Massively Slipped Vertebral Apophyseal Ring with Intervertebral Disc Herniation in an Overweight Girl: A case report

Article Sidebar

pdf
Published: Oct 1, 2020
Keywords:
Slipped vertebral apophyseal ring lumbar disc herniation teenage

Main Article Content

Akom Prommahachai, MD
Devision of Orthopaedic Surgery, Udon Thani Hospital, Udon Thani, Thailand

Abstract

Purpose: To present a rare spine condition in a very young teenage diagnosed combined slipped vertebral apophyseal ring with lumbar disc herniation of L4-5.


Methods: The author demonstrates a case by describing the patient’s history, physical examination, imaging, surgical treatment and postoperative outcomes. Literature reviews and discussion were included.


Results: An 11-year-old overweight female patient presented with chronic bilateral lumbar radicular pain and neurogenic claudication for 4 months. CT scan of lumbar spine demonstrated a large apophyseal fracture of the inferior end-plate of the L4 vertebral body and MRI showed a massively herniated nucleus pulposus at L4-L5 level. Extensive L4 laminectomy combined with avulsed fragment removal and discectomy was performed to decompress the spinal canal and neural structures. The patient showed a complete absence of the clinical symptoms of radicular pain and claudication within 1 month and regained complete neurological recovery in 3 months. The patient was able to return to full activities of daily living and sport in 6 months after the surgery.


Conclusion: Combined slipped vertebral apophyseal ring with lumbar herniated nucleus pulposus in a very young overweight girl is a very rare condition. High degree of suspicion is important to properly investigate these conditions. Adequately surgical decompression is the key to obtain an excellent clinical result. 

Article Details

Issue
Vol. 44 No. 3-4 (2020): July-October
Section
Case Report

References

1. Martínez-Lage JF, Poza M, Arcas P. Avulsed lumbar vertebral rim plate in an adolescent: trauma or malformation?. Childs Nerv Syst. 1998; 14(3): 131-4.
2. Luukkonen M, Partanen K, Vapalahti M. Lumbar disc herniations in children: A long-term clinical and magnetic resonance imaging follow-up study. Br J Neurosurg. 1997; 11: 280-5.
3. Wu X, Ma W, Du H, Gurung K. A review of current treatment of lumbar posterior ring apophysis fracture with lumbar disc herniation. Eur Spine J. 2013; 22(3): 475-88.
4. Faizan A, Sairyo K, Goel VK, Biyani A, Ebraheim N. Biomechanical rationale of ossification of the secondary ossification center on apophyseal bony ring fracture: a biomechanical study. Clin Biomech 2007; 22(10): 1063-7.
5. Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine. 1992; 17(12): 1489-96.
6. Mendez JS, Huete IL, Tagle PM. Limbus lumbar and sacral vertebral fractures. Neurol Res. 2002; 24: 139-44
7. Bae JS, Rhee WT, Kim WJ, Ha SI, Lim JH, Jang IT. Clinical and radiologic analysis of posterior apophyseal ring separation associated with lumbar disc herniation. J Korean Neurosurg Soc. 2013; 53(3): 145-9.
8. Mattila VM, Saarni L, Parkkari J, Koivusilta L, Rimpelä A. Early risk factors for lumbar discectomy: an 11-year follow-up of 57,408 adolescents. Eur Spine J. 2008; 17(10): 1317-23.
9. Zheng ZZ, Tu Z, Li Y, Dai Y, Wu PF, Jiang B, et al. Full-Endoscopic Lumbar Discectomy for Lumbar Disc Herniation with Posterior Ring Apophysis Fracture: A Retrospective Study. World Neurosurg. 2018 Dec 24. [Epub ahead of print]
10. Matsumoto M, Watanabe K, Tuji T, Ishii K, Takaishi H, Nakamura M, Chiba K, Toyama Y. Microendoscopic discectomy for lumbar disc herniation with bony fragment due to apophyseal separation. Minim Invasive Neurosurg. 2007; 50: 335-9.
11. Baba H, Uchida K, Furusawa N, Maezawa Y, Azuchi M, Kamitani K, et al. Posterior limbus vertebral lesions causing lumbosacral radiculopathy and the cauda equina syndrome. Spinal Cord. 1996; 34: 427-32.
12. Scarfo GB, Muzii VF, Mariottini A, Bolognini A, Cartolari R. Posterior retroextramarginal disc hernia (PREMDH): definition, diagnosis, and treatment. Surg Neurol. 1996; 46: 205-11.
13. Farrokhi MR, Masoudi MS. Slipped vertebral epiphysis (report of 2 cases) J Res Med Sci. 2009; 14: 63-6.
14. Talha A, Cronier P, Toulemonde JL, Namour A. Fracture of the vertebral limbus. Eur Spine J. 1997; 6: 347-50.
15. Savini R, Di Silvestre M, Gargiulo G, Picci P. Posterior lumbar apophyseal fractures. Spine 1991; 16(9): 1118-23.
16. Chang CH, Lee ZL, Chen WJ, Tan CF, Chen LH. Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation. Spine 2008; 33(16): 1750-54.
17. Shirado O, Yamazaki Y, Takeda N, Minami A. 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. 2005; 431: 120-8.
18. Laredo JD, Bard M, Chretien J, Kahn MF. Lumbar posterior marginal intra-osseous cartilaginous node. Skeletal Radiol. 1986; 15: 201-8.