Advertisement

European Spine Journal

, Volume 22, Issue 3, pp 475–488 | Cite as

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

  • Xueyuan Wu
  • Wei MaEmail author
  • Heng Du
  • Kiran Gurung
Review Article

Abstract

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.

Keywords

Ring apophysis fracture Lumbar disc herniation Low back pain Adolescent Systematic review 

Notes

Conflict of interest

None.

References

  1. 1.
    Albeck MJ, Madsen FF, Wagner A, Gjerris F (1991) Fracture of the lumbar vertebral ring apophysis imitating disc herniation. Acta Neurochir (Wien) 113:52–56CrossRefGoogle Scholar
  2. 2.
    Bick EM, Copel JW (1951) The ring apophysis of the human vertebra; contribution to human osteogeny II. J Bone Joint Surg Am 33(A):783–787PubMedGoogle Scholar
  3. 3.
    Gooding CA, Hurwitz ME (1974) Avulsed vertebral rim apophysis in a child. Pediatr Radiol 2:265–268PubMedCrossRefGoogle Scholar
  4. 4.
    Epstein NE, Epstein JA (1991) Limbus lumbar vertebral fractures in 27 adolescents and adults. Spine (Phila Pa 1976) 16(8):962–966CrossRefGoogle Scholar
  5. 5.
    Leroux JL, Fuentes JM, Baixas P, Benezech J, Chertok P, Blotman F (1992) Lumbar posterior marginal node (LPMN) in adults. Report of fifteen cases. Spine (Phila Pa 1976) 17(12):1505–1508CrossRefGoogle Scholar
  6. 6.
    Farrokhi MR, Masoudi MS (2009) Slipped vertebral epiphysis (report of 2 cases). J Res Med Sci 14:63–66PubMedGoogle Scholar
  7. 7.
    Chen LH, Chang CH, Lee ZL, Niu CC, Lai PL, Tan CF, Chen WJ (2004) Intervertebral disc herniation in adolescents. Chang Gung Med J 27:22–28PubMedGoogle Scholar
  8. 8.
    Kuh SU, Kim YS, Cho YE, Yoon YS, Jin BH, Kim KS, Chin DK (2005) Surgical treatments for lumbar disc disease in adolescent patients; chemonucleolysis/microsurgical discectomy/PLIF with cages. Yonsei Med J 46:125–132PubMedCrossRefGoogle Scholar
  9. 9.
    Smorgick Y, Floman Y, Millgram MA, Anekstein Y, Pekarsky I, Mirovsky Y (2006) Mid- to long-term outcome of disc excision in adolescent disc herniation. Spine J 6:380–384PubMedCrossRefGoogle Scholar
  10. 10.
    Epstein NE (1992) Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine (Phila Pa 1976) 17(12):1489–1496CrossRefGoogle Scholar
  11. 11.
    Epstein NE, Epstein JA, Mauri T (1989) Treatment of fractures of the vertebral limbus and spinal stenosis in five adolescents and five adults. Neurosurgery 24:595–604PubMedCrossRefGoogle Scholar
  12. 12.
    Akhaddar A, Belfquih H, Oukabli M, Boucetta M (2011) Posterior ring apophysis separation combined with lumbar disc herniation in adults: a 10-year experience in the surgical management of 87 cases. J Neurosurg Spine 14:475–483. doi: 10.3171/2010.11.SPINE10392 PubMedCrossRefGoogle Scholar
  13. 13.
    Chang CH, Lee ZL, Chen WJ, Tan CF, Chen LH (2008) Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation. Spine (Phila Pa 1976) 33(16):1750–1754. doi: 10.1097/BRS.0b013e31817d1d12 CrossRefGoogle Scholar
  14. 14.
    DeOrio JK, Bianco AJ (1982) Lumbar disc excision in children and adolescents. J Bone Joint Surg Am 64:991–996PubMedGoogle Scholar
  15. 15.
    Matsumoto M, Watanabe K, Tuji T, Ishii K, Takaishi H, Nakamura M, Chiba K, Toyama Y (2007) Microendoscopic discectomy for lumbar disc herniation with bony fragment due to apophyseal separation. Minim Invasive Neurosurg 50:335–339. doi: 10.1055/s-2007-993202 PubMedCrossRefGoogle Scholar
  16. 16.
    Shirado O, Yamazaki Y, Takeda N, Minami A (2005) Lumbar disc herniation associated with separation of the ring apophysis: is removal of the detached apophyses mandatory to achieve satisfactory results? Clin Orthop Relat Res 431:120–128PubMedCrossRefGoogle Scholar
  17. 17.
    Grevitt MP, Gardner AD, Spilsbury J, Shackleford IM, Baskerville R, Pursell LM, Hassaan A, Mulholland RC (1995) The Graf stabilisation system: early results in 50 patients. Eur Spine J 4(3):169–175 (discussion 135)PubMedCrossRefGoogle Scholar
  18. 18.
    Molina V, Court C, Dagher G, Pourjamasb B, Nordin JY (2004) Fracture of the posterior margin of the lumbar spine: case report after an acute, unique, and severe trauma. Spine (Phila Pa 1976) 29(24):E565–E567CrossRefGoogle Scholar
  19. 19.
    Asazuma T, Nobuta M, Sato M, Yamagishi M, Fujikawa K (2003) Lumbar disc herniation associated with separation of the posterior ring apophysis: analysis of five surgical cases and review of the literature. Acta Neurochir (Wien) 145(461–466):466. doi: 10.1007/s00701-003-0044-z Google Scholar
  20. 20.
