Pain Physician 2024; 27:E275-E284 • ISSN 1533-3159

Case Study

A Proposed Treatment Algorithm for Low Back

Pain Secondary to Bertolotti’s Syndrome

Ahish Chitneni, DO1, Richard Kim, DO1, Zachary Danssaert, DO1, and Sanjeev Kumar, MD2

From: 1Department of Background: Chronic low back pain is widely prevalent, and there are a range of conditions that
Rehabilitation and Regenerative may result in the low back pain. In general, treatment of low back pain starts with conservative
Medicine, New York- Presbyterian
Hospital - Columbia and Cornell, management such as medications, physical therapy, and home exercise regimens. If conservative
New York, NY; 2Anesthesiology measures fail, a range of interventional techniques can be employed to manage back pain. An
and Pain Medicine, University of uncommonly recognized cause of back pain is Bertolotti’s syndrome which is a result of back
Florida, Gainesville, FL pain due to lumbosacral transitional vertebrae (LSTV). LSTV is a congenital abnormality either
Address Correspondence:
characterized by the lumbarization of the sacrum where the first sacral bone fails to fuse with
Ahish Chitneni, DO the rest of the sacrum or the sacralization of the lumbar spine where the L5 vertebra fuses with
Department of Rehabilitation the sacrum creating a longer sacrum. In many cases, the condition can be recognized by imaging
and Regenerative Medicine, New techniques such as an x-ray, computed tomography, or magnetic resonance imaging.
York- Presbyterian Hospital -
Columbia and Cornell
525 E. 68th St Objectives: To propose a treatment algorithm for patients with low back pain secondary to
New York, NY 10065 Bertolotti’s syndrome.
E-mail:
[email protected] Study Design: Case study and treatment algorithm proposal
Disclaimer: There was no external
funding in the preparation of this Methods: A treatment algorithm for patients with low back pain secondary to Bertolotti’s
manuscript. Syndrome which involves starting with local anesthetic and steroid injection of the pseudo-
articulation, followed by radiofrequency ablation of the pseudo-articulation, and then complete
Conflict of interest: Each author
certifies that he or she, or a endoscopic resection of the pseudo joint.
member of his or her immediate
family, has no commercial Results: The proposed stepwise treatment guideline has the ability to diagnose Bertolotti’s
association (i.e., consultancies, syndrome as the cause of low back pain and provide symptomatic relief.
stock ownership, equity interest,
patent/licensing arrangements,
etc.) that might pose a conflict of Limitations: Several limitations exist for the study including the fact that the algorithmic
interest in connection with the approach may not fit every patient. Additionally, there would be benefit in future research studies
submitted manuscript. comparing each step of the algorithm with conservative measures to compare efficacy and long-
term outcomes of the procedures.
Manuscript received: 06-07-2023
Revised manuscript received:
10-06-2023 Conclusions: Our stepwise approach to diagnosing and managing the pain resulting from
Accepted for publication: Bertolotti’s syndrome is an effective method of treatment for the condition.
10-17-2023

Free full manuscript: Key words: Chronic pain, low back pain, Bertolotti’s syndrome, pseudo joint, radiofrequency
www.painphysicianjournal.com ablation, endoscopic resection

Pain Physician 2024: 27:E275-E284

C hronic low back pain is widely prevalent and

has been cited as the leading cause of disability
in Americans younger than 45 years (1).
Furthermore, chronic low back pain is the second most
common reason to visit a physician for a chronic ailment
as mechanical or non-mechanical. Mechanical back pain
is often aggravated by the loading of the spine (i.e.,
by sitting or standing) and forward bending positions
and it usually improves when the spine is offloaded
(i.e., by lying supine). Conversely, patients with back
(2). Low back pain is considered chronic if it is present pain due to non-mechanical causes, including vascular
for more than three months and it can be characterized or visceral pathology, will have constant back pain

