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| CASE REPORT |
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| Year : 2020 | Volume
: 18
| Issue : 1 | Page : 48-51 |
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Lumbar vertebral ring apophysis fracture with disc herniation in a young male
Raj Kumar Kollam1, Emmanuel Akanksh Bheri2, Samson Sujit Kumar Gaddam1
1 Unicorpus Polyclinic, A Unit of Unicorpus Health Foundation, Secunderabad, Telangana, India
2 Christian Medical College, Vellore, Tamil Nadu, India
| Date of Submission | 14-Sep-2019 |
| Date of Decision | 07-Oct-2019 |
| Date of Acceptance | 09-Sep-2019 |
| Date of Web Publication | 03-Feb-2020 |
Correspondence Address:
Dr. Samson Sujit Kumar Gaddam
Unicorpus Polyclinic, 20/B, Plot 10-3-163, St. Johns Road, Secunderabad - 500 025, Telangana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_40_19
Lumbar vertebral ring apophysis fracture is an uncommon cause of low back pain. It usually occurs in adolescents and young adults following a history of trauma. A high degree of suspicion and computed tomography of the spine is necessary to differentiate these injuries from the regular isolated lumbar disc herniations to enable appropriate further management. These fractures are usually associated with lumbar disc herniation in adolescents. Conservative management is the mainstay in patients without neurological deficits. Those with deficits may require surgical intervention – usually bilateral laminectomy or laminotomy and the removal of avulsed bone fragments and associated prolapsed disc. We report a case of a 24-year-old male with lumbar (L4) vertebral ring apophysis fracture with disc herniation who responded to conservative treatment.
Keywords: Apophysis, back pain, lumbar, ring fracture, slipped
How to cite this article:
Kollam RK, Bheri EA, Gaddam SS. Lumbar vertebral ring apophysis fracture with disc herniation in a young male. Curr Med Issues 2020;18:48-51 |
| Introduction | |  |
Musculoskeletal injuries are a common cause of back pain in adolescents and young adults. Low back pain due to vertebral ring apophysis fracture associated with disc herniation is a rare entity in this age group compared to adults. Vertebral ring apophysis fracture usually involves a fracture of the posterior inferior apophysis of the vertebral body. The bone fragment can move toward the thecal sac causing back pain and neural compression.[1],[2],[3],[4],[5],[6],[7],[8] In medical literature, this entity is also known by other terms such as “slipped vertebral apophysis,” “slipped vertebral epiphysis,” “avulsed vertebral rim apophysis,” “limbus vertebral fractures,” lumbar posterior marginal node,” “ring apophysis fracture,” and “lumbar posterior ring apophysis fracture.”[8] It is common in adolescents because fusion between the vertebral body and ring apophysis occurs at the age of 18–25 years. These lesions are common in the lumbar region and can be associated with disc prolapse due to attachments between the ring apophysis and annulus fibrosus. We report a case to emphasize the importance of considering vertebral ring apophysis fracture as a differential diagnosis in adolescents and young adults presenting with back pain or sciatica.
| Case Report | | |
We present a case of a 24-year-old male with severe low back pain for 6 months that started following a strenuous activity. The intensity of pain gradually increased over the initial few months. There were no symptoms of radicular pain or radiculopathy. On examination, there were no sensory or motor deficits. The bladder and bowel functions were normal. He was initially managed conservatively with analgesics, but later as the pain became severe, he underwent magnetic resonance imaging (MRI) of the lumbar spine [Figure 1] and [Figure 2] which revealed sacralization of L5 and diffuse disc bulge of L4–L5 intervertebral disc with another component superior to the prolapsed disc that is in continuity with the bone of L4 vertebral body (on T1-weighted [T1W] and T2W sequences), causing ventral thecal sac indentation [Figure 1] and [Figure 2]. MRI also revealed an incidental enlarged central canal in the cervical spinal cord. A vertebral ring apophysis fracture was suspected and Computed Tomography (CT) of the lumbar spine [Figure 3] and [Figure 4] done revealed a fracture of posteroinferior apophysis of the L4 body with the movement of the fragment into the canal. No myelogram was done. Since there were no neurological deficits, the patient was managed conservatively with bed rest and analgesics. At the follow-up of 1 year, he remains asymptomatic. | Figure 1: T1-weighted sagittal magnetic resonance imaging of the lumbar spine shows L4–L5 disc prolapse and separation of the posteroinferior part of the L4 body, bulging into the canal.(Sacralized L5)
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 | Figure 2: T2-weighted sagittal magnetic resonance imaging of the lumbar spine shows L4–L5 disc prolapse into the canal and into the gap between bone fragment and L4 body
