Chiropractic is fairly new in Singapore (+/- 30 years). Square One is also new – we are about a year and a half old.
What we do at our chiropractic clinic is virtually unheard of in Singapore – pain solutions through exercise. (Manual therapy like chiropractic adjustments and soft tissue “release” is still all the rage.)
So, a big part of what we do is write content. We aim to provide high value information that is based on the latest research data. We want you know everything there is to your pain. And we want you to be at a position to make a truly informed decision.
We just started pushing content on LinkedIn and a person we reached out to mention sacralisation of the L5.
We have never blogged about it before so here we are. Let’s see what does the latest research say!
#1 Sacralisation is considered a lumbosacral transitional vertebra (LSTV) and they are normal
Lumbosacral transition veretebrae refers to either sacralisation of the L5 or lumbarisation of the sacrum. They are also referred to as transitional vertebrae.
The most important thing to know is that not only are they are COMMON congenital anomaly, they are also NORMAL anatomical variants.
What that means is that they look different from what most people have but there is no clinical significance to having them. I.e. they look different but they don’t cause problems.
#2 Transitional vertebrae are not uncommon
While it is true that transitional vertebrae deviate from what a conventional sacrum or L5 vertebra will look like, they are actually not uncommon at all. Research has shown that they can be found in up to a third of the population.
That is one in every three people!
#3 We have known about LSTV for a very long time
The earliest report of LSTV was published by Bertolotti in 1917. More than a hundred years later, we are still debating if sacralisation is a cause for lower back pain.
Study 1: The transitional vertebra of the lumbosacral spine: its radiological classification, incidence, prevalence, and clinical significance (1977)
A study in 1977 (that is 40 years ago!) looked at 4000 x-rays and found no relationship between transitional vertebrae and lower backache. Wow, that’s a lot of film for a very old study. The study also mentioned that earlier studies – Brocher (1973), Rubin (1971) – have considered an LSTV to be of clinical importance because it should lead to unfavourable weight bearing in the lower spine from a biomechanical perspective.
The authors of the paper challenged Brocher’s and Rubin’s beliefs with the extensive material presented to show that there is no relationship between a transitional vertebra and low backache.
Study 2: Spinal radiographic findings and nonspecific low back pain (1997)
Another old study but I was unable to get a copy of the full text of this article. The sample size was not published in the abstract. Regardless, the study found no relationship between transitional vertebrae (together with spondylolysis and spondylolisthesis, spina bifida, spondylosis, and Scheuermann’s disease) and low back pain.
Interestingly enough, spinal disc degeneration (e.g. disc space narrowing, osteophytes, and sclerosis) were found to be associated with low back pain. Regardless, the latest research have found no association between degeneration and lower back pain. We have blogged about the details are MRI and Slipped Discs.
So that’s two papers – one 42 years old and another 22 years old – to tell us there is no relationship between LSTV and lower backache. Why are we still discussing this?
#4 Studies have found LSTV to be associated with lower back pain
Study 3: Clinical significance of congenital lumbosacral malformations in young male population with prolonged low back pain (2005)
This study looked at 881 young male patients with low back pain lasting for more than four weeks. Transitional vertebra were found in 48 of them. The authors published pain scores were statistically higher in patients with a transitional vertebra.
However, the authors failed to highlight that the scores were not clinically significant.
In the transition vertebra group, sacralisation visual analog scale (VAS) score – used to measure pain intensity) was 4.3 while lumbarisation VAS score was 4.5. The VAS score was 2.7 in lower back pain patients without a congential malformation. The minimal clinically important difference (MCID) score for VAS is 2.
The MCID score measures how much change is needed before a person is able to perceive a difference. If you were handed a weight that is 1000g vs. one that is 1001g, the likelihood for you to be able to tell a difference in their weight is almost impossible.
Likewise, if the difference between groups is less than 2 points on a VAS, as per in this instance, it is very unlikely the patients with a transitional vertebra were in fact experiencing more pain than than those without. So, this paper doesn’t actually tell us conclusively that individuals with transitional vertebra are at higher risk of lower back pain.
Fun stuff, huh?