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 Pain Physician: February 2024 27:E275-E284

regardless of their position, and they require further I is an enlarged and dysplastic transverse process, type
diagnostic evaluation. A thorough physical exam can II involves the pseudo-articulation of the sacrum and
uncover if patients are predisposed to develop back transverse process, with incomplete lumbarization or
pain by identifying biomechanical and compensatory sacralization and the enlargement of the transverse
changes. For example, leg-length discrepancies, process with pseudo-arthrosis, and type III involves the
scoliosis, and postural dysfunction can all play a role fusion of the transverse process with the sacrum and
in the development of back pain. Special tests, such as complete lumbarization or sacralization with an en-
the straight leg test that checks for radiculopathy, can larged transverse process that is completely fused. Each
influence the next steps in diagnosis and treatment. type of LSTV can be further subdivided into unilateral
The overall treatment for low back pain gener- or bilateral. Type IV LSTV is a combination of type IIa
ally begins with a conservative approach involving on one side and type IIIa on the contralateral side (7).
physical therapy (PT), spine care education, exercise, Importantly, there is a variance in the transitional
medications, and other non-invasive treatment modali- anatomy of individuals which is not necessarily respon-
ties. PT is focused on strengthening the surrounding sible for a patient’s chronic back pain. The abnormal
musculature, improving mobility, postural correction connection between L5 and S1 vertebrae places more
and utilizing various modalities to reduce pain. If the stress on the adjacent vertebral level and creates a
conservative treatment is not effective, interventional higher incidence of disc herniation and facet arthrosis
spine procedures are utilized to exacerbate the chronic (8,9). When low back pain occurs in patients with LSTV,
pain and allow patients to better participate in their it is classified as “Bertolotti’s syndrome” (10). The in-
therapy program while delaying or avoiding surgery. cidence of LSTV is reported to be between 4 and 30%
Furthermore, injections are often used as a diagnostic (11). However, the incidence of Bertolotti’s syndrome is
tool to localize the pain generator. Epidural steroid much lower, between 4 and 8%, which indicates that
injections, intraarticular facet blocks, medial branch Bertolotti’s syndrome might be underdiagnosed (12).
blocks, medial branch radiofrequency neurotomy, and Patients with Bertolotti’s syndrome often complain of
spinal cord stimulation are some of the most common nonspecific back pain that can radiate to the buttock
spinal interventions used to treat back pain (3). and lateral hip. A comprehensive physical examination
Overall, chronic back pain can be difficult to treat needs to be performed to rule out other syndromes
because its etiology is often multifactorial, involving such as lumbar spondylosis, degenerative disc disease,
psychosocial, structural, and biomechanical causes. Ad- lumbar radiculopathy, sacroiliac joint dysfunction
ditionally, the origin of the back pain can be difficult and lumbar spinal stenosis with neurogenic claudica-
to localize. While the most common diagnosis for back tion. Nonspecific tenderness, focal tenderness, and a
pain is muscular strain, there are multiple structures decrease in range of motion are common symptoms
that can be producing the pain, including the liga- found in patients with Bertolotti’s syndrome. Plain ra-
ments, muscles, facet joints, vertebrae and interverte- diographs are a useful diagnostic tool which may show
bral discs (4). The origin of a patient’s chronic back the enlargement of the L5 transverse processes and the
pain is often attributed to degenerative changes found apophysis of L5 that articulates with the sacrum. The
upon imaging. However, studies have shown that there Ferguson radiograph, an anterior-posterior (AP) view
is no correlation between symptoms of chronic back of the lumbosacral function with 30 degrees of cepha-
pain and the degree of degeneration (5). lad angulation, is the reference standard method to
Lumbosacral transitional vertebrae (LSTV) is a con- detect LSTV (13). Computed tomography (CT) can also
genital abnormality characterized by the lumbarization help clarify the degree of fusion. Furthermore, CT and
of the sacrum occurring when the first sacral bone fails magnetic resonance imaging (MRI) are both helpful for
to fuse with the rest of the sacrum, creating an L6 numbering of the vertebrae, which is critical for the
vertebra. Conversely, LSTV can also be characterized by treatment approach (9).
the sacralization of the lumbar spine when the L5 ver- Similar to other causes of low back pain, the initial
tebra fuses with the sacrum creating a longer sacrum. management of Bertolotti’s syndrome involves a con-
In LSTV, the degree of lumbarization or sacralization is servative approach with nonsteroidal anti-inflammato-
a spectrum and there have been intermediate incom- ry drugs (NSAIDs) and PT. If conservative measures fail
plete transitions recognized (6). LSTV has been further to provide relief of pain, interventional spine injections
classified according to the Castellvi classification: type can be administered. Corticosteroid injections under

