Treatment Options for Patients
Conservative Therapy
Conservative management should be considered after performing a thorough diagnostic workup. Combining pharmacological management, activity modification, and physical therapy may decrease pain, improve function, and prevent or postpone more invasive treatments. Conservative management has been shown to provide significant improvement of symptoms in select patients (Crane et al., 2021; Jain et al., 2013).
Conservative treatment may not work for every patient, but intervention should be attempted prior to interventional or surgical management when possible.
Pharmacological Management
There are many potential causes of pain in patients with Bertolotti Syndrome (Bsy). This can include inflammation in the pseudoarticulation itself, arthritis, adjacent segment disease, nerve irritation, or secondary biomechanical effects from the LSTV.
NSAIDS can help treat symptoms by decreasing local inflammation. Over-the-counter options include ibuprofen, naproxen, and meloxicam. If long term anti-inflammatory medication is needed, meloxicam may be the preferred pharmaceutical due to its selective mechanism of action and decreased GI upset when compared to traditional NSAIDS. (Hopkins et al., 2025; Wojtulewski et al., 1996).
Muscle relaxers could be considered if there is significant muscle guarding or spasms.
Activity Modification
Movement patterns may be altered in the presence of an LSTV. Specific activities and movement patterns may cause excess motion or load through the lumbosacral junction.
Educating patients on activities that aggravate their symptoms can help guide activity modification. Modification may include:
Avoiding excessive or repetitive lumbar flexion, extension, or rotation if they cause symptoms.
Limiting high impact activities that cause excessive loading through the lower back (i.e. repetitive jumping).
Pacing and activity modification when flare-ups occur.
Proper lifting techniques: Hinge at the hips and knees, maintain a neutral spine, and keep loaded objects close to your body.
Physical Therapy
Physical therapy is another mainstay of conservative management. Due to changes in spinal biomechanics, patients with Bertolotti Syndrome (Bsy) may experience compensatory movement patterns, overuse of certain muscle groups, decreased core stability, and increased loading through adjacent segments.
Evaluation by a physical therapist with knowledge in Bertolotti Syndrome (Bsy) can help determine if there are correctable biomechanical deficits that need to be addressed. Therapy may focus on:
Core strengthening and motor control.
Movement retraining.
Correcting muscle imbalances.
Increasing strength and endurance.
Instructing patients on proper body mechanics for daily activities, work, and sports.
Patients will present to physical therapy with different symptoms and goals, so therapy programs should be tailored to the individual.
Conservative management can help many patients with symptom management and help determine if they are candidates for further intervention.
Interventional Therapy
If pain and symptoms do not respond to conservative measures adequately, interventional pain management may be considered. Interventional pain management should be pursued in the setting of identifiable symptoms that are not responsive to appropriate medical therapy (e.g., medications, activity modification, physical therapy).
Unfortunately, the literature specific to Bertolotti Syndrome(Bsy) is currently limited to case reports, small case series, and retrospective reviews. Therefore, we will review all therapies that have been utilized and described throughout the literature. Ultimately, treatment should be based on clinical presentation, diagnostic studies, and response to prior treatment.
Corticosteroid Injections
Diagnostic and therapeutic injections can be performed in patients suffering from Bertolotti Syndrome. Image guidance can be used to direct injections to the pseudoarticulation, transitional articulation, adjacent facet joints, or any other potential pain generators.
In patients with significant inflammation at the site of injection, corticosteroids may help to alleviate pain and improve function (Holm et al., 2017). Some patients may experience prolonged periods of symptom relief when injections are combined with other conservative measures.
That being said, other patients who initially respond to injections will continue to experience symptoms and may require repeated injections every few months as part of their long-term management strategy (Jain et al., 2013).
Radiofrequency Ablation (RFA)
Radiofrequency ablation is another treatment option that can be considered for patients who have had temporary pain relief with diagnostic or therapeutic injections but have persistent or recurrent symptoms.
Radiofrequency ablation essentially targets the sensory nerves that supply the painful structure in hopes of decreasing pain signal transmission. In the setting of Bertolotti Syndrome (Bsy), radiofrequency has been shown to decrease pain from both the pseudoarticulation itself and adjacent structures such as the facet joint above the transitional vertebra (Burnham, 2010; Yadav et al., 2024).
