Santavirta1 , K. Tallroth1, P. Ylinen1 and H.

Suoranta1

(1) Orthopedic Hospital of Invalid Foundation, Tenholantie 10, SF-00280 Helsinki, Finland
Summary We surgically treated 16 patients with Bertolotti's syndrome (chronic, persistent low back pain and
radiographically diagnosed transitional lumbar vertebra). Eight had posterolateral fusion and another eight
resection of the transitional articulation. Thirteen patients had in addition to the chronic low back pain,
suffered from repeated episodes or chronic sciatica. In six cases with resection treatment, local injections were
administered at the transitional articulation before deciding for resection of the transitional joint; each patient
reported transient relief of pain, while this preoperative test did not correlate with successful outcome of
treatment. Six patients had to be treated with second operations. Ten of the 16 operatively treated patients
showed improvement of the low back pain, and this result was similar in the group treated with fusion and in
that treated with resection. Seven had no low back pain at follow-up, and the improvement according to the
Oswestry pain scale was similar in the two groups, and statistically significant. Eleven patients still had
persisting episodes of sciatica (versus 13 preoperatively). The average disability according to the Oswestry
total disability scale was 30%, corresponding with moderate outcome, and both operatively treated groups did
equally well. At follow-up the first disc above the fused segments was found to be degenerated in seven out of
eight cases, and in the group treated with resection the first disc above the transitional vertebra was
degenerated in five cases. As conservatively treated controls, we had 16 comparable, but not randomly chosen
patients whose age and type and duration of pain prior to the first clinical examination, and the length of
follow-up were similar to those in the operatively treated group. The operatively treated patients had slightly
better Oswestry pain score (mean 1.9 versus 2.5; statistically significant), while in regard to the total Oswestry
disability scale, the results did not differ. We suggest operative treatment only to very selected patients with
Bertolotti's syndrome. Patients with no disc deneration and whose chronic pain is truly associated with the
transitional joint may be treated with resection of the transverse process. Patients with similar pain and with
degeneration of the disc below but not above the transitional vertebra may have alleviation of pain and
disability after posterolateral fusion.

Bertolotti's syndrome
From Wikipedia, the free encyclopedia

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Bertolotti's syndrome is a form of lumbago in the lumbosacral transitional vertebrae. The syndrome is not
usually treated, as not much is known yet about these spinal segments. It is named for Mario Bertolotti, an
Italian physician [1]

Bertolotti's syndrome is defined by a transitional 5th lumbar vertebra resulting in partial sacralization. Of
importance is that this syndrome will result in a pain generating 4th lumbar disc resulting in a "sciatic" type of
a pain correlating to the 5th lumbar nerve root. Usually the transitional vertebra will have a "spatulated"
transverse process on one side resulting in articulation or partial articulation with the sacrum or at time the
illium and in some cases with both. This results in limited / altered motion at the lumbo-sacral articulation.
This loss of motion will then be compensated for at segments superior to the transitional vertebra resulting in
accelerated degeneration and strain through the L4 disc level which can become symptomatic and inflame the
adjacent L5 nerve root resulting in "sciatic" or radicular pain patterns. This is a congenital condition and is
usually not symptomatic until one's later twenties or early thirties, yet there are cases found where Bertolotti's
is symptomatic at a much earlier age.MRI help to detect this syndrome.
[edit] References
1. ^ Dorlands Medical Dictionary, accessed September 4 2007

Bertolotti's syndrome: a case report.

Mitra R, Carlisle M.

Interventional Spine Center, Division of Physical Medicine & Rehabilitation, Stanford University School of
Medicine, 300 Pasteur Dr., Edwards Bldg., Palo Alto, California 94305, USA. rrmitra@stanford.edu

STUDY DESIGN: A case report and literature review is presented. OBJECTIVE: To review relevant data for
the management of Bertolotti's syndrome and to determine whether the transverse process-ilium articulation
may be a pain generator. BACKGROUND: Bertolotti's syndrome is associated with axial low back pain
secondary to arthritic changes; the pain generator in the disorder is unclear. METHODS: We present a case
report of symptomatic Bertolotti's syndrome managed with intra-articular steroid injections. RESULTS: A
patient with Bertolotti's syndrome had significant relief of axial pain after steroid injection of the ilium-
transverse process articulation. CONCLUSIONS: Steroid therapy may be a non-surgical alternative for the
treatment of symptomatic Bertolotti's syndrome.

