Bertolotti’s Syndrome

Bertolotti’s Syndrome is the clinical presentation of back pain, sciatica (electrical pain that shoots down the leg), or both, associated with the congenital anomaly of a bone in the spine rubbing against part of the pelvis, also known as a lumbosacral transitional vertebra (LSTV).  Because of the overlap of the symptoms with other more common conditions (herniated disks, spondylolisthesis, SI joint instability, hip pathology, and other regional conditions), it is often overlooked as a cause of patient’s pain.  In fact, it is one of the more difficult to identify because it often sounds like something else, and the imaging (CT, X-ray, MRI) is not always done in a way that shows the anomaly well.  It is also not well understood by many spine surgeons, so it is often missed.

Early in spine development, there comes a time when the bottom 4 vertebrae of the spine (also known as the sacrum, the black bone in the first image) fuses (or becomes one bone) and then sits in the middle of the two halves of the pelvis known as the iliac wings (white bones in first image).  These three bones make up the pelvis, and the other 24 vertebral bodies of the spine (blue bones, first image) sit on top of the sacrum.

Image 1: front of normal spine and pelvis

In about 10% of people, the junction between the 5 mobile lumbar vertebrae and the single block vertebra of the sacrum … becomes a bit blurred.  Image 2 shows a model of a patient with one variant of the congenital anomaly.  The bottom lumbar vertebra (L5) seems to “try” to fuse into the sacrum, by having a much larger transverse process (TP) that is much closer to the sacrum (red line, second image) than it is to the L4 transverse process (green line) and the outside top of the sacrum seems to reach up to meet this larger transverse process (blue arrow; blue lines are where “normal” bone margins would be located on the sacrum and L5 TP, see second image)

Image 2: Model of Bertolotti’s patient, back of spine and sacrum (without iliac bones)

When a patient has other findings on MRI or X-ray that could also contribute to the symptoms, it is useful to have diagnostic tools to help separate the symptoms from Bertolotti’s syndrome from those of other spinal conditions: herniated disks, stenosis, facet arthritis, sacroiliac instability, fractures, slipped discs (“spondylolisthesis”), hip problems, a hernia, and other lesions in this area.   The use of direct injections into the region of the bone interface, similar to epidural steroid injections but targeting the specific anatomy of the anomaly can be very helpful.  Response to this particular injection seems to be fairly specific and sensitive to the diagnosis of Bertolotti’s. In Bertolotti’s syndrome, we believe that the back pain is due to the direct contact between the bone of the L5 transverse process with either the ala or the iliac bone, which because the anomaly is not a normal joint, does not have the proper articular cartilage to protect it.  This bone-on-bone contact can be caused by normal movement bringing them into contact with each other.   It can also cause leg pain because the nerve root runs just in front of the bones.  In other cases, the bones are so close they make a false joint, and movement of that false joint causes pain because it doesn’t have the normal cartilage lining that protects the bone.

Traditional conservative management of Bertolotti’s Syndrome consists of injections for pain management, and physical therapy.  If that doesn’t work, surgical treatments have historically consisted of big open surgeries, either to open up the space, or to fuse the two bones together so they don’t move any more, or putting a probe next to one of the nerves in the area to burn it and make the area numb.  We have developed a procedure, done minimally invasively and that is usually done as an outpatient procedure (go home same day) where we trim down the two bones so they don’t come into contact with each other anymore.  We have presented our results at international meetings, and continue to study the treatments to determine the best approach for each patient.

If you or your doctor thinks you may have Bertolotti’s Syndrome, please feel free to have them contact our office at 212-241-8175 for an evaluation.  One of our trained doctors may be able to consult on your case to determine what the next steps should be for you.  To read more, click here.

  1. Please help!!!
    My name is Alberto, i´m 27 years old, im from Costa Rica. I worked as an architect.
    > I was healthy until 22 years, but in the last 6 years i have suffered a congenital deformation called bertolotti´s syndrome or (L5 tranverse mega apophysis articulated to the sacrum). Also i suffer an intense and permanent burning pain in my soles foot, legs and many other parts of my body when those parts receive any weight of my body, (like hypersensibility or alodinia) I was diagnosed with L4, L5 and S1 radiculopathy.
    > Those 2 things are ruining my life, the pain is horrible.
    > This limit almost all the things that i want to do, i cant be seated or stand on foot.
    > I feel all the time like my spine is cracking with strong sounds , a sensation almost like if the bones and vertebrae are colliding with each other, but in the Rx, MRi and other test, all appear normally.
    > Here the doctors, always says, “keep a life whitout stress” or “you only need to do some exercises”, “you dont need a surgery its too dangerous, it is very dangerous”. What i should do?? i tried almost everything and nothing works! i know that in US must to exist something for this terrible problem.
    > I have available all the tests results and diagnostics to confirm my condition.
    > I heard that are some specifically doctors in US that are experts treating this condition, so one person there recomends Cleveland Clinic or Dr. Arthur Jenkins III on Mount Sinai, NY.
    > I want to know how to treat this condition effectively. I will appreciate your help.

