The management of Bertolotti's Syndrome follows a standard treatment cascade. This approach begins with the least invasive options and progresses to more involved procedures only when necessary. Here, we aggregated the treatment cascade into three steps: Conservative therapy, Injections and ablation, and surgery.
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This step follows an integrative approach utilizing pharmacotherapeutics, activity modification and physical therapy. Conservative approaches have had varying degrees of success in mitigating pain symptoms and delaying the need for surgical intervention (Crane et al., 2021; Jain et al., 2013). Nevertheless, it is critical that all conservative therapeutic approaches are explored before considering surgery.
Pharmacotherapeutics – Patients with Bertolotti’s Syndrome experience pain due to the inflammation caused by the arthritic pseudo-articulation or through secondary effects of the LSTV. These symptoms can be mitigated using non-steroidal anti-inflammatory drugs (NSAIDs) such as Naproxen, Meloxicam and Ibuprofen. Meloxicam is preferred for long-term management of symptoms over Naproxen given its selectivity in its mechanism of action as well as lower risk of causing ulcers or renal side effects (Hopkins et al., 2025; Wojtulewski et al., 1996). In patients presenting with severe muscle spasms in response to pain, muscle relaxer may also be prescribed.
Activity modification – When discussing the altered biomechanics due to LSTV, we highlighted that certain movements lead to aggravation of symptoms in patients. Providing guidance to patients on how to modify daily activities to reduce strain can be an effective way to reduce pain. These recommendations should include:
· Avoiding provocative movements – Counsel patients to avoid or modify activities that require repetitive lumbar flexion, rotation and extension. Furthermore, high impact activities such as jumping exercises should be reduced or avoided.
· Proper lifting mechanics – Instruct patients proper lifting techniques (i.e., bending at the knees and keeping load close to the body) and to avoid excessive loading of the back. Patients should work closely with their physical therapist to determine safe ways to perform activities that induce strain on the lower back.
Physical therapy – Patients with Bertolotti’s Syndrome have altered biomechanics due to the LSTV. These changes include hypermobility at adjacent segments, core instability, and asymmetric muscle tonicity in the lower back. To devise the best treatment approach that is specific to each patient, a physical therapist should perform thorough examination. The treatment protocol should aim to improve core stability and teach the patient ways to safely perform daily tasks without increasing pain levels.
If the conservative therapeutic approaches fail to provide adequate relief, interventional pain management techniques such as corticosteroid injections and RFA become important second line intervention for patients. Due to the paucity of published research on the use of injections or RFA for treating Bertolotti’s Syndrome, we have relied on case reports and small-scale studies in our analysis.
Corticosteroid injection to the pseudo-articulation can be administered in order to alleviate inflammation (Holm et al., 2017). This, coupled with conservative therapies outlined above can lasting pain relief for patients. In some cases, corticosteroid injections only provide temporary relief requiring periodic re-administration (Jain et al., 2013).
In some patients, L4/L5 facet joint RFA has been used to successfully reduce pain levels (Burnham, 2010; Yadav et al., 2024). Based on our findings, there is no consensus on the relative efficacy of the different type of RFA techniques: thermal, cooled or pulsed RFA. This further emphasizes the need of further clinical research to identify interventional pain management techniques that would be effective for Bertolotti’s Syndrome patients.
When a comprehensive course of conservative and interventional management fails to provide lasting relief for a patient with debilitating pain from Bertolotti's Syndrome, surgical intervention becomes a viable option. Irrespective of the surgical approach used, a positive response to a diagnostic injection of local anesthetic into the anomalous joint is required to confirm that the pseudo-articulation is a primary source of the patient's pain (Jenkins, Chung, et al., 2023; McGrath et al., 2022). Two surgical approaches are commonly used to directly address the direct effects of LSTV: resection (pseudoarthrectomy) or fusion.
Resection surgery aims to directly address the source of mechanical pain by surgically removing or "shaving down" the enlarged transverse process. This eliminates the bone-on-bone contact leading to leads to mechanical grinding, inflammation, and the formation of osteophytes (Poe, 2013). Given recent advances, resection surgery utilizes minimally invasive surgical techniques using microscopic tubular resection or endoscopic resection. These utilize smaller incisions and specialized instruments to minimize damage to the surrounding muscles and tissues (Ahn et al., 2024). Resection surgery is typically performed in patients with minimal co-morbidities; namely, spinal stenosis, significant degeneration of adjacent segments, disc herniation, or the congenital conditions associated with Bertolotti’s Syndrome.
Fusion surgery aims to completely eliminate motion at the painful segment by creating a solid bridge of bone, effectively making the transitional vertebra a permanent part of the sacral base. This is typically achieved with posterolateral fusion using bone graft material and stabilization with pedicle screws and rods (Jenkins, Chung, et al., 2023). Bone grafts are infused with Recombinant Bone Morphogenic Protein-2 (rhBMP-2) to ensure successful fusion.
Resection vs Fusion
There is likely no “one size fits all” surgical approach for Bertolotti’s Syndrome patients. The right surgical approach must take into account a multitude of factors such as the type of LSTV, patient co-morbidities, age of patient, surgical history, and more. Resection surgery holds appeal to many patients given the minimally invasive approach and the fast recovery time. However, it does come with the risk of introducing further instability. The LSTV, while pathological, often provides some degree of abnormal stability to the lumbosacral junction. Removing this structure without addressing underlying instability can lead to poor long-term outcomes (Jenkins, Chung, et al., 2023).
On the other hand, Fusion is generally considered the more appropriate choice for patients who have evidence of spinal instability, advanced degenerative disc disease at the adjacent level, spondylolisthesis, or in cases where a simple resection is deemed likely to cause further spine instability. However, fusion surgery can come with its own set of risks including accelerating degeneration of segments above fusion site (i.e., adjacent segment disease) and hardware related issues.
A recent retrospective cohort study of 150 individuals by Jenkins et al has taken steps to develop a systematic framework uses the anatomy of the LSTV for determining the appropriate surgical approach (Jenkins, Chung, et al., 2023). Patient outcomes were tracked up to 2 years post-surgery. Based on these results, the authors offer surgical recommendations for the different classes of LSTV: resection surgery for Type 1 patients, bilateral fusion surgery for Type 2 patients, and unilateral fusion for Type 4 patients.