a 40-year - old female patient presented to our emergency department after a simple fall . she reported pain upon palpation of the lower lumbar spine and radiating pain to her left buttock and lower leg . the patient reported a history of low back pain and left sciatica , with exacerbation of the symptoms after the fall . simple radiological control of the lumbar spine revealed a sagittal cleft of the body of l4 vertebra on the ap view ( fig . 1a ) and a wedge - shaped deformity of the same vertebra on the lateral radiograph ( fig . additional hematologic evaluation that included total leukocyte count , erythrocyte sedimentation rate , serum calcium , serum alkaline phosphatase , and serum protein electrophoresis was performed , in order to rule out a pathologic fracture or infection . computed tomography ( ct ) imaging of the lumbar spine showed a large , symmetrical cleft - like defect involving the entire vertebral body of l4 with no evidence of canal compression ( fig . the spinal arch of l4 was intact and no paravertebral soft tissue swelling was evident ( fig . a posterolateral prolapse of the l5-s1 intervertebral disc was evident , which correlated with the patient 's symptoms . a thorough clinical examination of the patient , the patient 's medical history , and her family 's medical history did not reveal any information associated with the incidental finding of the butterfly vertebra . subsequently , a simple radiological evaluation of the entire spine was performed , in addition to ultrasonography of the heart , urogenital , and hepatobiliary systems , so as to exclude associated congenital abnormalities . a magnetic resonance imaging ( mri ) of the lumbar spine reconfirmed the sagittal defect of the l4 vertebral body , occupied by intervertebral disc tissue that included nucleus pulposus material ( fig . the intervertebral discs l3-l4 and l4-l5 communicated with a bar of disc material which prolapsed in the cleft of the l4 body . incidentally , a hemangioma was found to be present in the body of l4 vertebra ( fig . the benign nature of the butterfly vertebra was explained to her and she was informed that no further treatment was required . however , it may be associated with other congenital anomalies such as mullerian hypoplasia / aplasia,2 ) alagille syndrome,3 ) jarcho - levin syndrome,4 ) crouzon syndrome,5 ) and pfeiffer syndrome.6 ) this defect is thought to occur between the third and sixth week of embryonic development . the vertebral body is formed by the fusion of two lateral sclerotomes that derive from the somites . failure of the fusion of the two sclerotomes results in the formation of butterfly vertebra.1 ) butterfly vertebrae is seen predominantly in the lumbar spine.1 ) in this case , the patient did not present with features of any known associated syndromes . further evaluation with ct and mri for other vertebral anomalies such as supernumerary lumbar vertebrae , spina bifida , diastematomyelia , and kyphoscoliosis , which could be associated with butterfly vertebra7 ) were all negative . in simple ap radiographs , the butterfly shape of the body of the vertebra is easily identifiable , while the pedicles may look divergent . in the lateral x - ray view , the butterfly vertebra usually presents with as a wedge - shaped deformity , which may be confused for a compression fracture . that is the reason why the ap radiographic view is particularly useful in establishing the diagnosis . in case of doubt , or in the setting of previous trauma , a ct scan is indicated.10 ) an mri may show possible degenerative changes of the overlying and underlying intervertebral discs , as well as the presence of disc material in the body defect of the butterfly vertebra . this can be explained by the ectopic development of disc tissue caused by the deficiency of sclerotomic substance during gestation.1 ) the degenerative changes of the intervertebral discs above and below the butterfly vertebra are suggestive of possible altered biomechanics in the spine . to our knowledge , there are no data regarding the long - term effects of this condition on the stability of the spinal elements . however , a thorough clinical examination of the patient , a detailed family history and , if necessary , additional imaging and laboratory evaluation may be needed in order to exclude pathologic fracture , infection , and congenital anomalies which are associated with this malformation . furthermore , in the emergency setting , awareness of this entity is needed so that a correct diagnosis can be established efficiently .
butterfly vertebra is a rare congenital malformation of the spine , which is usually reported in the literature as an isolated finding . 
 we describe a 40-year - old woman that presented to our emergency department with back pain and sciatica . 
 initial radiological evaluation revealed an incidental finding of a l4 butterfly vertebra in the anteroposterior and lateral view radiographs . 
 the patient presented with no neurological deficit . 
 this rare congenital anomaly is usually asymptomatic , and awareness of its non - traumatic nature is critical in order to establish a correct diagnosis . 
 further evaluation of the patient is necessary to exclude pathologic fracture , infection , or associated vertebral anomalies and syndromes , such as alagille , jarcho - levin , crouzon , and pfeiffer syndromes . 
 furthermore , in the emergency setting , awareness of this entity is needed so that a correct diagnosis can be established .