Radiology of posterior lumbar apophyseal ring fractures: report of 13 cases

Percutaneous endoscopic lumbar discectomy in lumbar disc herniation with posterior ring apophysis fracture: A case report in a 15-year-old child

RATIONALE

Lumbar disc herniation (LDH) with posterior ring apophysis fracture (PRAF) is rather rare in children, and in all age-stratified LDH patients, the incidence of RAF was 5.3% to 7.5%. Interestingly, the incidence of LDH with RAF in children (15%-32%) is several times higher than in adults, the mis-diagnosis of which may lead to delayed treatment.

PATIENT CONCERNS

Here, we report a 15-year-old schoolboy who suffered from sudden low back pain and radiating pain in both lower limbs after sport activities. Symptoms persisted after 3 months of conservative treatment. Computer radiography and magnetic resonance imaging indicated central disc herniation with PRAF at L4-5.

DIAGNOSIS

LDH with PRAF.

INTERVENTIONS

The herniated disc and epiphyseal fragments were successfully excised by the percutaneous endoscopic lumbar discectomy minimal-invasive technique.

OUTCOMES

Surgery was successful. Symptoms were immediately relieved postoperatively with a wound of only about 7.0 mm. Discharged on the next day. No perioperative complications occurred. Moreover, the imaging and clinical outcomes were also more satisfactory during the post-operative 15 months outpatient follow-up.

LESSONS

Pediatric LDH with PRAF is extremely uncommon, and there is a lack of training among physicians for such cases, which may lead to delayed diagnosis and treatment. Once a diagnosis for LDH with PRAF is established, percutaneous endoscopic lumbar discectomy is a safe and effective minimally invasive treatment to be considered, and we hope that this technique can provide more assistance in the future.

Percutaneous Transforaminal Endoscopic Discectomy and Fenestration Discectomy to Treat Posterior Ring Apophyseal Fractures: A Retrospective Cohort Study

Objective

To compare the efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) and fenestration discectomy (FD) for posterior ring apophyseal fractures (PRAF).

Methods

This study was a retrospective cohort control study. A total of 96 patients with lumbar PRAF who underwent surgical treatment at the Henan Provincial People's Hospital of Henan University from September 2013 to December 2017 were retrospectively examined, of which 51 were treated by PTED and 45 by FD. The average age of those in the PTED group was 28.24 years, including 38 males and 13 females. The average age of those in the FD group was 28.07 years, with 33 males and 12 females. Operation time, total blood loss, hospitalization days, preoperative and postoperative visual analog scale (VAS), and Oswestry disability index (ODI) scores were evaluated. Modified MacNab criteria were used to evaluate the clinical effect at the last follow‐up.

Results

Both operations were successful and no serious complications occurred. All patients were followed up for 12–30 (average 16.7 ± 3.2) months, and no patients were lost to follow‐up. No statistically significant difference was found in the mean age and gender between the PTED group and the FD group (P < 0.05). Operation time, total blood loss, and length of hospital stay were significantly lower in the PTED group (87.65 ± 13.15 min, 12.78 ± 4.95 mL, and 6.80 ± 1.67 days, respectively) than in the FD group (114.11 ± 14.39 min, 30.89 ± 7.09 mL, and 11.71 ± 1.98 days, respectively) (P < 0.05). The VAS and ODI scores of the two groups at postoperative day 1 (PTED: 3.82 ± 0.97, 37.73% ± 3.72%; FD: 3.62 ± 1.09, 36.62% ± 3.05%), and at 3 months (PTED: 2.90 ± 1.08, 26.02% ± 2.90%; FD: 3.07 ± 0.99, 27.16% ± 4.02%), 6 months (PTED: 2.31 ± 0.88, 22.53% ± 2.67%; FD: 2.36 ± 0.77, 21.18% ± 3.35%), and the last follow‐up (PTED: 1.90 ± 0.83, 19.88% ± 3.01%; FD: 1.89 ± 0.86, 18.22% ± 3.03%) were significantly different from the preoperative scores (PTED: 6.53 ± 1.00, 55.24% ± 4.54%; FD: 6.78 ± 1.31, 53.56% ± 5.73%) (P < 0.05). The VAS and ODI scores at 3 months postoperatively, 6 months postoperatively, and the last follow up were not significantly different between the two groups (P > 0.05). In the PTED group, 2 patients developed a transient nerve stimulation symptom within 1 day after surgery and 1 patient had recurrence at 3 months after surgery. In the FD group, 2 patients had severe dural ruptures due to adhesion during surgery, 1 patient developed infection complications, and 2 patients relapsed at 2 and 3 months after surgery. At the last follow‐up, the modified MacNab criteria for clinical effect were 93.3% and 94.1% in the FD and PTED groups, respectively.