Types of radiofrequency include thermal, cooled, and pulsed. Each technique has its own proposed advantages and disadvantages. However, there is not enough evidence to draw strong conclusions about which type of radiofrequency is superior in patients with Bertolotti Syndrome 9Bsy).
Although short-term studies have been positive, further studies are needed to better elucidate which patients are most likely to benefit from radiofrequency ablation and what the longest-term effects are.
Selective Interventional therapies may serve as a bridge between conservative therapy and surgery for the appropriately selected patient.
Surgical Treatment
Conservative and interventional therapies may be unsuccessful in providing symptomatic relief or may not provide lasting benefits for some patients. Surgery may be considered when pain persists, activities of daily living are significantly impacted, and imaging and diagnostic pathways confirms the lumbosacral transitional vertebra as a pain generator.
Patient selection is key prior to surgical intervention. Many surgeons consider a positive response (consistent with clinical diagnosis) to image-guided diagnostic injection as one piece of the criteria that helps confirm the transitional segment or pseudoarticulation as the source of a patient’s symptoms prior to proceeding with surgery (Jenkins, Chung, et al., 2023; McGrath et al., 2022).
Resection and fusion remain the two most common operative procedures performed for patients with Bertolotti Syndrome (Bsy). Each procedure has multiple variations and can be tailored based on anatomy of the transitional segment, associated spinal pathology, patient-specific biomechanics, and overall treatment goals.
Resection (Pseudoarthrectomy)
Resection involves removal of the offending pseudoarticulation. This process is done by removing or resecting the enlarged transverse process that forms the pseudoarticulation with the sacrum. Removal of the articulation is done with the goal of eliminating mechanical irritation/inflammation and preventing progressive degenerative changes from repetitive impingement between the aberrant process and sacrum.
This procedure can now be performed with minimally invasive techniques including microscopic tubular and endoscopic approaches with the benefit of decreasing morbidity to surrounding soft tissue while still providing adequate decompression and resection of offending anatomy (Ahn et al., 2024).
This procedure is typically reserved for patients that are felt to have the pseudoarticulation as their primary pain generator with no significant instability, severe degeneration, or other complicating spinal pathology.
Fusion
Fusion works on the principle of decreasing motion at the offending transitional segment. Unlike resection which removes the articulation, spinal fusion works by creating a stable construct between the transitional vertebra and sacrum.
Instrumented fusion is the most common technique performed and involves using bone graft material along with pedicle screws and rods to permanently stabilize the painful segment. By stabilizing this segment motion is decreased with the goal of preventing symptomatic progression.
Fusion is typically considered when there is evidence of instability, severe degeneration of adjacent segment levels, spondylolisthesis, or a belief that resection would not provide a long lasting result.
Selecting the Ideal Operation for the Patient
Ideally, there would be one procedure that could be recommended to treat all patients with symptoms from Bertolotti Syndrome (Bsy). Unfortunately, this is not the case and each patient needs to be considered individually when determining the ideal treatment plan.
Some of the factors that should be considered when discussing treatment options with your patient include the morphology of the patient’s specific lumbosacral transitional vertebra, associated spinal pathology, age, previous surgeries performed, biomechanical considerations, and other patient specific factors. Resection would be considered less invasive of a procedure with a quicker recovery but may not treat some patients with underlying instability. Fusion has the ability to treat instability but may lead to hardware complications and potentially cause adjacent segment degeneration to progress more quickly.
Jenkins et al. recently developed and introduced a way to help guide treatment recommendations based on the patient’s transitional anatomy. Using The Jenkins Classification patients were grouped based on their morphology and treated accordingly. Surgical recommendations were then tailored based on transitional morphology. Early results have been promising and help to further emphasize the need for patient-specific surgical planning (Jenkins, Chung, et al., 2023).
We are learning more about Bertolotti Syndrome (Bsy) every day and with that knowledge comes the ability to better treat our patients. Matching the patient’s pain generator with the appropriate operation is key and should help providers deliver the best care possible.