Journal List > J Korean Soc Spine Surg > v.22(3) > 1076056

J Korean Soc Spine Surg. 2015 Sep;22(3):118-122. Korean.
Published online September 30, 2015.  https://doi.org/10.4184/jkss.2015.22.3.118
© Copyright 2015 Korean Society of Spine Surgery
Posterior Ring Apophysis Fracture Associated with Lumbar Disc Herniation Treated by Immobile Bony Fragment Excision: A Case Report
Woo Dong Nam, M.D., Jae Hwan Cho, M.D.,* Jemin Yi, M.D., and Jaewoo Lee, M.D.
Department of Orthopaedic Surgery, College of Medicine Kangwon National University, Chuncheon, Korea.
*Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.

Corresponding author: Jemin Yi, M.D. Department of Orthopaedic Surgery, Kangwon National University Hospital 17-1 Hyoja 3-dong, Chuncheon 200-722, Korea TEL: +82-33-258-9209, FAX: +82-33-258-2149, Email: firekimdo@gmail.com
Received January 12, 2015; Revised May 06, 2015; Accepted August 12, 2015.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

Study Design

A case report.

Objectives

We report a case of posterior ring apophysis fracture (PRAF) with lumbar disc herniation treated by immobile bony fragment excision.

Summary of Literature Review

PRAF causes severe radiculopathy, so treating with surgery is common.

Materials and Methods

A 30-year-old male diagnosed with PRAF with lumbar disc herniation was treated with discectomy, but his clinical symptoms were not relieved. Consequently, bony fragment excision, extended laminectomy and interbody fusion were also done.

Results

Radicular pain was relieved and showed good clinical outcome.

Conclusions

When treating PRAF, bony fragment excision and extended laminectomy should be considered even if an immobile bony fragment exists.

Keywords: Posterior ring apophysis; Bony fragment; Interbody fusion

Figures


Fig. 1
(A-B) A sagittal and axial T2 weighted MRI of L4-5 level shows herniated disc material and bony fragment (white arrow) located centrally and markedly occupying the spinal canal space. Bony defect (asterisk) was noted at the posterior endplate of L5.
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Fig. 2
An intraoperative microscopic photo shows adequate decompression at the lateral recess to the foramen and mobilization of the left L5 root.
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Fig. 3
(A-B) Postoperative MRI and CT show a decompressed left lateral recess.
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Fig. 4
(A-B) After second operation, a sagittal and axial MRI shows adequate decompression was done at the L4-5 level.
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Fig. 5
Postoperative views after three years, (A-B) The anteroposterior and lateral views of the plain radiograph show bony union.
Click for larger image

References
1. Akhaddar A, Belfquih H, Oukabli M, Boucetta M. 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 2011;14:475–483.
2. Beggs I, Addison J. Posterior vertebral rim fractures. Br J Radiol 1998;71:567–572.
3. Yang IK, Bahk YW, Choi KH, Paik MW, Shinn KS. Posterior lumbar apophyseal ring fractures: a report of 20 cases. Neuroradiology 1994;36:453–455.
4. Savini R, Di Silvestre M, Gargiulo G, Picci P. Posterior lumbar apophyseal fractures. Spine (Phila Pa 1976) 1991;16:1118–1123.
5. Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine (Phila Pa 1976) 1992;17:1489–1496.
6. Chang CH, Lee ZL, Chen WJ, Tan CF, Chen LH. Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation. Spine (Phila Pa 1976) 2008;33:1750–1754.
7. Asazuma T, Nobuta M, Sato M, Yamagishi M, Fujikawa K. Lumbar disc herniation associated with separation of the posterior ring apophysis: analysis of five surgical cases and review of the literature. Acta Neurochir (Wien) 2003;145:461–466.
8. 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):120–128.
9. Banerian KG, Wang AM, Samberg LC, Kerr HH, Wesolowski DP. Association of vertebral end plate fracture with pediatric lumbar intervertebral disk herniation: value of CT and MR imaging. Radiology 1990;177:763–765.