#5 New studies have found there is no relationship between LSTV and lower backache
Study 4: A cross-sectional study comparing pain and disability levels in patients with low back pain with and without transitional lumbosacral vertebrae (2005)
I understand you may be reluctant to consider older studies as good evidence. Newer studies have also published to find no relationship between LSTV and lower backache.
353 patients with low back pain and divided them into two groups – with and without transitional vertebra. Out of the 353 patients, 43 patients (12%) had a transitional lumbosacral vertebra. There were no differences, in both pain scales and the Revised Oswestry Disability Questionable, between both groups.
According to the authors, the presence of a transitional lumbosacral vertebra did not correlate to an increased in low back pain or disability.
Study 5: Prevalence and clinical significance of lumbosacral transitional vertebra (LSTV) in a young back pain population with suspected axial spondyloarthritis: results of the SPondyloArthritis Caught Early (SPACE) cohort (2017)
In the cohort of 273 lower back patients, no difference in pain scores or spinal mobility was found between patients with and without LSTV.
#6 It is possible to attribute lower back pain in patients with transitional vertebra to other spinal disorders
Study 6: Lumbosacral Transitional Vertebra-Related Low Back Pain: Resolving the Controversy (2018)
So all the earlier 5 studies compared lower back pain patients with or without transitional vertebra. This study compared 372 patients with lower back pain vs. 224 patients without lower back pain.
They found that LSTV was associated with an increased prevalence of lower backache. However, the authors also added it is possible that the lower back pain groups had other spinal disorders which may have confounded (confused) the results.
Does a transitional vertebra cause lower back pain?
From the six studies, it doesn’t seem like there is a relationship between lower back pain and transition vertebrae. Only two studies reported a difference. In one of the studies, the difference was too small to be clinically meaningful. In the second study, it was determined that other spinal conditions could have accounted for an increased in lower back pain occurrence among lower back pain patients with a transitional vertebra.
However, it should be also mentioned that research is fairly lacking in this area. Most of the other research we came across did not examine the relationship between lower back pain and LSTV.
Given how prevalent transitional vertebrae are in the population and that most studies do not suggest a relationship between LSTV and lower back pain, it seems more likely that they are normal variants that do not have a clinical significance.
Putting transitional vertebra into the bigger low back pain picture
To attribute lower back pain to sacralisation or lumbarisation is largely looking at pain from a biomedical model. We have discussed extensively about pain in our lower back pain treatment blog entry and how the biomedical approach to musculoskeletal care doesn’t fit into our current understanding of pain.
Furthermore, chronic pain such as lower back pain is a disease in its own right. It is completely reasonable for a person to experience low back pain in the absence of spinal pathology. As such, finding the “cause” of a person’s lower back pain may not even be valuable in the absence of red flags.
Seek chiropractic first
We have talked about how chiropractors deliver outcomes that are superior to physiotherapists and are more clinical guideline compliant than physiotherapists and medical doctors in our blog entry lower back pain treatment and six things an orthopaedic surgeon with 20 years experience got wrong. You can check those blog posts for the relevant studies.
The bottom line is that sacralisation or lumbarisation may not be the cause of your lower back pain. If you are suffering from chronic back aches despite previous treatment, it is plausible that you are not getting better due to poor quality of care. Clinical guidelines tell us exercise and active care is the first choice of treatment while chiropractic adjustments or other forms of manual therapy are at best adjunctive.
Back pain exercises work. Research has also shown exercise to deliver outcomes that remain even after three years. To read more, check out why we choose exercise.
If you are currently suffering from back pain and you are looking for treatment, seek care from an evidence based chiropractor or physiotherapist. A good chiropractor or physiotherapist puts patient outcomes first. We justify all our clinical decisions with the latest research and data and our patients get superior results compared to other clinicians.
We know this is a long and heavy read, if you have any questions or concerns please do reach out to us. We will be happy to help.
You can also book an appointment via our request form below. Our chiropractic clinic is located at Bukit Pasoh Road just two minutes from Outram Park MRT. If you are coming from Tanjong Pagar or Tras Street, a short scroll through the Duxton Plain Park will bring you right to our door step.