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 Bertolotti’s Syndrome Treatment Algorithm

fluoroscopic guidance into the abnormal articulation tor tip placement looked appropriate on fluoroscopy,
can provide significant pain relief and help localize the a working channel was placed over it and its position
pain generator for future management (14). Multiple was checked too. The dilator was then removed, and
case studies also report that radiofrequency sensory ab- an endoscope was placed. Continuous normal saline
lation is an effective technique to reduce pain caused irrigation was maintained through the endoscope
by LSTV (15,16). Furthermore, if conservative measures throughout the procedure. The bipolar radiofrequency
fail, and the diagnostic injection at the pseudo joint cautery and pituitary Rongeur was used to remove the
provides only a temporary improvement of symptoms, soft tissues over the pseudo joint. Then, the pseudo
surgical resection of the enlarged transverse process joint line was identified via the endoscope. At the
has been shown to provide long-lasting relief (14,17). If pseudo joint line, a diamond burr was used to take
the spine is unstable at the L5-S1 segment, it has been down the inferior edge of the transverse process of
demonstrated that performing a spinal fusion can L5 all along the pseudo joint from the lateral to the
provide long-lasting relief. However, as with all spinal medial aspect. The entire pseudo joint articulation was
fusions, there may be adjacent segment degeneration also drilled out from the dorsal to the ventral aspect of
over time (18). the joint. At the anterior aspect of the pseudo joint, the
Overall, there is a lack of clarity regarding the far lateral L5-S1 herniated disc material was visualized.
treatment of Bertolotti’s syndrome after a patient has Using pituitary forceps and bipolar trigger flex cautery,
failed to show improvement conservative measures. In the extruded disc material was resected until the exist-
this review article, we propose a treatment algorithm ing L5 nerve was seen to be free coming out of the left
in increasing order of invasiveness to treat Bertolotti’s L5-S1 foramen. Hemostasis was achieved with trigger
syndrome. flex cautery and then the endoscope and working tube
were taken out.
Methods
Description of Procedures
Case Report
We present the case of a 73-year-old woman who Local Anesthetic & Steroid Injection to Pseudo
presented with left-sided low back, buttock pain, Joint
chronic left leg weakness and left foot drop from To conduct this procedure, a fluoroscopic C-arm
chronic left L5 radiculopathy. On physical examination, device, local anesthetic (bupivacaine), steroid (triam-
the patient presented with 4/5 strength on the muscle cinolone), and contrast solution were required. For this
strength grading scale in the left EHL and tibialis ante- procedure, the patient was prepped in a prone position
rior. Prior to presentation at the clinic, the patient used to visualize the pseudo-articulation, sacral ala, and the
a rollator walker for ambulation for short distances be- L5 transverse process. The C-arm was typically placed in
fore reporting fatigue and requiring to sit down. MRI the anterior/posterior (A/P) position. With fluoroscopic
was significant for identifying the extruded far lateral guidance, a 22-gauge, 3.5 inch spinal needle was guided
L5-S1 disc herniation and an L5-S1 pseudo-articulation to the pseudo joint line under anteroposterior and con-
compressing the exiting left L5 nerve root. In this case, tralateral oblique fluoroscopic views. Once the needle
the patient underwent the treatment algorithm out- tip was seen and felt to be inside the joint capsule, 0.5
lined below and eventually underwent an endoscopic mL of triamcinolone (40mg/mL) mixed with 1 mL of bu-
resection of the pseudo-articulation. A 22-gauge spinal pivacaine was injected at the pseudo-articulation (15).
needle was introduced to the left L5-S1 pseudo joint After the procedure, the patient was asked to maintain
on the lateral aspect of the L5-S1 facet. The position of a pain diary recording pain intensities for a week after
the injection was checked under AP and contralateral the procedure. Figure 1 depicts fluoroscopic images of
oblique fluoroscopy. The site of the pseudo joint was needle placement at the pseudo joint.
anesthetized using a 50/50 mixture of 0.5% bupiva-
caine and 1% lidocaine with epinephrine. Then, a #11 Radiofrequency Ablation of Pseudo Joint
blade was used to make a 1.5 cm horizontal incision Similarly, to conduct this procedure, a fluoroscop-
down through the thoracolumbar fascia. The blunt tip ic C-arm device, local anesthetic (lidocaine), 18-gauge
dilator was placed and pushed down to the pseudo radiofrequency cannulas, and radiofrequency probes
joint line under fluoroscopic guidance. Once the dila- were used. For this procedure, the patient was

