How is Bertolotti syndrome managed?

Management of Bertolotti Syndrome

Begin with conservative management including physical therapy and NSAIDs, followed by diagnostic/therapeutic injection of the transitional articulation with local anesthetic ± steroids, then proceed to radiofrequency ablation if injections provide temporary relief, and reserve surgical resection for refractory cases. 1, 2

Initial Conservative Management

• Start with medical management using NSAIDs for pain control combined with structured physical therapy focusing on core strengthening and flexibility 1
• Continue conservative measures for 6-12 weeks before escalating to interventional approaches 1
• Home exercise regimens should be incorporated as part of the conservative strategy 2

Interventional Treatment Algorithm

Step 1: Diagnostic and Therapeutic Injection

• Perform injection at the pseudo-articulation (transitional segment) using local anesthetic alone or combined with corticosteroids 1, 2
• Epidural steroid injection at the level of the transitional articulation has established effectiveness 1
• Ipsilateral transforaminal epidural steroid injection can be performed, though the anatomy may be technically challenging 3
• This step serves dual purposes: confirms the transitional vertebra as the pain source and provides therapeutic benefit 2, 4

Step 2: Radiofrequency Ablation (RFA)

• If injection provides temporary relief (confirming the diagnosis) but pain recurs, proceed to RFA around the transitional segment 1, 2
• Recent evidence suggests RFA may provide more durable pain relief than repeated injections 1
• This represents an intermediate step before considering surgical intervention 2

Step 3: Surgical Management

Surgery is reserved exclusively for patients who fail both injection therapy and RFA 1, 2, 5

Surgical options include:

• Resection of the transitional mega-apophysis (transverse process) - this is the primary surgical approach when the pseudo-articulation itself is the pain source 1, 5
• Decompression of stenosed foramina if radiculopathy is present 1
• Spinal fusion in select cases 1
• Surgical resection has been shown to be safe and effective in patients where the mega-apophysis is confirmed as the pain source 5

Important Clinical Considerations

Diagnostic Confirmation

• Diagnosis requires both imaging evidence (X-ray, CT, or MRI showing lumbosacral transitional vertebrae) AND clinical correlation with pain patterns 1, 2
• The incidence of transitional vertebrae is 4-36%, but Bertolotti's syndrome is only diagnosed when pain is definitively attributed to this anatomy 1
• Pain typically localizes to the sacroiliac joint, groin, and hip region, with or without radiculopathy 1

Common Pitfalls

• Do not assume all patients with transitional vertebrae have Bertolotti's syndrome - the anatomical variant must be the confirmed pain generator 1
• Diagnostic injection is critical to avoid unnecessary surgery in patients whose pain has alternative sources 2, 5
• The condition can present at any age, including elderly patients as a first presentation, though this is uncommon 4
• Careful anatomical assessment is needed as the transitional anatomy creates technical challenges for interventional procedures 3

Evidence Limitations

• Most supporting evidence consists of case series and lower-level studies with small cohorts 1
• There is no consensus on optimal therapy, and larger comparative studies are needed 1, 5
• The stepwise algorithmic approach may require modification based on individual patient factors such as severity of symptoms, presence of radiculopathy, and response to each treatment level 2