Conclusion

While PTED has the same efficacy as FD for treating PRAF, it is associated with shorter operation time, less trauma, and quicker recovery.

Diagnostic Imaging in Fracture of Lumbar Vertebral Ring Apophyses

The findings at plain radiography, myelography, CT, and MR imaging in 3 cases of fracture of the lumbar vertebral ring apophysis are presented. Familiarity with this entity is important in evaluating low back pain in children and young adults. Conventional radiographs and/or MR imaging may suggest ring apophysis fracture; CT will confirm and classify the diagnosis.

Apophyseal ring fracture associated with two levels extruded disc herniation: case report and review of the literature

Apophyseal ring fractures are rare injuries that may be associated with lumbar disc herniation in young patients. We report a unique case in the literature of a 15-year-old male patient who played football and was admitted at our service complaining of sciatica radiating into the left leg. An apophysial ring injury of L5 vertebral body was observed. This injury caused two extruded disc herniation in adjacent levels. Surgical procedure was indicated after failure of conservative treatment.

A review of current treatment of lumbar posterior ring apophysis fracture with lumbar disc herniation

PURPOSE

Lumbar posterior ring apophysis fracture (PRAF) is an uncommon disorder frequently accompanied by lumbar disc herniation (LDH). Over the years, there have constantly been published studies concerning this disorder. Due to its rarity, there is lack of an agreed treatment strategy, and lots of different opinions exist, including the choice of decompressive modalities, whether removal of apophyseal fragments or/and disc material, and the necessity of additional spinal fusion. The purpose of this review is to provide a collective opinion on the treatment of PRAF with LDH.

METHODS

A MEDLINE search in the English language literature was performed from 1980 to 2012. To be included in the study, it was strictly necessary for each clinical article to provide information about the description of apophyseal fracture such as location, treatment methods and clinical outcome. The studies were mainly analyzed for general features, the related classifications and treatments.

RESULTS

The literature searching yielded 19 articles reporting 366 patients experiencing 380 sites of fractures. All of them were case reports or case series. The classification systems of PRAF were various based on the morphology, mobilization, size or localization, and relationship between disc and fragment. The most used surgical options were posterior discectomy simultaneous excision of apophyseal fragments without spine fusion. Surgical treatment for PRAF with LDH had equally excellent clinical outcome compared with LDH alone.

CONCLUSIONS

The diverse features of apophyseal fracture lead to various modalities of classifications and operation options. Prior to operation, the surgeons should carefully make a plan to consider decompressive scope, removal of apophyseal fragment or/and disc and fusion or not. Because of methodological shortcomings in publications, it is not possible to definitively conclude what treatment modality is the best for the treatment of PRAF. More high-quality clinical studies are needed to draw more confirmable conclusions.

Back pain in the pediatric and adolescent athlete

Clinicians taking care of athletes are likely to see many young patients complaining of back pain. The young athlete places significant repetitive stresses across the growing thoracolumbar spine, which can cause acute and overuse injuries that are unique to this age and patient population. Fortunately, by using a careful and systematic approach, with a sport-specific history, careful physical exam, and proper imaging, most problems can be properly identified. Although it is important to always remember that rare and more serious problems such as a neoplasm or infection maybe a source of pain in the athletic patient, most problems are benign and can be treated conservatively. Accurate diagnosis and management of back pain not only can prevent long-term deformity and disability, but it can also allow young athletes to return to doing what they love to do most: play sports.

Posterior lumbar ring apophysis fracture

Lumbar posterior ring apophysis fracture (PRAF) is an uncommon cause of low back pain in the pediatric age group, and a detailed understanding of this disease is important for the orthopaedic surgeon because it is easily misdiagnosed. However, to date no comprehensive review of PRAF has been published. The majority of published reports are in the form of cases report generally targeted at either diagnosis or therapy, or both. In this essay, we comprehensively review the pathogenesis, clinical presentation, diagnosis and treatment of PRAF.

Posterior lumbar apophyseal ring fractures in adolescents: a report of four cases

Posterior lumbar apophyseal ring fractures are rare in adolescents. We report 4 such cases in Chinese adolescents. Two of the patients had a slipped capital femoral epiphysis; 3 of them were overweight/obese. All presented with low back pain and radicular pain. Apophyseal fractures of the upper lumbar spine usually involve the lower end plate, whereas those of the lumbar sacral spine usually involve the upper end plate. The radiological features and pathophysiology are discussed. Two of the patients were treated with laminotomy and diskectomy after conservative treatment failed. All patients had complete resolution of their neurological deficits at a mean follow-up of 2 years. Despite its benign nature, long-term follow-up is necessary to define the natural course and prognosis of the disease. A high index of suspicion is needed to diagnose these fractures in adolescents.

Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation

STUDY DESIGN

Retrospective review and post-test-only control group design.

OBJECTIVE

To study the incidence and associated factors of ring apophysis fracture in adolescent lumbar disc herniation and to evaluate the long-term morbidity of untreated apophyseal fracture.

SUMMARY OF BACKGROUND DATA

Ring apophysis fracture is a feature in adolescent disc herniation, but the incidence and prognosis are unknown. It is still controversial whether to remove the apophyseal fragment at time of discectomy.

METHODS

We studied 96 adolescents (mean age, 14.7 years) with clinical diagnosis of disc herniation proved by computerized tomography (CT). In CT scan ring, apophyseal fracture is classified by the size (large/small) and the location (central/lateral). We used modified Oswestry classification in the nonoperative patients for pain and functional evaluation. Patients with and without apophyseal fracture were compared to define the significance of the lesion.

RESULTS

Twenty-seven of the 96 CT studies (28%) demonstrated apophyseal fractures. All but 2 were at the level of the herniated disc. Large-central fragments were the most common in 16 patients (48%), large-lateral fragments in 2, small-central fragments in 6, and small-lateral fragment in 6. Rate of surgery was significantly higher in the disc herniation patients with apophyseal fractures. Sixty-four nonoperative patients were evaluated 6.6 years (range, 2.3-14.3) after the CT study and questionnaires were completed in 54 patients (84%). Patients with large apophyseal fragments had more chance of chronic back pain and limitation of daily activities than the patients with small fragments and patients without apophyseal fracture.

CONCLUSION

Apophyseal fracture is not uncommon in adolescent lumbar disc herniation. The surgical decision must depend on clinical symptoms instead of radiologic findings, but disc herniation with apophyseal fracture may exhibit more severe symptoms. Patients with large apophyseal fragments must be informed of a greater chance of chronic back pain later on. Small apophyseal fragments had no clinical significance.

Whole-spine dynamic magnetic resonance study of contortionists: anatomy and pathology

OBJECT

Whole-spine magnetic resonance (MR) images were obtained using a cylindrical 3-T MR imaging system in 5 contortionists to assess the pathological changes possibly associated with the practice of contortion. Whole-spine dynamic MR images were obtained using a 1-T open MR imaging system in 2 of these contortionists with the purpose of defining the range of motion (ROM) achieved during extreme contortion. The range of spinal motion in this unique population was then quantified.

METHODS

The study included 5 female contortionists 20-49 years of age. Imaging was performed using open 1-T and cylindrical 3-T high-field MR imaging systems. Data were viewed and analyzed with DICOM-compliant tools. Real-time, dynamic, and standard MR imaging allowed for quantification of the contortionists' ROM.

RESULTS

There was a difference of 238 degrees between full spinal extension and full flexion. Three of the 5 contortionists had 4 anterosuperior limbus vertebrae at T-11 and the upper lumbar levels.

CONCLUSIONS

Whole-spine dynamic MR imaging is a valuable tool for the evaluation of the extreme ROM in contortionists, allowing for the quantification of extreme mobility. The limbus fractures present in 3 of the 5 contortionists is postulated to be due to avulsion on hyperextension. Future research may open the use of whole-spine dynamic MR imaging into such areas as pain management and traumatic spinal injuries.

Biomechanical rationale of ossification of the secondary ossification center on apophyseal bony ring fracture: a biomechanical study

BACKGROUND

Apophyseal ring fracture is one of the important pathologies causing low back pain in children and adolescents. Most of the patients are reported to be in the ossification stage of the ring during growth period rather than early cartilaginous ring stage. There is no previous study clarifying the mechanism of the high prevalence of this disorder in the ossification stage. Thus, in this study, we investigated the effects of ossification of the ring on lumbar spine biomechanics.

METHODS

Two three-dimensional finite element pediatric lumbar models were created and analyzed. One model had ossified apophyseal rings and the other one had cartilaginous apophyseal rings. To simulate standing posture, 341N axial compression was applied. Then, 10Nm moment was applied to the model in the six directions of lumbar motion: flexion, extension, lateral bending and axial rotation. Maximum Von Mises stresses in the apophyseal ring were calculated and compared between the two models.

