Surgical Experience in Symptomatic Bertolotti Syndrome: Clinical Follow-up of Three Patients Refractory to Conservative Management

Introduction: Bertolotti syndrome (BS) is an underdiagnosed cause of chronic low back pain associated with lumbosacral transitional vertebrae (LTV). Although conservative management is usually the first-line approach, a subset of patients remains refractory and may benefit from surgical intervention. Reports on surgical outcomes remain scarce, and evidence is predominantly limited to isolated case reports. We present a case series of three patients with symptomatic BS who did not respond to conservative management and underwent surgical treatment. Case Report: Three patients (two females, one male; age range 21-32 years) presented with chronic low back pain and radicular symptoms. All had imaging findings consistent with Castellvi Type II or Type III LTV. Prior management included physical therapy, non-steroidal anti-inflammatory drugs, image-guided injections, and activity modification, with inadequate symptom relief. Surgical management consisted of resection of the anomalous transverse process articulation in all cases. Clinical follow-up evaluated pain Visual Analog Scale, function, and return to activity. All patients reported significant improvement in pain and functional outcomes, with sustained benefit at final follow-up (6-24 months). No neurological complications or reoperations occurred. Conclusion: Surgical resection may be considered in carefully selected patients with symptomatic BS who fail conservative management. This case series reinforces the importance of appropriate diagnosis, patient selection, and surgical expertise in addressing this uncommon but impactful cause of persistent low back pain. Further studies with larger cohorts are needed to better define indications and outcomes.