• Jayson Lian, Nicole Levine, and Woojin Cho.
• Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA.
• Eur Spine J. 2018 May 1; 27 (5): 995-1004.

PurposeTo review the current literature on methods of accurate numeration of vertebral segments in patients with Lumbosacral transitional vertebrae (LSTVs). LSTVs are a common congenital anomaly of the L5-S1 junction. While their clinical significance has been debated, unquestionable is the need for their identification prior to spinal surgery. We hypothesize that there are no reliable landmarks by which we can accurately number transitional vertebrae, and thus a full spinal radiograph is required.MethodsA Pubmed and EMBASE search using various combinations of specific key words including "LSTV", "lumbosacral transitional vertebrae", "count", "vertebral numbering", and "number" was performed.ResultsThe gold standard for spinal segment numeration in patients with LSTV remains whole spine imaging and counting caudally, starting from C2. If whole spine imaging is not available, the use of the iliac crest tangent sign on coronal magnetic resonance imaging (MRI) has fairly reliable sensitivity and specificity (81 and 64-88%, respectively) for accurate numeration of LSTV. The role of paraspinal anatomic markers such as the right renal artery, superior mesenteric artery, aortic bifurcation, and conus medullaris, for identification of vertebral levels is unreliable and should not be used.ConclusionsA sagittal whole spine view should be added as a scout view when patients obtain lumbar MRI to standardize the vertebral numbering technique. To date, there has been no other method for accurate numeration of a transitional vertebral segment, other than counting caudally from C2. These slides can be retrieved under Electronic Supplementary Material.

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