
with lumbar back pain, reporting the rate of degenerative
changes present in patients with and without LSTVs. These
1288 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296

Table 1
Castellvi classification of lumbosacral transitional vertebrae (LSTV)

Type Description Unilateral (a) Bilateral (b)

Type I Enlarged L5 transverse
process(es) (TP) either
unilaterally (Ia) or bilat-
erally (Ib).

Type II Incomplete sacraliza-

tion (of L5) or incom-
plete lumbarization (of
S1) in addition to an
enlarged TP that forms
a “pseudoarticulation”
with the sacral ala. (IIa
or IIb)
Type III The pseudoarticulation
between the TP and ala,
as seen in type II, how-
ever in this case the
sacralization or lumba-
rization is considered
complete with the L5 or
S1 segment, respec-
tively. (IIIa or IIIb)
Type IV Unilateral Type IIa on
one side with a Type
IIIa on the contralateral
side of the same LSTV.

Castellvi, A. E., Goldstein, L. A., & Chan, D. P. (1984). Lumbosacral transitional vertebrae and their relationship with lumbar Extradural defects. Spine, 9
(5), 493-495. doi:10.1097/00007632-198407000-00014
Art reprinted with permission from Jancuska JM et al. A review of symptomatic lumbosacral transitional vertebrae: Bertolotti’s syndrome. Int J Spine
Surg. 2015;9:42. (c) 2020 International Society for the Advancement of Spine Surgery.

included protrusion/extrusion (45.3% incidence in level
superior to LSTV vs. 30.3% in patients without LSTV),
disc degeneration (52.8% vs. 28%), facet degeneration
(60.4% vs 42.6%), and nerve root canal stenosis (52.8% vs
27.9%) (Table 3). These issues, when present in patients
with an LSTV, are significantly more likely to occur at the
most caudal mobile segment adjacent to the LSTV, with
degenerative disc disease at the level of the LSTV being
exceedingly rare [12−16].
Additional anatomic changes seen in lumbar sacrali-
zation are a reduction in height of the pedicle and pars
interarticularis (pars), as well as a reduction in the width
of lamina. In theory, a smaller pars may predispose
these patients to isthmic spondylolisthesis, however
studies to date have only shown an increase in severity
Table 3
Adjacent segment degeneration in LSTV

Table 2 Degenerative Incidence in level Incidence in same

Prevalence of LSTV Castellvi type and associated low back pain Pathology superior to LSTV level among control
(ie, L4-L5) patients (no LSTV)
Castellvi Type Prevalence Prevalence of reported
among LSTVs low back pain Disc Protrusion/ 45.3% 30.3%
Extrusion
Type I 41.72% 46% Disc Degeneration 52.8% 28.0%
Type II 41.40% 73% Facet Degeneration 60.4% 42.6%
Type III 11.50% 40% Foraminal Stenosis 52.8% 27.9%
Type IV 5.20% 66%
Vergauwen S, Parizel PM, van Breusegem L, et al. Distribution and
Nardo L, Alizai H, Virayavanich W, et al. Lumbosacral transitional incidence of degenerative spine changes in patients with a lumbo-sacral
vertebrae: Association with low back pain. Radiology. 2012;265(2):497- transitional vertebra. European Spine Journal. Published online 1997.
503. doi:10.1148/radiol.12112747. doi:10.1007/BF01301431.
 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
of spondylolisthesis in LSTV patients compared to spon-
dylolisthesis without an LSTV, without any increase in
incidence [17−19].
More recently, a biomechanical study was done by Golu-
bovsky et al. in which Type IIa LSTV pseudoarticulating
joints were 3D printed and fixated to normal cadaveric
spines. This study is the first of its kind attempting to
develop a more comprehensive biomechanical model of
LSTVs. They found that Type IIa, while not a fusion
between L5 and S1, still causes a significant reduction in
axial rotation and lateral side bending at the transitional
level, while increasing torque and motion above the LSTV.
Additional studies have confirmed these findings through
biomechanical analysis and imaging, suggesting that
this chronic increase in motion can be a cause of the fre-
quent adjacent segment degeneration seen in Bertolotti
patients [9−11].