PMID: 19037900 [PubMed - indexed for MEDLINE]

Chir Narzadow Ruchu Ortop Pol. 1998;63(5):487-94.

[Results of treatment of unilateral sacralization of

transverse process of the fifth lumbar vertebrae]
[Article in Polish]

Malawski S, Milecki M.

Klinika Ortopedii, Centrum Medycznego Kształcenia Podyplomowego, Otwocku.

Pathology and symptomatology of unilateral sacralization of transverse process of the fifth lumbar vertebrae
articulating with sacral and iliac bone is presented. Five patients (4 females, 1 male) aged 27-42 are reported.
Symptoms included spinal pain, radicular pain, L4/L5 disc prolapse, and lumbar scoliosis. Patients were
operated on: resection of the transverse process has been done in all cases, discectomy in 2 cases. Good
results were found at the mean follow-up of 3 years. Author's experience supports idea of early surgical
intervention in described condition.

PMID: 10093395 [PubMed - indexed for MEDLINE]

Partial Lumbosacral Transitional Vertebra Resection for
Contralateral Facetogenic Pain
Brault, Jeffrey S. DO; Smith, Jay MD; Currier, Bradford L. MD

Abstract

Study Design. Case report of surgically treated mechanical low back pain from the facet joint contralateral to
a unilateral anomalous lumbosacral articulation (Bertolotti's syndrome).

Objectives. To describe the clinical presentation, diagnostic evaluation, and management of facet-related low
back pain in a 17-year-old cheerleader and its successful surgical treatment with resection of a contralateral
anomalous articulation.

Summary of Background Data. Lumbosacral transitional vertebrae are common in the general population.
Bertolotti's syndrome is mechanical low back pain associated with these transitional segments. Little is known
about the pathophysiology and mechanics of these vertebral segments and their propensity to be pain
generators. Treatment of this syndrome is controversial, and surgical intervention has been infrequently
reported.

Method. A retrospective chart analysis and radiographic review were performed.

Results. Repeated fluoroscopically guided injections implicated a symptomatic L6-S1 facet joint contralateral
to an anomalous lumbosacral articulation. Eventually, a successful surgical outcome was achieved with
resection of the anomalous articulation.

Conclusion. Clinicians should consider the possibility that mechanical low back pain may occur from a facet
contralateral to a unilateral anomalous lumbosacral articulation, even in a young patient. Although reports of
surgical treatment of Bertolotti's syndrome are infrequent, resection of the anomalous articulation provided
excellent results in this patient, presumably because of reduced stresses on the symptomatic facet.

© 2001 Lippincott Williams & Wilkins, Inc.

Anomalous Lumbosacral Articulations and Low-Back Pain:
Evaluation and Treatment
JÖNSSON, BO; STRÖMQVIST, BJÖRN; EGUND, NIELS

Abstract

Eleven patients ranging from 13 to 76 years in age with low-back pain and asymmetric sacro-transverse Joints
were studied. Preoperatively, sclntlmetry was performed in eight of the patients, in all cases with normal
results. Ten of the 11 patients had their sacrotransverse joint anesthesized in fluoroscopy. Nine of these
experienced pain reduction or alleviation. Resection of the transverse process was performed In all cases. At
follow-up, at 6 to 42 months postoperatively, seven patients reported total alleviation of pain, and two,
significant Improvement. Two patients had unchanged symptoms; one patient was 76 years of age, had
associated degenerative changes of the spine, and had no effect of local anesthetics in his joint, and the other
was a 13-year-old male competitive swimmer. The authors conclude that, in patients with anomalous
unilateral lumbosacral articulations and lowback pain, in whom local anesthesia into the joint gives pain
alleviation, resection of the transverse process may be a worthwhile procedure.

(C) Lippincott-Raven Publishers.

