Abstract: Objective: Lumbosacral transitional vertebrae (LSTV) are relatively common skeletal anomalies with a debated role in low back pain. There are few documented cases of conservative care being used to address LSTV-associated symptomatology. The current report discusses chiropractic management of 2 patients with unilateral sacralization.Clinical Features: Two patients with LSTV involving unilateral sacralization of L5, a Castellvi type IIIa variant, presented with back pain to a chiropractic clinic. Each case presented with symptomatology similar to piriformis syndrome.Intervention and Outcome: Manual therapy, including spinal manipulation soft tissue therapies and exercise/stretching, was used to address the presenting symptoms. Approximately 2 weeks after initial treatment, the first patient subjectively reported a 70% improvement in symptoms, with lumbar extension increased to full in active range of motion at the lumbar spine but with continued tenderness and hypertonicity at the left piriformis and gluteus medius. After 4 weeks of treatment, the second patient reported improvement in pain and perceived mobility, although prolonged standing remained an aggravating factor. Although both showed improvement, neither case resulted in complete resolution of symptoms.Conclusion: The presenting cases demonstrated partial resolution of symptoms after chiropractic management. It is proposed that sacralization is a possible cause of back pain in these cases.