The biomechanical implications that have been dis-
cussed with LSTVs should be given consideration in assess-
ing sources of pain. Sources of pain in these patients can all
be attributed in part to discrepancies in spine motion and
loading. It is known that patients with abnormal spinal cur-
vature have asymmetric loading and wear on the facet
joints, which can contribute to degenerative changes at the
pseudoarticulation as well as in segments adjacent to the
LSTV [20]. In addition to abnormal curvature incited by an
LSTV, the additional articulation acts to stabilize the
involved segments causing a reduction in motion that would
be seen in a normal spine. Available literature regarding
adjacent segment disease in LSTV patients demonstrates
similar pathologies to those without LSTVs who undergo
lumbar or lumbosacral fusion. These pathologies are largely
biomechanical in nature, and it is important to understand
these effects on the natural history of LSTV sequelae as it
can help guide conversations and expectations from early in
the treatment process [21].
Clinical significance
Prevalence
LSTVs have a wide range of estimated prevalence, from
4%-35% of the general population with an overall average
of 12.3% [1,2,13,22,23]. Overall, the prevalence of LSTVs
is higher in men than in women, at least twice as common
in some studies. Among LSTV morphology, sacralization
of L5 is also more common in men, while accessory L5-S1
articulations and lumbarization of S1 are both more com-
mon in women [3,24].
Symptomatology
The clinical picture of a Bertolotti Syndrome is compli-
cated, as these patients may present with no symptoms at
all, or a myriad of nonspecific symptoms. Fully asymptom-
atic LSTVs however are relatively rare, as low as 13% [22].
Physical exam signs most commonly include nonradiating
1289
low back pain (LBP) that limits range of motion. It has
been proposed that the primary source of this back pain is
mechanical, resulting from the bony contact of the pseu-
doarticulation between L5 and S1, however the source of
pain in these patients and their response to localized treat-
ment varies between individuals [25].
Due to the congenital nature of LSTVs, these patients
may present to a physician for low back pain (LBP) at a
much younger age compared to patients suffering other
causes of chronic low back. Therefore, LBP in younger
populations, particularly males under the age of 30, is dis-
proportionately due to the presence of an LSTV rather than
other causes of chronic LBP. Quinlan et al. studied MRI
scans of 769 consecutive patients with low back pain and
found that 11.4% of people under the age of 30 had an
LSTV, with an average age of those with an LSTV being
32.5 years [26]. Another study done by Kapetanakas et al.
found that 4%-8% of patients with LBP had diagnosable
Bertolotti Syndrome, with 18.5% of these patients being
under the age of 30 [22]. We will discuss in more detail the
relationship between LSTVs and LBP, but it is important to
understand that LSTVs affect the younger population at a
significant rate.
With LBP being the most common presenting symptom
in Bertolotti patients, identifying this disease based on pre-
sentation alone can be challenging seeing as up to 80% of
adults will seek a physician for low back pain at some point
in their lives. It has been reported that the prevalence of
LSTVs among patients seeking care for LBP can be as high
as 36%. Over the years however, data on LSTVs and LBP
has been controversial. Tini et al. found no significant dif-
ference between the prevalence of LSTV in patients pre-
senting with LBP (6.7% of which had LSTV) and those
with no LBP (5% incidental LSTV rate). This study deter-
mined that while a LSTV is a predictor of LBP, LBP is not
necessarily a predictor of the presence of an LSTV [27].
More recent data however seems to demonstrate that LBP
and LSTVs are more tightly intertwined. It has been dem-
onstrated that among patients presenting with LBP, up to
10% of them may have an unidentified LSTV [28], and up
to 73% of patients with an identified LSTV, particularly
those with Castellvi classes II and IV, experience chronic
LBP. LSTVs have also been shown to increase the severity
of a patient’s LBP in addition to causing a reduction in
physical activity [3,29]. Furthermore, Vergauwen et al.
determined that patients with spine-related symptoms
severe enough to warrant an MRI are 2.3 times as likely to
have an LSTV than someone without these symptoms, and
3.6 times as likely to have a LSTV if presenting with an
adjacent (last mobile segment) disc herniation requiring dis-
cectomy. What this suggests is that the presence of a LSTV
predicts a worse clinical presentation and is more likely to
be present in patients with symptoms ultimately requiring
surgical intervention [12].