Bertolotti's Syndrome Revisited: Transitional Vertebrae of the

Lumbar Spine
ELSTER, ALLEN D. MD

Abstract

Bertolotti's syndrome refers to the association of back pain with lumbosacral transitional vertebrae. Such
vertebrae were observed in 140 of 2,000 adults with back pain over a 4-year period of study. Each patient had
radiographic evaluation of the lumbar spine by plain films as well as a sectional imaging modality (magnetic
resonance [MR] or computed tomography [CT]). The overall incidence of structural pathology (eg, spinal
stenosis and disc protrusion) detected by CT or MR was not apparently higher in patients with transitional
vertebrae, but the distribution of these lesions was significantly different. Disc bulge or herniation, when it
occurred, was nearly nine times more common at the interspace immediately above the transitional vertebra
than at any other level. Spinal stenosis and nerve root canal stenosis were more common at or near the
interspace above the transitional vertebra than at any other level. Degenerative change at the articulation
between the transverse process of the transitional vertebra and the pelvis was an uncommon occurrence; when
seen there was no significant correlation with the reported side of pain. It is postulated that hypermobility and
altered stresses become concentrated in the spine at the level immediately above a lumbar transitional
vertebra. Accelerated disc and facet joint degeneration at this level may then result.

(C) Lippincott-Raven Publishers.

[Sacralization of the 5th lumbar vertebra and
backache: what's the possible relationship?]
[Article in Italian]

Bonaiuti D, Faccenda I, Flores A.

Unità Operativa Medicina Fisica e Riabilitazione, Ospedale Bassini, Cinisello Balsamo, Milano.

Transitional vertebrae is a controversial problem in occupational health and in forensic medicine, in view of
its prognostic value and especially because of the implications of law 626/94 which requires a worker
assessment for manual handling tasks. The purpose of this review was to assess the relationship between
transitional vertebrae and low back pain. Data sources comprised computer-aided search of published studies
on Medline and Embase. There were seven studies evaluating the prevalence of the abnormality, the
relationship with low back pain and the different aspects of spinal degeneration. Only two studies indicated a
positive relationship with low back pain. Four studies reported absence of any prognostic value of this
vertebral abnormality. One study examined a twenty year old population: even if it did not show a relationship
with a higher incidence of disc degeneration with MRI, we did not include it in our review because of the
young age of the samples. It is concluded that present knowledge does not reveal any correlation between
transitional vertebrae and low back pain. Further studies are needed to support any conclusion about this
important issue.

Radiographic appearances in lumbar disc prolapse

JG MacLean, JK Tucker, and JB Latham

Norfolk and Norwich Hospital, England.

The pre-operative lumbar spine radiographs of 200 consecutive patients who had undergone discectomy for
prolapsed intervertebral disc were reviewed. Prolapse was recognized as bulging or sequestration of the disc
with consequent root compromise. Measurement of the lumbar level of the interiliac line was shown to
correlate with the level of disc prolapse and the incidence of transitional vertebrae at the lumbosacral junction
was significantly higher than normal. A pathological value for the lumbosacral angle could not be identified.
Lumbosacral transitional vertebral articulation: evaluation by
planar and SPECT bone scintigraphy
PEKINDIL, G; SARIKAYA, A; PEKINDIL, Y; GÜLTEKIN, A; KOKINO, S

Abstract

It has been suggested that low back pain (LBP) may arise from lumbosacral transitional vertebral articulation
(LSTVA) itself. It is known that bone scintigraphy is a valuable tool for the recognition of pain arising from
bone and articular diseases. Therefore we aimed to show planar and SPECT bone scintigraphic findings of
LSTVA and compare them with the LBP and X-ray findings. Twenty-eight patients (aged 20-63 years) in
whom LSTVA had been identified radiographically were evaluated with planar bone scintigraphy, utilizing
99m
Tc methylene diphosphonate; and single photon emission computed tomography (SPECT) bone
scintigraphy. Eighteen patients had LBP whereas 10 had not. There were 25 type IIA, one type IIB and two
type IIIA LSTV articulation. On planar images, normal or non-focal minimally increased uptake
superimposed on the upper sacroiliac joint was seen in patients without degenerative changes regardless of
LBP whereas SPECT showed non-focal mild increased uptake on the area medial to the upper sacroiliac joint.
Planar scans showed normal to non-focal mild, and mild-to-moderately increased uptake whereas SPECT
demonstrated focal mild-to-moderately and markedly increased uptake in patients with degenerative changes
without LBP and with LBP, respectively. The X-ray results showed an association of LBP degenerative
changes, and the SPECT results showed a focal, markedly increased, uptake. We conclude that this focal,
markedly increased, uptake may show the metabolically active degenerative changes of LSTV articulation
and may help to reveal the pain arising from LSTVA. Therefore we propose that bone scintigraphy may be
considered for the evaluation of patients with LBP thought to arise from LSTV articulation

