Bertolotti syndrome presenting as pudendal neuralgia: A case report

Introduction: Bertolotti syndrome involves clinical symptoms resulting from a lumbosacral transitional vertebra (LSTV). This condition can alter pelvic biomechanics and may create a rub site between the transverse process (TP) and the sacral ala and/or ilium. Anatomically, it is found in up to 36% of the population and can present with a variety of symptoms, including back, groin, and leg pain. We present the first reported case of genital pain attributed to Bertolotti syndrome to increase awareness of the multiple pain referral sites associated with transitional structures. Case description: A 68-year-old female presented with a 30-year history of right-sided vulvodynia extending to her rectum. She had previously undergone years of pelvic physical therapy, tried multiple oral and topical medications, and had multiple non-diagnostic pudendal nerve and ganglion impar blocks. Pelvic CT revealed a LSTV with peaked sacral alae and a reduced gap between the L5 TP and sacral ala on both sides. Two fluoroscopically guided diagnostic lidocaine injections into the interaction site between the TP and sacral ala resulted in a 60%–70% reduction in vulvodynia. These were the only procedures in her 30-year pain history that provided relief. Conclusion: Bertolotti syndrome can refer pain to the pelvis, mimicking pudendal neuralgia. A stepwise diagnostic approach ruled out other sources and confirmed the transitional vertebra as the pain generator.