While patients with LSTVs are more likely to experience
symptoms, namely chronic LBP, the origin of these
1290 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
symptoms seems to be largely patient dependent. Arthritic
changes, disc and facet degeneration, spinal and nerve root
stenosis and adjacent segment pathology have all been cited
in the literature as sources of pain [1,5,12,15,25,28,30,31].
Those with LSTVs may have variations in lumbosacral
nerve distribution as well, which can further complicate a
patients clinical picture. Using electromyography (EMG),
Hinterdorfer et al. compared LSTV to non-LSTV patients
and showed varying degrees of overlap in S1 and S2 nerve
distribution in LSTV patients, reinforcing that in addition
to pain patterns, each patient can have a significantly differ-
ent clinical picture than the next [32].
Patient burden
Currently, there exists little data to help physicians iden-
tify a source of pain in individuals prior to undergoing treat-
ment. If a specific treatment provides pain relief or
resolution, it is then appropriate to retrospectively identify
the treatment site as a source of pain. Because clinical suc-
cess can only be confirmed after enacting a certain treat-
ment plan, patients are subject to chronic physical,
psychological, and financial burden. The financial cost to
patients experiencing LBP varies widely in the literature,
ranging from approximately $2 billion per year to over
$100 billion per year in the United States depending
whether loss of productivity and wages are accounted for
[33−35]. Given the prevalence of LSTVs reported in
patients with back pain and the heterogeneity in clinical
presentation, these costs reinforce the need to better under-
stand the role that LSTVs have in LBP.
Without definitive diagnostic and treatment strategies,
Bertolotti patients are also predisposed to more chronic
symptomatology than those with more well understood
spine pathologies. It has been shown by Golubovsky et al
that Bertolotti patients undergo significantly more epidural
steroid injections and experience symptoms for a longer
period prior to seeking surgical treatment than age and sex
matched controls with lumbosacral radiculopathy. Berto-
lotti patients on average have significantly worse PROMIS
mental and physical health T-scores than radiculopathy
patients after adjusting for the increase in injections and
time from symptom onset. In other words, these patients are
likely to have a worse mental and physical quality of life
than patients with lumbosacral radiculopathy. It is reason-
able to expect that in conjunction with the financial burden
these patients experience, experiencing chronic symptom-
atology and multiple ineffective treatments can have a sig-
nificant impact on the mental health of these patients [36].
Diagnosing Bertolotti Syndrome
Imaging
Reliable imaging is a vital component of the diagnosis
and management of Bertolotti Syndrome, as it allows physi-
cians to accurately assess the LSTV and its biomechanical
sequelae while avoiding surgical errors due to inaccurate
numbering [27]. In the case of numbering the lumbosacral
spine (spine is to be numbered from bottom to top), the low-
est vertebral body with a rectangular shape is located and
considered to be that of L5. This can be problematic in the
case of an LSTV in which this may correspond to a L4 or
L6 vertebra [28]. Exact numbering is of relatively low
importance, whereas consistent numbering among pro-
viders along the patient’s continuity of care is the most
important aspect to be followed. The following segment
outlines imaging options and their utility in Bertolotti
patients.
X-ray
Traditional radiographs have well-documented utility in
diagnosing and classifying LSTVs. While more advanced
imagery remains available, anteriorposterior (AP) and lat-
eral films require little time commitment, monetary cost,
and radiation exposure to the patient, while also allowing
for an assessment of the axially-loaded spine. An AP radio-
graph with 30˚ of cranial angulation is known as a Ferguson
radiograph, and is traditionally the standard for successful
identification of LSTVs. Sagittal films can also be useful, as
this view is helpful in reducing the image height of the tran-
sitional disc and in identifying “squaring” of the transitional
segment. Squaring refers to a cranial shift of the spine that
occurs during lumbarization of the S1 segment and may be
beneficial in identifying LSTVs [23]. Standard radiographs
demonstrate 76%-84% sensitivity in identifying LSTVs and
only 53%-58% accuracy in correctly classifying the Cas-
tellvi type. While Ferguson radiographs of the lumbosacral
spine have been shown to slightly improve sensitivity, this
level of reproducibility is not ideal in clinical practice
[16,37,38].