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prepped in a prone position to visualize the pseudo- Complete Endoscopic Resection of Pseudo Joint
articulation, sacral ala, and the L5 transverse process A complete endoscopic resection of the pseudo
with the C-arm placed in an A/P position. After injec- joint can be conducted when the pain is refractory to
tion of local anesthetic on the skin and subcutaneous other procedures but is known to be caused due to the
tissues, two 18-gauge radiofrequency cannulas were pseudo-articulation as evidenced by short-term relief
placed 2-3 mm both above and below the pseudo- from injections or RFA. For this procedure, a patient
articulation margins. Thermal radiofrequency lesions typically underwent general anesthesia and was placed
were created between the cannulas at 80°C for 90 in a prone position on a Wilson frame. EMG needles
seconds as described in one of the first documented were placed over the tibialis anterior muscle as well as
cases of radiofrequency ablation (RFA) for Bertolotti extensor hallucis longus muscle for continuous moni-
Syndrome (15). Figure 1 depicts fluoroscopic images toring of the corresponding L5 nerve root to ensure
of thermal lesioning cannula placement above and safety during this surgery. Initially, a 22-gauge spinal
below the pseudo joint line. needle was introduced into the L5-S1 pseudo joint.

Fig. 1. Fluoroscopic A/P view of needle placement for Bertolotti pseudo joint anesthetic injection (a), with radiofrequency
cannula placement above and below pseudo joint line (b), with bipolar thermal lesioning (c), as well as bipolar thermal
lesioning in fluoroscopic oblique view (d).

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 Bertolotti’s Syndrome Treatment Algorithm

Fluoroscopy in the A/P and contralateral oblique view, section procedure. Figure 3 depicts endoscopic images
as seen in Fig. 1, were used to confirm the position of with visualization of the pseudo joint as well as post-
the needle. After confirmation, the site of the pseudo resection visualization of retroperitoneal fat.
joint was anesthetized with an equal mix of 0.5% bu-
pivacaine and 1% lidocaine with epinephrine. After
Results
local anesthesia was applied, a 1.5 cm horizontal inci-
sion was made on the skin through the thoracolumbar Case Report – Follow-up
fascia using a #11 blade. After access was obtained, One week post-procedure, the patient reported
the blunt tip dilator was advanced to the level of the complete resolution of her left sided lower back and
pseudo joint with confirmation of the path and place- buttock pain. On examination, the patient demonstrat-
ment using fluoroscopy. Next, the working tube was ed an objective improvement to a 4+/5 strength during
placed over the dilator and its position was checked to left ankle dorsiflexion and left EHL dorsiflexion. Dur-
ensure that it was directly over the pseudo joint line. ing the 3-month postoperative follow up, the patient
The dilator was removed and an endoscope was placed reported a 5/5 strength during left ankle dorsiflexion
using continuous normal saline irrigation during the and left EHL and reported increased ability to ambulate
procedure. Then, bipolar radiofrequency cautery and without a walker for over one mile.
pituitary Rongeur was used to remove soft tissue ma-
terial overlying the pseudo joint. After identifying the Treatment Algorithm
pseudo joint line with the endoscope, a diamond burr We propose an algorithm for the treatment of
was used to dissect the inferior edge of the transverse Bertolotti’s Syndrome in a stepwise approach. The first
process of L5 along the pseudo joint going from lateral step for treatment involves conservative treatment with
to medial. Next, the entirety of the pseudo joint was the use of NSAIDs, PT, and a home-exercise regimen.
resected from the dorsal to the ventral aspect of the If patients find relief with the conservative treatment,
joint using a combination of diamond burr, Kerrison, further interventional procedures are likely not needed.
bipolar cautery and pituitary rongeurs until the soft In the next step for treatment, patients undergo an in-
tissue anterior to the L5-S1 articulation was visualized. jection with local anesthetic and steroid at the pseudo-
Hemostasis was achieved with using bipolar trigger flex articulation. If patient experience temporary pain relief,
cautery and the endoscope, and the working tube was they can proceed to RFA of the pseudo-articulation. If
taken out. Figure 2 depicts fluoroscopic (A/P) views of patients do not experience any temporary pain relief,
the pseudo joint before and after the endoscopic re- other possible causes of the low back pain must be

Fig. 2. Fluoroscopic A/P view of the Bertolotti pseudo joint pre (a) and post (b) endoscopic resection procedure.