THE TRANSITIONAL VERTEBRA OF THE LUMBOSACRAL

SPINE: ITS RADIOLOGICAL CLASSIFICATION,
INCIDENCE, PREVALENCE, AND CLINICAL
SIGNIFICANCE
P. G. TINI, C. WIESER and W. M. ZINN

Medical Department, Bad Ragaz, and Department of Radiology, Cantonal Hospital Chur, Switzerland

This report presents interim results from a series of studies of the lumbosacral region of the spine. A new
classification of the lumbosacral transitional vertebra (LSTV) is proposed. An LSTV was found with similar
frequency in patients and in population samples. The radiological findings were related to the presence of
symptoms and to evidence of urological problems. Whilst Brocher (1973), Rubin (1971), and others have
considered an LSTV to be of importance because it should lead to unfavourable weight bearing in the lower
spine, the present extensive material shows that there is no relation between an LSTV and low backache.
There may be a genetic factor involved in the various types of LSTV.
Bertolotti’s syndrome
A CAUSE OF BACK PAIN IN YOUNG PEOPLE

J. F. Quinlan, MCh, AF FRCSI, Orthopaedic Specialist Registrar1; D. Duke, MRCPI, Fellow of the
Faculty of Radiologists, RCSI, Radiology Fellow1; and S. Eustace, MRCPI, Fellow of the Faculty of
Radiologists, RCSI, Consultant Radiologist1
1
Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Republic of Ireland.

Correspondence should be sent to Mr J. F. Quinlan at 35 Rockford Manor, Stradbrook, Blackrock, County Dublin, Republic of
Ireland; e-mail: jfquinlan@hotmail.com

Bertolotti’s syndrome is characterised by anomalous enlargement of the transverse process(es) of the most
caudal lumbar vertebra which may articulate or fuse with the sacrum or ilium and cause isolated L4/5 disc
disease.

We analysed the elective MR scans of the lumbosacral spine of 769 consecutive patients with low back pain
taken between July 2003 and November 2004. Of these 568 showed disc degeneration. Bertolotti’s syndrome
was present in 35 patients with a mean age of 32.7 years (15 to 60). This was a younger age than that of
patients with multiple disc degeneration, single-level disease and isolated disc degeneration at the L4/5 level
(p 0.05). The overall incidence of Bertolotti’s syndrome in our study was 4.6% (35 of 769). It was present in
11.4% (20 patients) of the under-30 age group.

Our findings suggest that Bertolotti’s syndrome must form part of a list of differential diagnoses in the
investigation of low back pain in young people.
Bertolotti's syndrome is characterized by the presence of a large transverse apophysis in one or both
sides of a lumbar transitional vertebra that articulates with the sacrum or with the iliac bone.
"Transitional vertebra" is anatomically defined as a vertebra that shares similar features with both upper
and lower vertebral segments. In Bertolotti's syndrome, the posterior arch or transverse apophysis of
the vertebra usually has both lumbar and sacral characteristics, occurring most commonly at L5, but can
also occur at L6.

The majority of patients are asymptomatic1,2 and despite its first description dates from 19173, little is
yet known about the biomechanical effects of such abnormal vertebra and its relation to low back pain.
It has been assumed that progressive modifications in the biomechanics of the spine can occur,
generating abnormal weight overload in the articular facets and adjacent intervertebral discs resulting in
degeneration4. Although Bertolotti's syndrome is a congenital abnormality, it is often clinically recognized
only after the second decade of life5. Nevertheless, there is evidence that a typical transverse mega-
apophysis may be the cause of low back pain in the region of the neo-articulation6.

Due to the multifactorial etiology of low back pain in patients with Bertolotti's syndrome, there are
several therapeutic options, whereas the most appropriate treatment for each case, as well as the
specific role of surgical resection of the transverse mega-apophysis in the therapeutic armamentarium,
still remain a matter of controversy.

METHOD

A literature review of the Bertolotti's syndrome was carried out through the MedlineTM database. The
following keywords were used: Bertolotti's syndrome, lumbosacral transitional vertebra and lumbar back
pain.

Thereafter, we analyzed five patients diagnosed with Bertolotti's syndrome and taking into account the
clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm
in order to guide the surgeon through the decision making process involved in the evaluation of back
pain and its possible relationship with a transitional vertebra.