    • Please reach out if you have not yet gotten satisfactory treatment. This condition usually responds to appropriate treatment, and this treatment is evolving as we learn from each patient we treat.

    • Hola Alberto, yo también soy tica y tengo el síndrome de Bertolotti, me acaban de diagnosticar. Veo que hace un año fue que usted escribió en la página y quería preguntarle si obtuvo alguna respuesta positiva para tratar su dolor y cualquier consejo que me pueda ofrecer es bienvenido.

      • Sorry for the delay in response. We would be happy to help you. Please reach out to my office at this telephone number. Hablamos Espanol.

  2. Recently diagnosed with Bertolotti’s Syndrome (bilateral) and experiencing considerable pain. Is it possible to have my film examined to see if I’m a candidate for resection.

  3. I hv bilateral bertolotti syndrome with pseudo arthrosis on left side ..I want to consult .any help would be appreciated

    • Please reach out to my office to schedule a telephone consultation

    • I appreciate your post. Its encouraged me to reach out. I’m going to call you guys to discuss further. I have X-ray films I could email for a quick glimpse.

      • Happy to help. We have a process for verifying the diagnosis that includes a review of your symptoms, Imaging, and response to certain tests we order. Let us know if you wish a consultation, either in person or remotely.

  4. Buenos estimados doctores, mi nombre es Andreina tengo 35 años y por los síntomas que ustedes describen creo tener o padecer el síndrome de Bertolotti. les agradecería si me pueden ayudar o atender. {} . Sin más a que hacer referencia y esperando su pronta respuesta muy Atte.,
    Venezula, Caracas, 7 de marzo de 2018.

    • por favor, telephoner mi officina si usted quires uno consultation.

  5. Hello doctor I am suffering from back pain since 6 months and i have Bertolotti syndrome on my right side lower back. how can I contact with you. Could you please provide your contact details..

    • Our contact information is on the main page as well as on the contact page. My office will reach out to you separately as well. Hopefully we will be able to come up with a plan to help you manage your spine, instead of it managing you.

  6. Hello. I have BS not sure what type. I done c.t, spect c.t and a mri. Doctor’s in the uk things that’s not my problem and rest of my spine is good. I have problem sitting down and standing up and lots of stiffness and spasm and discomfort, but no consistent pain. How do i get this sorted please. I am from UK. Thank you

    • Well, we could arrange for a remote consultation. Please reach out to my office to discuss.

  7. i im 41 had back pain since 2002, I’ve been to see 3 consultants who have all stated I don’t have bertolotti as don’t have false joint. I do have castellvi type 3b sacralised L5 vertical body with completely fused L5 TP/ Sacrol Alar articulation. I also have Degenerative disc desease with L4/L5 with incidental Broad base upper disc pretrusion and constitutionally minimally norrow cancel. I also have left hip Cam inpingment with osteoarthritis.
    My symptoms are severe back pain with spasms sciatic pain pins and needles in feet and groin. I find difficulty walking and use a stick in house and wheelchair out doors. I get pain around my hips hypersensitivity in my right foot, I’m at a loose end the consultants have said surgery is a no go and to just put up with the pain. I can’t work and I’m. Losing my job of 19yrs in social care. I don’t know what to do anymore. Can you please provide any help / support? Thanks Mr Clements PS I have copies of my spec CT scam MRI and xrays.

    • Sounds complicated. It would require a thorough evaluation. LSTV’s can cause L4/5 DJD and spondylolisthesis, herniated disks, etc. It is hard to figure out what the primary pain generator is in situations where there are multiple things “wrong” on imaging. Especially when speaking with clinicians who don’t understand the role the LSTV plays in pain generation and spinal degeeneration.

  8. Dr. Jenkins,

    This article is very informative. What are your thoughts or input on patients that have their pain on the opposite side of their anomaly . This is clearly not the bone on bone pain as described in your article.


    • First, there’s no guarantee that having the anomaly means it’s your pain generator. Second, I’d have to see your films to see what your particular anatomy looks like. The pain can come, including back pain, even from a “solidly fused” partial segment, if the other side, facet joints, and the disk are open/not fused. So the answer is more complicated than just pain from “bone-on-bone”, but that’s the way MOST anomalies present when they cause pain. Sounds like a consultation might be indicated.

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