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Fig. 3. Endoscopic images with visualization of pseudo joint (row a) and visualization of retroperitoneal fat after resection
(row b).

Discussion
evaluated. After proceeding with a RFA, if patients ex-
perience adequate pain relief, further treatment with Initial Conservative Approaches
conservative measures and PT can be conducted along- As with other cases of low back pain, the initial
side. If patients do not have long-lasting pain relief after conservative treatment of Bertolotti’s syndrome involves
RFA, operative management with endoscopic resection NSAIDs and PT. Two case reports of patients with Ber-
of the pseudo-articulation can be pursued as outlined tolotti’s syndrome showed complete resolution of low
in the procedure section (18). The proposed treatment back pain after stretching, exercise, and chiropractic ma-
algorithm can be seen in Fig. 4. nipulation (19,20). The authors theorized that the LSTV
results in decreased mobility, which changes weight
Level of Evidence – Grading distribution at the involved spinal level. Ultimately these
Overall, with the case report presented, the treat- changes are thought to add stress to the muscles in the
ment algorithm has a Level of Evidence of 4. lumbosacral and sacroiliac regions that support the af-

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 Bertolotti’s Syndrome Treatment Algorithm

Fig. 4. A proposed treatment algorithm for management of Bertolotti’s syndrome.

fected side. Therefore, PT helps by relieving stress to the resection of the pseudo joint. Ten of the 16 postopera-
altered lumbopelvic musculature by muscle strengthen- tive patients demonstrated improvement of back pain,
ing, postural correction and improving range of motion and the pain improvement was similar in the fusion
(19,20). and resection groups. The surgically treated group
had slightly lower Oswestry Disability Index (ODI) pain
Interventional Techniques for Bertolotti’s scores compared to the conservatively treated controls,
Syndrome but the total ODI scores did not differ. Based on the
Injections of local anesthetics or steroids into results, the authors suggested providing operative
the pseudo joint can provide temporary pain relief. treatment to select patients with Bertolotti’s syndrome.
Avimadje et al. performed a retrospective study of 12 Specifically, they recommended resection for patients
patients with low back pain and an expanded L5 trans- that have pain proven to be from the transitional joint,
verse process articulating with the sacrum or ilium. 9 for whom conservative management was unsuccessful,
patients reported a 50% decrease in pain after one if they have no disc degeneration in the area. Postero-
month, and on reevaluation after 6 to 24 months, 7 of lateral fusion may be an option if the transitional disc
the patients were improved or free of symptoms (21). is degenerated but the disc above the pseudo joint is
Furthermore, injection at the pseudo joint provides intact (23).
diagnostic value by guiding the treatment target. In a
study of 7 patients with Bertolotti’s syndrome, patients Local Anesthetic and Joint Resection
were required to experience temporary relief of back In patients with Bertolotti’s syndrome, surgical
pain after steroid and/or anesthetic injection in order resection of the LSTV is thought to improve symptoms
to be included in the treatment group that received by relieving the mechanical stress caused by pseudo-
resection of the LSTV (22). Radiofrequency sensory articulation (24). However, it is of utmost importance
ablation is another treatment approach, which demon- to determine whether the LSTV is the primary pain gen-
strated 100% relief of buttock pain for 16 months in a erator prior to such an intervention. Indeed, an anes-
patient with unilateral LSTV (15). In another case, there thetic block (via low volume lidocaine injection) local-
was complete resolution of a patient’s low back pain ized at the pseudo-articulation is typically performed
after denervation at the area between the transverse for verification prior to a more invasive procedure such
process of the 5th lumbar vertebra and the sacral ala as resection or fusion. While no large-scale prospective
(16). trials have been published to date investigating the
role of resection in treatment of Bertolotti’s syndrome,
Posterolateral Fusion vs. Resection vs. multiple retrospective reviews, and cases with promis-
Conservative Approaches for Bertolotti’s ing findings provide the basis for a treatment guideline
Syndrome and an impetus for more robust future studies.
Santavirta et al (23) surgically treated 16 patients In a retrospective review by Almeida et al (14), 5
with Bertolotti’s syndrome. Eight of the patients had patients with suspected low back pain secondary to Ber-
posterolateral fusion and the other 8 patients had tolotti’s syndrome received anesthetic block injections