    Mendez JS, Huete IL, Tagle PM (2002) Limbus lumbar and sacral vertebral fractures. Neurol Res 24:139–144PubMedCrossRefGoogle Scholar
  21. 21.
    Martinez-Lage JF, Poza M, Arcas P (1998) Avulsed lumbar vertebral rim plate in an adolescent: trauma or malformation? Childs Nerv Syst 14:131–134PubMedCrossRefGoogle Scholar
  22. 22.
    Talha A, Cronier P, Toulemonde JL, Namour A (1997) Fracture of the vertebral limbus. Eur Spine J 6:347–350PubMedCrossRefGoogle Scholar
  23. 23.
    Baba H, Uchida K, Furusawa N, Maezawa Y, Azuchi M, Kamitani K, Annen S, Imura S, Tomita K (1996) Posterior limbus vertebral lesions causing lumbosacral radiculopathy and the cauda equina syndrome. Spinal Cord 34:427–432PubMedCrossRefGoogle Scholar
  24. 24.
    Scarfo GB, Muzii VF, Mariottini A, Bolognini A, Cartolari R (1996) Posterior retroextramarginal disc hernia (PREMDH): definition, diagnosis, and treatment. Surg Neurol 46:205–211PubMedCrossRefGoogle Scholar
  25. 25.
    Savini R, Di Silvestre M, Gargiulo G, Picci P (1991) Posterior lumbar apophyseal fractures. Spine (Phila Pa 1976) 16(9):1118–1123CrossRefGoogle Scholar
  26. 26.
    Takata K, Inoue S, Takahashi K, Ohtsuka Y (1988) Fracture of the posterior margin of a lumbar vertebral body. J Bone Joint Surg Am 70:589–594PubMedGoogle Scholar
  27. 27.
    Fujita K, Shinmei M, Hashimoto K, Shimomura Y (1986) Posterior dislocation of the sacral apophyseal ring. A case report. Am J Sports Med 14:243–245PubMedCrossRefGoogle Scholar
  28. 28.
    Laredo JD, Bard M, Chretien J, Kahn MF (1986) Lumbar posterior marginal intra-osseous cartilaginous node. Skeletal Radiol 15:201–208PubMedCrossRefGoogle Scholar
  29. 29.
    Techakapuch S (1981) Rupture of the lumbar cartilage plate into the spinal canal in an adolescent. A case report. J Bone Joint Surg Am 63:481–482PubMedGoogle Scholar
  30. 30.
    Yang IK, Bahk YW, Choi KH, Paik MW, Shinn KS (1994) Posterior lumbar apophyseal ring fractures: a report of 20 cases. Neuroradiology 36:453–455PubMedCrossRefGoogle Scholar
  31. 31.
    Peh WC, Griffith JF, Yip DK, Leong JC (1998) Magnetic resonance imaging of lumbar vertebral apophyseal ring fractures. Australas Radiol 42:34–37PubMedCrossRefGoogle Scholar
  32. 32.
    Ehni G, Schneider SJ (1988) Posterior lumbar vertebral rim fracture and associated disc protrusion in adolescence. J Neurosurg 68:912–916. doi: 10.3171/jns.1988.68.6.0912 PubMedCrossRefGoogle Scholar
  33. 33.
    Faizan A, Sairyo K, Goel VK, Biyani A, Ebraheim N (2007) Biomechanical rationale of ossification of the secondary ossification center on apophyseal bony ring fracture: a biomechanical study. Clin Biomech (Bristol, Avon) 22(10):1063–1067. doi: 10.1016/j.clinbiomech.2007.04.012 CrossRefGoogle Scholar
  34. 34.
    Sairyo K, Goel VK, Masuda A, Vishnubhotla S, Faizan A, Biyani A, Ebraheim N, Yonekura D, Murakami R, Terai T (2006) Three-dimensional finite element analysis of the pediatric lumbar spine. Part I: pathomechanism of apophyseal bony ring fracture. Eur Spine J 15:923–929. doi: 10.1007/s00586-005-1026-z PubMedCrossRefGoogle Scholar
  35. 35.
    Mupparapu M, Vuppalapati A, Mozaffari E (2002) Radiographic diagnosis of limbus vertebra on a lateral cephalometric film: report of a case. Dentomaxillofac Radiol 31:328–330. doi: 10.1038/sj.dmfr.4600698 PubMedCrossRefGoogle Scholar
  36. 36.
    Dietemann JL, Runge M, Badoz A, Dosch JC, Beaujeux R, Bonneville JF, Wackenheim A (1988) Radiology of posterior lumbar apophyseal ring fractures: report of 13 cases. Neuroradiology 30:337–344PubMedCrossRefGoogle Scholar
  37. 37.
    Ikata T, Morita T, Katoh S, Tachibana K, Maoka H (1995) Lesions of the lumbar posterior end plate in children and adolescents. An MRI study. J Bone Joint Surg Br 77:951–955PubMedGoogle Scholar
  38. 38.
    Banerian KG, Wang AM, Samberg LC, Kerr HH, Wesolowski DP (1990) Association of vertebral end plate fracture with pediatric lumbar intervertebral disk herniation: value of CT and MR imaging. Radiology 177:763–765PubMedGoogle Scholar
  39. 39.
    Liquois F, Demay P, Filipe G (1997) Sciatica caused by avulsion of the vertebral limbus in children. Rev Chir Orthop Reparatrice Appar Mot 83:210–216PubMedGoogle Scholar
  40. 40.
    Dang L, Liu Z (2010) A review of current treatment for lumbar disc herniation in children and adolescents. Eur Spine J 19:205–214. doi: 10.1007/s00586-009-1202-7 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of Orthopaedics, The First Affiliated HospitalMedical School of Xi’an JiaoTong UniversityXi’anChina

Personalised recommendations