Does lumbarization cause low back pain?

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Last updated: October 20, 2026 • View editorial policy

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Lumbarization Does Not Directly Cause Low Back Pain

Lumbarization itself is a congenital anatomical variant that does not inherently cause low back pain, though it may be associated with pain in some patients through secondary mechanisms such as altered biomechanics, facet tropism, or disc degeneration at adjacent levels.

Understanding the Evidence

The provided guidelines 1 focus on degenerative disc disease, stenosis, and spondylolisthesis as causes of low back pain requiring fusion, but do not identify lumbarization (or lumbosacral transitional vertebrae/LSTV) as a primary pain generator. This is a critical distinction.

What the Research Shows

Recent studies reveal a nuanced picture:

  • Prevalence does not equal causation: A 2023 study found LSTV prevalence of 38.33% in chronic low back pain patients versus 21.66% in controls (statistically significant) 2, but a 1989 study found no greater prevalence of lumbarization in patients with low back pain compared to those without 3. This inconsistency suggests lumbarization alone is insufficient to cause pain.

  • Secondary pathology matters more: A 2024 whole-spine MRI study demonstrated that patients with sacralization (not lumbarization) had significantly higher rates of disc degeneration, end plate changes, and facet tropism at adjacent levels 4. Lumbarization was primarily associated only with facet tropism in patients with radicular pain, not axial low back pain 4.

  • Bertolotti's syndrome is the exception: When lumbarization creates a pseudo-articulation that becomes symptomatic (Bertolotti's syndrome), it can cause pain 5, 6. However, this represents a specific subset where the transitional anatomy creates a pain-generating structure, not lumbarization per se.

Clinical Approach

When to Suspect Lumbarization as Pain Source

Look for these specific features:

  1. Unilateral low back pain localized to the pseudo-articulation site
  2. Young patient (adolescent to young adult) with chronic pain
  3. High iliac crest line on AP radiographs (81% of patients with high ICL and PA <20° have lumbarization) 7
  4. Failure of standard conservative management for non-specific low back pain
  5. Absence of other clear pain generators (disc herniation, stenosis, spondylolisthesis)

Diagnostic Imaging Characteristics

On imaging, rapidly identify lumbarization by:

  • Anterior superior angle (ASA) of last presacral vertebra <85.7° (versus 90.6° in normal anatomy) 7
  • Posterior angle (PA) between last presacral vertebra and first sacral segment <19.7° (versus 36.9° normal) 7
  • Iliac crest line location above the inferior edge of transverse processes of the vertebra above the last presacral vertebra 7

Treatment Algorithm

For incidental lumbarization without clear pain correlation:

  • Treat as non-specific low back pain per ACP guidelines 8
  • Start with non-pharmacological interventions (physical therapy, spinal manipulation, exercise)
  • Avoid attributing pain to the anatomical variant without supporting evidence

For suspected Bertolotti's syndrome (symptomatic pseudo-articulation):

  1. First-line: Local anesthetic and steroid injection of the pseudo-articulation (diagnostic and therapeutic) 5
  2. Second-line: Radiofrequency ablation of the pseudo-articulation if injection provides temporary relief 5
  3. Third-line: Complete endoscopic resection of the pseudo-joint for refractory cases 5, 6
  4. Consider fusion only for persistent symptoms after resection in carefully selected patients 6

Critical Pitfalls to Avoid

  • Do not assume causation from radiographic findings alone: The presence of lumbarization on imaging does not automatically explain a patient's pain. Many asymptomatic individuals have LSTV 3.

  • Avoid wrong-level surgery: LSTV are a main cause of surgical errors 7. Always obtain whole-spine imaging when transitional anatomy is suspected to accurately count vertebral levels.

  • Do not rush to surgical intervention: Conservative management should be exhausted first, as recommended for non-specific low back pain 1, 8. The guidelines emphasize that lumbar fusion is reserved for degenerative disc disease refractory to 6+ weeks of conservative treatment, not for anatomical variants.

  • Recognize that facet tropism and disc degeneration may be the actual pain generators: In patients with lumbarization, adjacent segment pathology (particularly facet tropism) may be responsible for symptoms rather than the transitional vertebra itself 4.

References

7
Research

A rapid method to identify lumbarization on lumbar spine radiography and computed tomography.

European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2025

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