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(2 mL lidocaine) at the neo-articulation, which pro- directly at the pseudo joint are followed by patients
vided significant temporary relief in all patients. Each experiencing pain relief. Together, the case study in this
patient subsequently underwent a radioscopy-guided review and previously published studies can be used to
radiofrequency denervation at the neo-articulation produce a holistic treatment guideline to relieve pain
which allowed 2 patients to experience significant pain caused by Bertolotti’s syndrome.
relief. The 2 patients who experienced relief from both A treatment guideline should specify the volume,
the anesthetic injection and the RFA procedure then injectate, technique and the magnitude and timing of
underwent surgical resection of the transverse mega- pain relief necessary to move forward in the treatment.
apophysis and reported experiencing complete pain A treatment guideline should also address the possibil-
relief at the one-year follow up (26). ity of concurrent or recent steroid injections which may
In a retrospective review, Mikula et al (27) com- obscure the clear localization of symptom etiology.
pared 27 patients who underwent surgical resection Steroid injections can diffuse its effects across multiple
(n = 18) versus fusion (n = 9). 78% of patients who potential mechanical sources of pain and could lead to
underwent surgical fusion and 28% of patients in the false positive relief ascribed to the pseudo-articulation.
resection group experienced long-term pain relief. Of Therefore, RFA acts as a confirmatory step in ensuring
note, 19 of the 27 patients had received a preopera- that the pain is derived from the pseudo-articulation
tive anesthetic injection at the Bertolotti joint which resulting from Bertolotti’s syndrome.
resulted in 16 patients experiencing subsequent pain Resection of the pseudo-articulation via endo-
relief. However, specifics regarding the volume, formu- scopic approach provides for a minimally invasive,
lation, technique and patient responses with regards to theoretically permanent solution for patients with
the anesthetic injection are not described. The baseline pseudo-articulation derived chronic low back pain.
characteristic “back pain at presentation” was also Improvements to this technique have been reported
notably heterogenous between study groups and was via recent cases and reviews, described below, showing
only present in 12 out of 18 patients in the resection promising results.
group versus 9 out 9 patients in the fusion group (27). An early study examining this approach is a ret-
The largest relevant study to date is a retrospective rospective review by Li et al (22), which observed 7
review by Ju et al (24) which identified 256 patients patients who underwent minimally invasive tubular
diagnosed with Bertolotti’s syndrome, 87 of whom resection via paramedian approach after receiving an
underwent resection. Of this group, 26 patients were anesthetic block injection for confirmation. Five of 7
excluded due to diagnosis of another concurrent spinal patients experienced pain relief, with one patient hav-
disease. Of the remaining 61 patients, all had received ing recurrence of pain at the one-year follow-up and
an anesthetic injection (1 mL 2% lidocaine) into the another patient experiencing pain recurrence 4 years
pseudo-articulation and had experienced pain relief. post-procedure. There is notably considerable hetero-
Select patients also had an anesthetic injected at the L4 geneity between patients in this study.
nerve root if pain relief from the pseudo-articulation A 2022 retrospective review by Afana et al (27)
injection was deemed less pronounced. If patients expe- followed 8 patients with isolated Bertolotti’s syndrome
rienced greater pain relief from the L4 nerve root block, who underwent a resection procedure the authors de-
which was the case for 22 patients, decompression of scribed as a new modified mini-open tubular microsur-
the L4 nerve root via soft tissue curettage was also per- gical transverse processectomy. Pain relief shortly after
formed during the resection procedure. The mean visual surgery was reported by all 8 patients with an average
analog scale (VAS) score prior to resection was 7.54 and VAS score reduction from 6.6 to 1.5. However, long-
the mean post-procedure VAS score was 2.86, with 87% term follow up results are not presented in the study.
of patients demonstrating significantly improved pain A case study published by Chang et al (28) de-
measures at a mean follow up period of 6.5 months (24). scribes a Bertolotti’s syndrome patient who underwent
Further research on the treatment of Bertolotti’s a minimally invasive microscopic tubular articular resec-
syndrome is sparse, however, in the other studies pub- tion with intraoperative 3-dimensional C-arm image
lished, the consensus is that confirming the pseudo- guidance. The patient experienced full symptom relief
articulation as the primary pain generator prior to the post-procedure and at the 2-year follow up.
resection procedure is of utmost importance. These A case study published in 2023 by Stein et al (19)
studies detail how small volume anesthetic injections describes a bilateral Bertolotti’s syndrome patient who