MRI/CT
Higher resolution imaging, although increasing the cost
and potential radiation exposure to the patient, provides
valuable detail in the work up of Bertolotti Syndrome. Both
CT and MRI imaging can more accurately diagnose and
classify LSTVs than traditional radiographs, while provid-
ing additional diagnostic information of adjacent segment,
disc, or nerve root pathology. In the literature however,
MRI accuracy is more commonly assessed than CT,
although CT scans offer the highest fidelity in assessing
bony anatomy and may be the most useful in working up
LSTVs. (Fig. 2)
MRI use has shown up to 80% sensitivity in identifying
LSTVs. Among which, T2-Weighted (T2W) coronal
images are the most effective at diagnosing the LSTV in
addition to a concomitant pathology known as “far out”
syndrome in which the exiting nerve root is impinged
between the TP of the last lumbar vertebrae and the sacral
ala. Sagittal images, however, have been shown to increase
the likelihood of misdiagnosis [15,16,37,38].
 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
Fig. 2. Coronal computed tomography (CT) scan of a Castellvi Type 2a
LSTV.
Imaging of the iliolumbar ligaments has also been used
to assist with vertebral numbering of LSTV patients. These
ligaments, although potentially underdeveloped in LSTV
patients, can be seen extending from the L5 TPs to the post-
eromedial iliac crest. While T2W MRIs are the most effec-
tive at identifying LSTVs, either T1W or T2W MRI can be
used to identify these ligaments. The aortic bifurcation and
right renal artery can also be used to assist in vertebral num-
bering in MRI, although compared to the iliolumbar liga-
ments these are believed to have only marginal benefit [39].
Magnetic resonance can be of further diagnosis utility of
LSTVs when adequate visualization of the transitional seg-
ment is in question. Chalain et al. determined that LSTVs
can present with exaggerated lumbar lordosis and a lack of
sharp angulations at the lumbosacral junction. Measuring
angles on a T2W MRI based on these concepts allows for
the accurate prediction of the presence of an LSTV. The
complementary angle to the sacral slope (the angle between
a line parallel to superior surface of sacrum and line perpen-
dicular to axis of table) of >40˚ predicts the presence of an
LSTV with 80% sensitivity and specificity. Furthermore,
the angle between a line parallel to the superior endplate of
L3 and a line parallel to superior surface of sacrum of >36˚
predicts the presence of an LSTV with 80% sensitivity and
54% specificity [40]. While the angular measurements dis-
cussed are those taken from supine MRI scans, upright X-
ray films may be a suitable substitute, although the sensitiv-
ity and specificity associated with using sacral angulation
1291
on upright X-ray to identify the presence of an LSTV has
not yet been defined in the literature.
Scintigraphy
In addition to standard radiography, CT, and MR, bone
scintigraphy has shown promise in helping physicians iden-
tify possible sources of pain in Bertolotti patients. Anoma-
lous articulation in LSTVs can result in degenerative and
metabolic changes which may be in part responsible for the
patient’s pain. These changes can be detected as increased
uptake in bone scintigraphy, which can complement the tra-
ditional imaging undergone by these patients. Pekindil
et al. evaluated 28 patients with planar and single photon
emission CT (SPECT) bone scintigraphy who were con-
firmed radiographically to have an LSTV. Moderate nonfo-
cal increase in uptake in the upper 33% - 50% of the SI
joint was associated with degenerative changes in either the
SI joint or LSTV pseudoarticulation. In symptomatic
patients with identified degenerative changes, SPECT
imaging showed a markedly increased uptake [41]. Another
study of 48 patients with Bertolotti Syndrome undergoing
skeletal scintigraphy showed an increased uptake at the
pseudoarticulation in 81% of patients. All patients in the
study had Castellvi Type II LSTVs [42]. These studies sug-
gest that positive findings in bone scintigraphy, in addition
to other diagnostic methods like radiography and injections,
can add substantial value in identifying the source of pain in
Bertolotti patients.