FINDINGS

The maximum stresses were always higher in the bony ring in all lumbar motion at all lumbar levels compared to the cartilaginous ring. The stresses at L4 caudal apophyseal ring in extension were 2.60 and 0.68 (MPa) for bony and cartilaginous rings respectively. In flexion, stresses were 3.95 and 1.49 (MPa), in lateral bending, stresses were 6.75 and 2.66 (MPa), and in axial rotation, stresses were reported to be 3.15 and 1.72 (MPa). Thus, the bony ring was stressed by at least 2-fold more than the cartilaginous ring.

INTERPRETATION

Apophyseal ring has at least two times more stresses in the ossified stage when compared to the cartilaginous stage resulting in frequent fractures at the interface of bone and cartilage.

Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases

OBJECT

The authors evaluated the mechanisms and patterns of thoracic, lumbar, and sacral spinal injuries in a pediatric population as well as factors affecting the management and outcome of these injuries.

METHODS

The records of 89 patients (46 boys and 43 girls; mean age 13.2 years, range 3-16 years) with thoracic, lumbar, or sacral injuries were reviewed. Motor vehicle accidents were the most common cause of injury. Eighty-two patients (92.1%) were between 10 and 16 years old, and seven (7.9%) were between 3 and 9 years old. Patient injuries included fracture (91%), fracture and dislocation (6.7%), dislocation (1.1%), and ligamentous injury (1.1%). The L2-5 region was the most common injury site (29.8%) and the sacrum the least common injury site (5%). At the time of presentation 85.4% of the patients were neurologically intact, 4.5% had incomplete injuries, and 10.1% had complete injuries. Twenty-six percent of patients underwent surgery for their injuries whereas 76% received nonsurgical treatment. In patients treated surgically, an anterior approach was used in six patients (6.7%), a posterior approach in 16 (18%), and a combined approach in one (1.1%). Postoperatively, six patients (26.1%) with neurological deficits improved, one of whom recovered fully from an initially complete injury.

CONCLUSIONS

Thoracic and lumbar spine injuries were most common in children older than 9 years. Multilevel injuries were common and warranted imaging evaluation of the entire spinal column. Most patients were treated conservatively. The prognosis for neurological recovery is related to the initial severity of the neurological injuries. Some pediatric patients with devastating spinal cord injuries can recover substantial neurological function.

Fracture of the vertebral limbus

An 18-year-old young man suffering from fracture of the limbus of L4 was admitted to the emergency ward after a car collision. Radiological evidence of the lesion was visible on plain film radiographs and CT scans. On surgery the posterior column was found to be intact. Treatment included a wide laminectomy, excision of the fragment, and osteosynthesis with Cotrel-Dubous-set instrumentation. The characteristics of these lesions are reviewed on the basis of the latest reports. The possibility of misreading these fractures is emphasized, especially in traumatic adult spine surgery.

Posterior lumbar apophyseal ring fractures: a report of 20 cases

Posterior apophyseal ring fracture (PARF) of the lumbar spine is an uncommon injury thought usually to occur in adolescence. We analysed CT findings in 20 cases (19 patients), whose age ranged from 16 to 45 years (average 30 years). The PARF could be divided into two distinct groups on the basis of the shape and location of the fracture and the defect of the vertebral rim. In group 1 (2 cases), PARF involved the central aspect of the inferior vertebral rim and bone fragments were large and broad-based. In group 2, PARF were located at the posterolateral margin of the superior vertebral rim and bone fragments were small and focal. The great majority of previously reported cases belonged to our group 1. A pathogenesis for each group is suggested.

Intervertebral disc herniations (limbus vertebrae) in pediatric patients: report of 15 cases

A revision of 15 cases of back pain and radiological features characteristic of anterior or posterior limbus vertebrae is presented. We comment on the radiological findings observed in the various imaging studies performed (conventional radiology, CT and MRI), which were attributed to the herniation of disc material into the vertebral body. In three patients who were followed up 12 years after the diagnosis, the initial roentgenograms of limbus vertebrae progressed in adult hood into radiological images characteristic of Schmorl's hernia as a sequela.

CT of adult lumbar disc herniations mimicking posterior apophyseal ring fractures

This report concerns 35 adult patients with lumbar or sciatic pain and axial CT findings reportedly associated with posterior apophyseal ring fractures. Review of the CT images suggested two pathophysiologic categories. (1) Posterior Schmorl--A posterior intravertebral disc herniation with posterior displacement of a fractured or remodelled vertebral margin. (2) Calcified subligamentous--Reactive annular and or posterior longitudinal ligament calcification at the periphery of a herniated disc with or without remodelling and anterior displacement of the posterior vertebral margin.