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 Bertolotti’s Syndrome Treatment Algorithm

previously received anesthetic injections, RFA and spi- lumbar branch of the iliolumbar artery is important to
nal cord stimulator placement but experienced limited note as it traverses the space involved in the procedure.
relief. The patient then underwent endoscopic resec-
tion of the entire length of the pseudo-articulation.
Conclusion
The patient experienced partial pain post-procedure Patients experiencing chronic low back pain with
and at subsequent follow-up visits, with no further in- no clear surgical cause generally undergo conservative
tervention required. The authors noted that they were treatment involving medications and dynamic modali-
continuing to improve their technique and have since ties, such as PT and home exercise. With the significant
reported further cases of patients treated via their re- shift away from opioid management and the justified
fined technique who have experienced complete pain aversion to initiating opioids as a long-term chronic low
relief. They discuss the utility of this minimally invasive back pain management option in non-cancer patients,
procedure in patients exhausting nonsurgical measures, success with interventional strategies is of increasing
including anesthetic injections and RFA, as well as the importance for this patient population. During the
importance of isolating the pseudo-articulation as the process of diagnosis, physical exam special tests and
source of pain. The treatment algorithm proposed in imaging can help determine the root cause of the pain.
the current review takes this concept a step further, Physicians should keep Bertolotti’s syndrome on their
noting relief with RFA as one of the inclusion criteria differential and actively seek to identify the presence
for successful resection. of LSTV in chronic low back pain patients. However,
the presence of this anatomical variant alone is insuf-
Pitfalls of Endoscopic Resection ficient to diagnose this condition or pursue surgical
As with any surgical procedure, various pitfalls and treatment. It is of utmost importance to diagnose Ber-
complications may exist. The review by Afana et al (27) tolotti’s syndrome as the true cause of low back pain
reports two postoperative events occurring after en- before considering surgical intervention. The stepwise
doscopic resection of a pseudo-articulation. One post- approach outlined here proposes a rule-in approach
operative complication included wound dehiscence utilizing commonly employed interventions in order to
due to a small transverse surgical approach. Another assuredly identify a patient for surgical resolution via
postoperative complication experienced by a patient minimally invasive, advanced endoscopic techniques.
was radicular postoperative pain described as sharp, We have found this surgical approach to be signifi-
burning, and constant. Additionally, the patient re- cantly effective when diagnostically qualifying under
ported diminished sensation in the L5 dermatome and the proposed algorithm.
the study concluded that this was due to intraopera-
tive nerve injury (27). In our surgical cases, we mitigate Author Contributions
the risk of an L5 nerve root injury by neuromonitoring AC, RK, ZD, SK were all involved in the draft of the
during endoscopic surgery for pseudo joint resection. initial manuscript, the conceptualization of the paper
During the surgical procedure, continuous EMG moni- outline and idea, and the critical revision of the manu-
toring during the surgical procedure was conducted to script. SK provided all the images in the paper.
assess the function of the tibialis anterior and extensor
hallucis longus muscles to ensure that no nerve injury Ethics Statement
occurs. Another study by Mikula et al (26) compares the 1) This material is the authors’ own original work,
use of resection to fusion for the treatment of Bertolot- which has not been previously published elsewhere; 2)
ti’s syndrome and concluded that the fusion group had This paper is not currently being considered for pub-
an overall higher rate of long-term pain improvement lication elsewhere; 3) This paper reflects the authors’
which further points towards a potential pitfall of en- own research and analysis in a truthful and complete
doscopic resection as a treatment option. Finally, when manner.
conducting endoscopic resection, the presence of the

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