EOS
The EOS imaging system is a relatively new method of
radiography that may have significant implications in the
field of spine biomechanics and understanding Bertolotti
Syndrome. EOS is useful in its ability to take standing
orthogonal images, create 3D reconstructions of skeletal
structures (particularly the spine and pelvis), and to deter-
mine relationships between anatomical regions and seg-
ments [43]. In addition to the technological advancement of
the EOS 3D reconstruction capabilities, it offers significant
advantage to both the patient and provider. Studies have
demonstrated up to a 27-fold reduction in radiation entrance
skin dose compared to digital radiography for imaging of
the whole spine [44]. Furthermore, EOS 2D imaging and
3D reconstructions have shown no statistical difference in
quality and skeletal detail compared to digital radiography
and 3D CT, respectively [45,46].
Currently CT and MRI may be the best imaging tech-
nique for classifying the LSTV, however CT exposes
patients to high levels of radiation and is not commonly
used to identify subacute or chronic spine pathology. Mag-
netic resonance can be used to classify LSTVs, however the
cost, time, and margin of error in correctly numbering spi-
nal levels have shown that it is also not optimal [38]. EOS
can provide value to LSTV imaging, allowing for 3D recon-
struction without the radiation of CT and eliminating the
1292 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
need for an MRI. The remaining challenge with EOS is the
need for the incorporation of LSTVs into their statistical
spine models, however future studies may allow EOS imag-
ing to add significant value to the diagnosis and manage-
ment of these patients.
Management of Bertolotti Syndrome
The treatment paradigm of Bertolotti Syndrome is
like that of many causes of chronic LBP. Patients are
treated conservatively prior to trialing more invasive
treatment options such as steroid and anesthetic injec-
tions, and ultimately surgical intervention in the form of
LSTV (pseudo)articulation resection, decompression, or
fusion depending on the patient’s clinical picture. His-
torically, progressive stepwise courses of treatment have
provided valuable diagnostic information and insight
regarding the primary source of pain. While treatment
outcomes have been measured, identifiable sources of
pain in Bertolotti patients vary in the literature. The suc-
cess of treatment in these patients has only been
reported retrospectively, with pain resolution being the
primary outcome measured.
Conservative
Patients presenting with chronic LBP with and with-
out a LSTV often undergo conservative management ini-
tially, with NSAIDs, physical therapy (PT) and spine
manipulation [47]. Some studies have reported chiro-
practic manipulation and PT alone helping patients
achieve near or complete resolution of their symptoms.
This treatment protocol addresses the biomechanical
changes in mobility that can be caused by asymmetric
loading and irregular motion at L5/S1 [48−50]. In addi-
tion to PT, exercise regimens involving posture correc-
tion have documented benefit in the literature as well,
suggesting that posture-modifying exercises can improve
symptoms through improving muscle strength, coordina-
tion, and flexibility [51,52].
Fig. 3. Intraoperative fluoroscopic guided injections of a LSTV pseudoar-
ticulation. A) Anteroposterior (AP) view B) Lateral view.
Injections
Steroid and anesthetic injections have demonstrated
multifaceted benefit in Bertolotti patients, providing pain
relief in addition to vital diagnostic information. (Fig. 3)
Localized injections allow for the identification of primary
pain sources in these patients, which can guide more spe-
cific surgical procedures or prevent them entirely if the pain
resolves. While large outcome studies on the use of injec-
tions in these patients are lacking, several small studies
and case reports have been published demonstrating this
benefit.
Two case reports of fluoroscopy guided ESIs to the pseu-
doarticulation resulted in a significant improvement in
Oswestry score at 1 month [53], and complete symptom
(LBP) relief after 12 months [1]. Marks et al. also studied
the effect of pseudoarticulation injections on 10 patients.
Resolution of pain was experienced in 9 of 10 patients
within 1 week, although 5 patients relapsed to former pain
level within 12 weeks [31]. Another study assessed 11 Ber-
tolotti patients with nonradiating LBP receiving local anes-
thetic injections to the pseudoarticulation, 9 of which
responded successfully [54]. Avimadje et al. also studied
epidural steroid injections (ESI) retrospectively. They iden-
tified 12 patients with unilateral LSTV and ipsilateral LBP
or buttock pain who received injections for their symptoms.
After one month, 9 patients had pain relief and 7 of 8 were
symptom free after 2 years [55]. While some of the larger
studies on ESIs have demonstrated considerable benefit for
Bertolotti patients, additional smaller studies have shown
less favorable outcomes. Ultimately the present data on
injections suggests that specific pain sources and response
to ESIs in Bertolotti Syndrome may vary widely between
patients [56−59].
