Bertolotti’s syndrome – Atypical Cause of Low Back Pain

Bartolotti's syndrome
Image courtesy Dr. Rebeca Monreal

By Chris Faubel, M.D. —

Bertolotti’s syndrome is an atypical cause of axial low back pain or buttock pain caused by a transitional lumbar vertebrae with a large, “spatulated” transverse process that either fuses with the sacrum (sacral ala) or ilium, or forms a pseudo-articulation at that location.  If it fuses with the sacrum, this could also be called a hemi-sacralization of the L5 vertebrae.

This is a congenital abnormality, but doesn’t usually become symptomatic until a patient’s 20’s or 30’s.

How and Where It Causes Pain

This pseudoarticulation can cause pain at the junction site –> axial low back pain

Alternatively, if the junction is fused, forces can be transferred to the sacroiliac joint (SIJ) causing pain there.

Think of getting AP x-rays of the lumbar spine and looking for Bertolotti’s syndrome in a patient with a clinical presentation of sacroiliac joint disorder/pain that is recurrent and just doesn’t get longterm relief from physical therapy and/or fluoroscopic intra-articular injections of the sacroiliac joint.

The fusion may also reduce movement unilaterally at the L5/S1 level, which may increase movement on the opposite side or lead to an L5/S1 or L4/5 disc herniation causing radiculopathy.

Imaging – To View Bertolotti’s Syndrome

The large transverse process pseudoarthrosis with the sacrum/pelvis is best viewed with an AP lumbar x-ray, or a lumbar CT scan.  A typical sagittal and axial lumbar MRI does not show this anatomical abnormality as well; coronal MRI views would be needed to view it well.

Treatments for Bertolotti’s Syndrome
  • Fluoroscopically-guided steroid injection and/or local anesthetic blocks at the pseudoarticulation site
  • Radiofrequency ablation (thermal) along the articulation
  • Surgical excision of the large transverse process

Surgical excision of Bertolotti’s large transverse process

Bertolotti’s syndrome. A cause of back pain in young people.

Bertolotti’s syndrome: a case report

Radiofrequency sensory ablation as a treatment for symptomatic unilateral lumbosacral junction pseudarticulation (Bertolotti’s syndrome): a case report

Lumbosacral transitional vertebra causing Bertolotti’s syndrome: a case report and review of the literature

Bertolotti Syndrome as a Potential Cause of Low Back Pain in Golfers

Note:  Many of the images are courtesy Dr. Rebeca Monreal who practices interventional spine management in Salem, Oregon at Salem Pain & Spine Specialists

Bartolotti's syndrome injection
Image courtesy Dr. Rebeca Monreal
Bertolottis syndrome injection - post contrast
Image courtesy Dr. Rebeca Monreal



  1. Hi, I would like to know what cpt to bill for Steroid injection into pseudoarticulation between the left L5 tranverse process and the sacrum. Medicare denied cpt 64493. So I am questioning weather we billed it correctly patient has Left Bertolotti syndrom. Please email me let me know. Thanks.

    • Hi Nancy,

      Dr. Duncan McBride at UCLA in Santa Monica, CA has treated people with Bertolotti’s Syndrome – myself included.

      I hope that helps?

  2. Why do so many American Drs refuse to believe that psuedo-articulation joints due to lumbarized S1/L6 or sacralized L5 enlarged deformed transverse processes can cause intractable pain. Resection of the deformed transverse process makes much more sense than fusions and treating the leg pain as if it originate from disk issues. It is very hard to find a doctor that is knowledgeable of Bertolotti’s syndrome.

  3. Dr. David Wu in Torrance, CA, treated me yesterday for my lower back pain. He discovered I had Bertolotti’s syndrome. He too has it and seems to be very knowledgeable about it. He spent quite a long time with me as a first time patient (which is extremely rare). We went ahead and injected a mild steroid right to the inflamed area along with an anti-inflammatory. He prescribed to me Meloxicam to use for about a month. He said I should feel a significant improvement in the next few days. I am 29 years old and just started having a constant back pain for the past 1.5 months.
    If you live in Southern California with this syndrome, please check him out.

    • Hi Samantha
      Just wondering how you are doing – I just got diagnosed and I’m working how your pain is doing?
      I just made an appointment with Dr. Wu.

  4. Is there anything, research paper wise, that I can give my docs to show them that this might be the cause of my pain? I had my 4th surgeon say I had this, but the office doctors disagree.

  5. HI. My daughter (14) suffers from mid back pain daily. She was recently diagnosed with scoliosis and Bertolottis. Any recommendations for a brace or something that might help alleviate the pain?
    Also, we are in So Cal now, but in July we are moving to North Carolina (Winston-Salem). Do you know of any physicians who specialize in this there?

  6. I was seen by Michael strikes in Cleveland ohio for bertolli syndrome, today he read my 81st scan and told me he couldn’t help me because it was infused please is there anyone close to ohio that can help me….I ‘ve been dealing with with is for over 7 yrs


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