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Three pediatric patients with back pain associated with Bertolotti syndrome are presented. After failing conservative management, 1 patient underwent mega-apophysis resection, another underwent resection with decompression, and the final underwent posterior fusion. All patients had complete resolution of back pain and returned to full activity at final follow-up. Lumbosacral transitional vertebrae are congenital anomalies spanning a spectrum from partial/complete L5 sacralization to partial/complete S1 lumbarization with varying clinical prese