With the current literature, there is demonstrable benefit
in the use of injections, although symptom improvement
may be transitory. Some patients remained symptom free
through follow up after localized injections, while others
had relief for only a short time. Any amount of pain relief
following local injections however offers valuable informa-
tion in its ability to guide surgical treatment should the
patient’s pain return. In the aforementioned study by Jons-
son et al., the 9 patients who received a reduction or resolu-
tion of pain following local anesthetic injections then
underwent resection of the abnormal pseudoarticulation. Of
these patients, 7 experienced complete resolution of pain
and the remaining 2 had significant improvement at 6−42
months postop, reinforcing the utility of a stepwise treat-
ment protocol [54]. Almeida et al. also demonstrated the
value in this approach. Patients who had improvement in
pain following an anesthetic injection to the mega-apophy-
sis then underwent radiofrequency neurolysis to that site.
Patients who experienced significant improvement then
underwent surgical resection of the mega-apophysis if
their pain returned or did not fully resolve. All patients
who eventually underwent surgical resection remained
 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
completely asymptomatic thereafter, suggesting that con-
servative measures can not only be used as a trial of treat-
ment, but they can specifically guide the next, more
invasive steps if necessary [47].
Radiofrequency ablation is a minimally invasive tech-
nique that may also have value in treating Bertolotti
patients before employing more invasive surgery such as
resection, fusion, or decompression. One patient reported
incomplete resolution of back pain following L4/L5 facet
radiofrequency ablation. A follow up local anesthetic injec-
tion to the posterior pseudoarticulation resulted in tempo-
rary complete pain relief. Follow up radiofrequency
ablation to that area resulted in complete resolution of the
patient’s back pain and a return to normal function, suggest-
ing that temporary success with injections may not always
necessitate follow-up surgical resection [60].
Resection and fusion
Surgical management, while reserved for patients who
ultimately fail more conservative measures or present with
signs of instability, typically consists of either unilateral or
bilateral resection of the pseudoarticulation (pseudoarthrec-
tomy), or a fusion of L4-S1 or L5-S1.
Santavirta et al. reported on 16 Bertolotti patients under-
going surgical treatment (8 posterior lumbar fusion (PLF)
and 8 resection) and 16 control patients receiving conserva-
tive treatment. Between the two surgical groups, postop
pain and Oswestry Disability Index (ODI) was similar
albeit improved compared to conservative management. At
a 9 year follow up however, 7/8 fusion patients and 5/8
resection patients had identifiable adjacent segment disc
degeneration [61]. Another study reported a Bertolotti
patients undergoing posterior spinal fusion (PSF) with reso-
lution of LBP and buttock pain at 1 year follow up [57].
The literature present on fusion outcomes in Bertolotti
patients is sparse, in part due to the fact that fusion is rarely
used to treat Bertolotti Syndrome in the absence of addi-
tional degenerative spine pathology. More substantial data
has been gathered on the use of pseudoarthrectomy and
decompression in patients with continued symptomatology.
Case reports of patients undergoing pseudoarticulation
resection (pseudoarthrectomy) demonstrate variable patient
outcomes. One study demonstrated only a 10% improve-
ment in pain at 6 weeks post op [62], while other cases
have demonstrated patients returning to work as early as 1
month post op and sustained improvements in LBP through
the 2-year follow up period [63,64]. Another study by Li
et al. evaluated 7 patients who underwent minimally inva-
sive resection of the LSTV joint. In this study, 5 of 7
patients had relief or resolution of their pain, and 3 of 6
patients had resolution of their radiculopathy [65]. Further-
more, Brault et al. determined that pain in Bertolotti
patients can originate in the facet joint contralateral to the
pseudoarticulation. In this study, a fluoroscopy guided
injection to the L5-S1 facet contralateral to the side of
1293
pseudoarticulation provided temporary, but complete, pain
relief. Although contralateral to the site targeted by the
injection, surgical resection of the pseudoarticulation
resulted in complete resolution of the pain [30].