RESULTS

A total of 31 articles were retrieved from the MedlineTM database. Of them, we selected only studies
written in English regarding diagnosis and treatment of Bertolotti's syndrome, which resulted in 18
articles revised1,2,6-21.

Among the patients with low back pain and transverse mega-apophysis followed in our service from
2000 to 2006, five of them did not improve with clinical treatment, including non-steroidal anti-
inflammatory drugs (NSAIDs), physiotherapy and physical exercises. These patients were thus
submitted to a therapeutic test with anesthetic block at the contact of the mega-apophysis with the
sacrum, which allowed temporary pain relief in all of them. Thereafter, they underwent a radiofrequency
neurolisys, whereby three had only a partial control of the pain and two had significant improvement.
The latter two patients had the mega-apophysis surgically resected and became asymptomatic after the
procedure and during the one year-follow up. Their cases are reported in order to illustrate the possible
pathways proposed in the diagnostic-therapeutic algorithm of Bertolotti's syndrome as follows.
Case 1

A 39 year-old woman was admitted to the hospital complaining of a 5-year severe low back pain. The
pain was described as being constant, dull, and localized on the paramedian right side. It worsened
when the patient performed extension or lateralization of her back to the same side of the mega-
apophysis, stood for more than 30 minutes or after physical exertion. Despite the use of NSAIDs and
opioids, the pain remained unchanged. Imaging exams showed a transverse mega-apophysis on the
right side at L5 that corresponded exactly to the point of pain and tenderness. Magnetic resonance
imaging (MRI) depicted no major disc degeneration or other vertebral abnormalities. An anesthetic
lumbar block test was performed at the neo-articulation point, which ensured total analgesia for 2 hours.
Only a small volume (2 ml) of lidocaine was injected into the site, avoiding any spreading of the
solution. After 2 hours of relief, the pain returned and remained exclusively in the region related to the
right transverse mega-apophysis. It was then decided to perform a surgical resection of the transverse
mega-apophysis. There were no complications, and the patient was discharged from the hospital two
days after the procedure with 90% improvement in low back pain; at the six month-follow up, she had
no low back pain at all.

Case 2

Female, 32 years of age, presented a history of unilateral right-sided low back pain lasting for the
previous 4 years. The pain increased when climbing stairs and sitting, and was relieved when lying
down. There were no complains of paresthesias or hypoesthesias and no major radiation. Neurological
examination was normal. The imaging exams included lumbosacral radiographs, a computed
tomography (CT)-scan and a MRI, which revealed bilateral transverse mega-apophysis of L5, articulating
with the sacrum. Despite the bilateral image findings the patient showed only major symptoms on her
right side (Figs 1 and 2). She was clinically treated without success for three years at which point she
underwent an anesthetic block of the lumbosacral articulation on the symptomatic side, resulting in
complete remission of pain for two hours. Following this outcome, a radioscopy-guided radiofrequency
denervation of the abnormal articulation was performed, resulting in 70% decrease in pain for four
months. It was then decided to resect the symptomatic transverse mega-apophysis, which led to total
resolution of the pain. After this procedure, the patient remained asymptomatic.
DISCUSSION

In 1917, Mario Bertolotti, an Italian surgeon, was the first author to put forward a possible relationship
between low back pain and congenital anatomical abnormalities in the last lumbar vertebra, described as
"sacral assimilation of the lumbar vertebrae"3. Since then, the term Bertolotti's syndrome has been used
to define the presence of a transverse mega-apophysis in a lumbar vertebra with transitional
characteristics associated with low back pain22.

Four to seven percent of patients with low back pain present transitional vertebrae1,21,23,24. Castellvi et
al.23 analyzed 200 patients with myelographic findings of lumbar disc herniation and discovered
vertebrae with transitional characteristics in 60 cases. The authors proposed a classification of four
groups based on the morphological characteristics of such abnormal vertebra.

In a recent study including patients with degenerative disc disease (DDD), a higher incidence of
transitional vertebra was found in the youngest group (present in up to 10% of the patients under 30
years of age with DDD) in comparison to the general population5.

There is a paucity of studies on biomechanical effects associated with the occurrence of transitional
vertebrae. It has been hypothesized that motion between the transitional vertebra and the sacrum is
reduced and asymmetrical. This asymmetry can result in early degenerative changes within the
"neoarticulation" or in the normal contralateral facet joint2, giving rise to facet pain4.

