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Transitional Vertebra – Definition, Symptoms & Treatment

A transitional vertebra is an anatomically altered vertebra located at the junction of two spinal segments. It can cause back pain and postural issues.

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Things worth knowing about "Transitional Vertebra"

A transitional vertebra is an anatomically altered vertebra located at the junction of two spinal segments. It can cause back pain and postural issues.

What Is a Transitional Vertebra?

A transitional vertebra is a vertebra located at the boundary between two spinal segments that displays anatomical characteristics of both neighboring segments. This variation occurs when a vertebra does not fully differentiate into one of the two adjacent spinal regions during embryonic development. The most common site is the junction between the lumbar spine and the sacrum, a condition known as a lumbosacral transitional vertebra (LSTV), often referred to as Bertolotti syndrome. Less frequently, transitional vertebrae occur at the cervicothoracic or thoracolumbar junctions.

Causes and Development

Transitional vertebrae arise from a disturbance in embryonic segmentation of the spine. Under normal conditions, the human spine consists of 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, 5 sacral vertebrae, and 4–5 coccygeal vertebrae. In a transitional vertebra, either sacralization occurs (the fifth lumbar vertebra fuses partially or completely with the sacrum) or lumbarization takes place (the first sacral vertebra takes on the morphology of a lumbar vertebra). The condition is congenital and genetically determined.

Classification According to Castellvi

Lumbosacral transitional vertebrae are commonly classified using the Castellvi classification, which identifies four types:

Type I: Dysplastic enlarged transverse process (unilateral or bilateral), without bony union
Type II: Incomplete bony fusion (pseudarthrosis) between the transverse process and the sacrum
Type III: Complete bony fusion of the transverse process with the sacrum
Type IV: Combined presentation with Type II on one side and Type III on the other

Symptoms

Many individuals with a transitional vertebra are asymptomatic and remain unaware of the anatomical variation. However, some patients experience notable symptoms:

Chronic or recurrent low back pain in the lumbar and sacral region
Pain radiating into the buttocks or legs (pseudoradicular symptoms)
Asymmetric loading of the spine, potentially leading to poor posture or scoliosis
Accelerated degeneration of adjacent intervertebral discs
Reduced mobility in the lower back

Diagnosis

The diagnosis of a transitional vertebra is typically established through imaging studies:

X-ray: Provides an initial assessment of vertebral morphology and Castellvi classification
Computed Tomography (CT): Offers detailed visualization of bony structures and potential fusions
Magnetic Resonance Imaging (MRI): Assesses intervertebral discs, nerve roots, and soft tissues
Diagnostic infiltration: Targeted injection of a local anesthetic to confirm the pain source

Accurate vertebral counting is essential, as this anatomical variant can complicate proper numbering and may increase the risk of wrong-level surgery.

Treatment

Treatment is only necessary when the transitional vertebra causes symptoms. The therapeutic approach depends on symptom severity and includes:

Conservative Treatment

Physiotherapy: Strengthening of core muscles, improving posture and spinal mobility
Pain management: Use of analgesics or anti-inflammatory medications (e.g., NSAIDs)
Injection therapy: Corticosteroid or local anesthetic infiltrations for targeted pain relief
Heat and cold therapy and other physical modalities

Surgical Treatment

In cases of persistent, treatment-resistant pain, surgical intervention may be considered. Options include resection of the anomalous transverse process or, in rare cases, spinal stabilization (fusion). Surgery is only recommended after conservative measures have been exhausted and with a clear clinical indication.

References

Castellvi AE, Goldstein LA, Chan DP. Lumbosacral transitional vertebrae and their relationship with lumbar extradural defects. Spine. 1984;9(5):493–495.
Konin GP, Walz DM. Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. American Journal of Neuroradiology (AJNR). 2010;31(10):1778–1786.
Weckbach S, et al. Prevalence and clinical significance of lumbosacral transitional vertebrae. Der Radiologe. 2014;54(7):682–690.

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