Resection of the pseudoarticulation may be of greatest
benefit to patients with pain originating at the pseudo joint,
as it has been shown that the greatest loading forces in the
LSTV are experienced at this pseudoarticulating surface in
motions such as ipsilateral side bending. Fusion, however,
is proposed to be of greater benefit only to patients who are
experiencing pain associated with increased motion and
instability and adjacent segments. In these cases, a fusion
procedure would include the unstable segments as well as
the LSTV, whereas patients without adjacent segment
degeneration undergoing fusion for an LSTV would likely
only receive an L5-S1 fusion. While surgical outcome stud-
ies for patients with LSTVs are sparce, it has been sug-
gested that patients without adjacent segment disease may
experience worse outcomes with fusion than resection, as
fusion of L5-S1 has been shown to cause more adjacent
segment motion than the LSTV alone, possibly accelerating
degenerative processes above the LSTV [11].
Decompression
Studies have shown posterior decompression is an easy,
safe, and useful treatment for spinal stenosis as well as intra
and extraforaminal nerve root compression [66]. When
present in Bertolotti patients, central canal and nerve root
compression are likely to be symptomatic. For instance,
while bone spurs forming at the pseudoarticulation site only
occur in approximately 13% of LSTV patients, 70% of
these patients can experience significant symptoms due to
nerve root compression [67]. Spinal stenosis can also cause
nerve root compression in these patients, however in the
absence of spondylolisthesis, spinal stenosis is more likely
to occur at the level superiorly adjacent to the LSTV [13].
Extraforaminal nerve root compression, or “far out syn-
drome” as described above, is another unique case that may
benefit from decompression [68].
Case reports of patients undergoing decompression have
yielded promising results, most likely due the presenting
symptoms being more definitive in their location of origin
than other presentations of Bertolotti Syndrome (eg, radi-
culopathy following specific dermatomes vs. poorly local-
ized LBP). Several cases of posterior decompression (and 1
case of anterior) have been reported for patients with Berto-
lotti Syndrome who presented with nerve root related symp-
toms. One patient (anterior decompression of a bone spur)
reported complete resolution of LBP and leg pain after 1
year [69]. In patients undergoing a posterior decompres-
sion, 1 patient reported complete resolution of hip and leg
pain at 3 months [56], while another patient reported LBP
relief and return to work within the same time frame [70].
Treatment of far out syndrome with decompression also has
1294 K. McGrath et al. / The Spine Journal 21 (2021) 1286−1296
shown promise, with 3 patients having significant or com-
plete relief of symptoms within a year post op [71,72].
Upon reviewing surgical treatment options, it is apparent
that different interventions have varying levels of efficacy
on resolving pain in Bertolotti patients. Decompression
may be the most beneficial for patients who present with
nerve root symptoms, while pseudoarthrectomy may show
the most promise in patients whose previous treatments
indicate that the pseudoarticulation is the primary source of
pain. Fusion of the lumbosacral spine is controversial in
these patients, as it may accelerate the development of the
adjacent segment disease that they are already predisposed
to, however in the case of adjacent segment destabilization
on presentation, fusion of the unstable segments may be the
best treatment option. Comparing outcomes among treat-
ment options is difficult at the present time due to a lack of
study power and standardization of patient outcome meas-
ures, however the current literature suggests that a step-
wise approach to treatment provides the best diagnostic
and/or therapeutic outcomes.
Conclusions
Bertolotti Syndrome often remains undiagnosed for
years, as patients suffer from chronic pain without a defini-
tive diagnosis or plan. These individuals can present at a
young age with unilateral LBP with or without radicular
pain, and patients presenting under the age of 30 with these
symptoms should be assessed to rule out the presence of an
LSTV. Bertolotti Syndrome can be diagnosed by combining
patient history, physical exam, diagnostic imaging such as
CT, MRI, and scintigraphy, and diagnostic injections if
needed. These methods, however, still result in sub-optimal
diagnostic accuracy and superior methods of diagnosis
should be studied. The efficacy data on treatment options
for these patients is limited and offers little reassurance
prior proceeding with surgery. Successfully resolving a
patient’s symptoms can be achieved, however further stud-
ies are needed with larger sample sizes and more standard-
ized measurements of clinical outcomes in order to
determine best management practices from the outset.
Declarations of Competing Interests
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
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