In addition to the reduction in motion, it is assumed that biomechanical stress transferred to the upper
mobile vertebral segment can accelerate the disc degeneration22,23,25. Elster et al.2 reported higher
incidences of disc herniations linked to degenerative disc disease above the transitional segment.
Conversely, the disc between the transitional vertebra and the sacrum is usually fibrotic and contains
little nuclear material. Tini et al.21 have demonstrated that very few disc herniations occur at this level.
In fact, recent series have confirmed that lumbar discs immediately above the transitional vertebra have
a higher incidence of degeneration and those between the transitional vertebrae and the sacrum are
significantly less likely to degenerate25.

Diagnostic imaging of low back pain usually includes X-rays, CT-scan and MRI. For the evaluation of
transitional vertebrae, X-ray films in anteroposterior, lateral and oblique incidences are of special
importance. Computed tomography may be helpful in the identification of associated stenosis,
osteophytes and areas of sclerosis surrounding the contact point of the mega-apophysis with the lateral
iliac or sacral bone. Magnetic resonance imaging is the standard method for studying DDD and possible
associated disc herniations that have been demonstrated to occur more frequently in Bertolotti's
syndrome.

Bone scintigraphy may reveal an inflammatory process within the articular facets, specifically at the level
of the mega-apophysis8, although some authors believe that arthritis is not the direct cause of pain in all
patients, as many subjects with Bertolotti's syndrome are young and have "cold" bone scans22. Single-
photon emission computed tomography may be useful in the identification of possible candidates for
local anesthetic infiltration and future radiofrequency blocks26.

The initial treatment of Bertolotti's syndrome, as with other causes of low back pain, is clinical, including
a combination of NSAIDs and rehabilitative physical therapy. The performance of anesthetic blocks at
the articulation level between the mega-apophysis and the sacrum or iliac bone may be effective in
temporarily relieving pain in some cases. This was useful in the identification of the origin of the pain,
although no previous study confirmed a prognostic value of this procedure. These blocks should be
performed with a minimal amount of anesthetic delivered precisely to the point of interest.

Figure 3

In our experience, conventional radiofrequency neurolysis proved to be a safe, non-invasive procedure

for those cases that had improved with anesthetic blocks, providing significant pain relief and aiding
future physical rehabilitation programs6. Nevertheless, the relief may be temporary, whereby major
studies concerning about the efficacy of radiofrequency denervation are required. Surgical resection of
the transverse mega-apophysis at the symptomatic site may be indicated in those refractory cases
associated with degenerated facets27. Our patients experienced a complete remission of the symptoms
following surgery and remained asymptomatic until the end of the follow up period.

Degenerative disc disease is managed according to the indications and particularities of each case. The
therapeutic armamentarium for DDD includes surgical microdiscectomy, nucleolysis and arthrodesis5.
The latter involves pedicular screws, transforaminal lumbar interbody fusion (TLIF), posterior lumbar
interbody fusion (PLIF) and, more recently, anterior lumbar interbody fusion (ALIF). (See proposed
diagnostic-therapeutic algorithm.)

Despite the existence of a significant number of asymptomatic patients, transitional vertebrae associated
with abnormal transverse mega-apophysis may be the cause of low back pain in others. This symptom
may be related to progressive modifications in the biomechanics of the spine, generating abnormal
weight overload in articular facets and adjacent intervertebral disc degeneration. Abnormal lateral
contact of transverse mega-apophysis with sacrum or iliac bone can also be the source of local pain.
Perhaps due to its rare occurrence, the pathophysiology of Bertolotti's syndrome is still obscure and
there is no consensus about the most appropriate therapy for each patient. Due to its multifactorial
causes and the common findings of low back pain in the general population, it becomes essential to
differentiate between low back pain due to transverse mega-apophysis contact with the sacrum from
other sources of back pain in patients with Bertolotti's syndrome. Based on our experience we propose
an algorithm in order to identify a subgroup of patients with Bertolotti's syndrome in which the
transverse mega-apophysis could be assigned as the cause of low back pain; consequently, these
patients might benefit from surgical resection.

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Received 25 August 2008, received in final form 5 December 2008. Accepted 18 February 2009.

Dra. Marília Grando Sória - Instituto de Neurologia de Curitiba - Rua Jeremias Maciel Perretto 300 -
81210-310 Curitiba PR - Brasil. E-mail: mgsoria@gmail.com.