From the Guidelines
An anomalous articulation between the transverse process L5 and sacral wing should be managed conservatively in most cases, with initial treatment including physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) for 1-2 weeks to manage pain and inflammation. This condition, also known as a transitional lumbosacral junction or Bertolotti's syndrome, occurs when the enlarged L5 transverse process forms an abnormal joint with the sacral ala, creating a pseudoarticulation that can cause mechanical low back pain, particularly on the affected side. The abnormal biomechanics can lead to accelerated degeneration at adjacent spinal segments, potentially causing radicular symptoms or facet joint pain over time 1.
Key Considerations
- Initial treatment should focus on conservative management, including physical therapy focusing on core strengthening, lumbar stabilization exercises, and proper body mechanics, along with NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks to manage pain and inflammation 1.
- Heat therapy and gentle stretching can provide additional relief.
- If conservative measures fail after 4-6 weeks, consider image-guided corticosteroid injections at the pseudoarticulation site.
- Surgery (resection of the anomalous articulation) is reserved for severe cases that don't respond to conservative treatment after 6-12 months.
Imaging Considerations
- MRI of the lumbar spine is the initial imaging modality of choice for evaluating low back pain, including cases with suspected anomalous articulation between the transverse process L5 and sacral wing 1.
- CT lumbar spine without IV contrast may be useful for preoperative planning and can assess facets and neural foramina, and is equal to MRI for predicting significant spinal stenosis and excluding cauda equina impingement 1.
- CT myelography of the lumbar spine can be useful in assessing the patency of the spinal canal/thecal sac and of the subarticular recesses and neural foramen, particularly in patients with significant artifact from metallic surgical hardware on MRI 1.
From the Research
Anomalous Articulation Between the Transverse Process L5 and Sacral Wing
- Anomalous articulation between the transverse process L5 and sacral wing is a condition that can cause low back pain, as seen in patients with Bertolotti's syndrome 2, 3, 4, 5.
- This condition is characterized by the enlargement of the transverse process at the most caudal lumbar vertebra, with a pseudoarticulation between the transverse process and sacral ala 2.
- Studies have shown that this anomalous articulation can cause buttock pain and leg pain, and can be a source of chronic low back pain in patients who do not have degenerative lesions classically responsible for this symptom 3, 4, 5.
Diagnosis and Treatment
- Diagnosis of anomalous articulation between the transverse process L5 and sacral wing can be made using imaging studies such as computed tomography (CT), plain x-rays, and magnetic resonance imaging (MRI) 4.
- Treatment options for this condition include steroid injections into the pseudoarticulation, as well as surgical resection of the anomalous transverse process 2, 3, 4, 5.
- Surgical treatment has been shown to be effective in relieving symptoms in patients with Bertolotti's syndrome, with satisfactory results achieved in 86.89% of cases in one study 4.
- A minimally invasive approach for disconnection of the abnormal joint with partial distal resection of the transverse process has also been described as a treatment option for this condition 5.
Clinical Relevance
- Anomalous articulation between the transverse process L5 and sacral wing is a condition that should be considered as a possible factor in the genesis of low back pain in patients who do not have degenerative lesions classically responsible for this symptom 3.
- Correlating clinical symptoms with aberrant anatomy is important in diagnosing and treating this condition, and selective surgery can provide symptomatic relief in patients with Bertolotti's syndrome 5.