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 | Figure 3: Axial computed tomography image of the L4 vertebral body shows apophysis ring fracture fragment bulging into the canal
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 | Figure 4: Sagittal computed tomography image of the lumbar spine shows posteroinferior apophysis ring fracture
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| Discussion | | |
The thickened periphery of the superior and inferior cartilaginous end plates of a developing vertebral body is called ring apophysis.[1] The ring apophysis appears at 5 years of age, calcifies at 13 years of age, and fuses with the vertebral body by the age of 18–25 years. The annulus fibrosus of the intervertebral disc is adhered to the superior and inferior vertebral end plates via the Sharpey's fibers and also to some fibers of the posterior longitudinal ligament.[3],[5]
Fracture of the vertebral ring apophysis is rare but an important cause of back pain in adolescents and young adults. Among all the age groups, it accounts for 5.3%–8% of lumbar disc herniations. However, it accounts for 5.8%–28% of cases with lumbar disc herniation in children and adolescents. During strenuous activity, especially in sports persons, there is avulsion of vertebral end plate fragment during herniation of the disc. However, a history of trauma or strenuous activity is elicited in only 60% of the patients.[8],[9] Experimental studies on the biomechanics of pediatric lumbar spine and animal studies have indicated the role of tension/shear stresses.[8],[10] During stress, the force is transmitted to Sharpey's fibers by the annulus fibrosus resulting in the fracture of osteocartilaginous junction and avulsion of end plate. Fractures are common along the posterior aspect of the body and in the midline, as nucleus pulposus herniates through weak point in the midline.[8] Disc material can also herniate superiorly into the vertebral body through fractured fragments and prevent proper healing and reunion of the avulsed fragment. Apophyseal ring fractures are commonly seen in end plates of L4, L5, and S1 vertebral bodies.
Based on the age of the patient, a high clinical suspicion and adequate investigations are necessary for proper management of these injuries.[4],[11],[12] CT of the lumbar spine is the investigation of choice to diagnose apophyseal fractures. CT scan helps in accurate demonstration of size, shape, and location of the fracture. It also identifies the relation between fracture fragment and the herniated disc apart from identifying calcified portions. MRI aids in the diagnosis of herniation of disc and its mass effect on neurological structures. MRI identifies only about 25% of apophyseal fractures when compared to CT scan. It is important to diagnose these fractures as the surgical management is different from that of routine lumbar disc herniations, especially in adolescents and young adults. These fractures are usually associated with single level disc herniation and very rarely two adjacent disc herniations.[13]
Based on the morphology of fracture on CT, these fractures are classified into three types by Takata et al.[14]
- Type I – There is a small and simple separation of the posterior margin of the vertebra, seen as an arcuate fragment in the canal on axial imaging. This type is common in children below 13 years
- Type II – There is a larger fragment due to avulsion fracture of the posterior rim of the vertebral body along with the overlying cartilage of the annulus fibrosus. This type is common in children and adolescents
- Type III – Fracture fragment is larger than the vertebral rim and leaves a round defect in the adjacent bone. This type is common in young adults. Our patient's findings correspond to this type of fracture. In our case, lack of neurological deficits in spite of it being Type III is probably due to the wide vertebral canal, as seen in the MRI and CT images.
A larger fracture fragment involving the superior and inferior end plates which is very rare is identified as an additional category of Type IV by Epstein et al.[7]
After diagnosis, these lesions can be managed either by conservative approach or by surgical treatment.[3],[8],[13] Type I and Type II lesions can be managed conservatively with rest and analgesics. Type III and IV lesions with neurological deficits may require surgical intervention. In our case, wide vertebral canal is probably the reason for the success of conservative treatment in spite of it being a Type III fracture. Surgery requires bilateral laminotomy or laminectomy for a good exposure, careful dissection of the sharp avulsed fragment, and excision of a prolapsed disc.[8],[12] Limited exposures such as unilateral laminectomy can lead to difficulty in dissection of mobile and sharp fractured fragment, thereby resulting in a dural tear or neurological injuries. Spinal fusion is usually not recommended as a routine if surgery is required.[8],[12]
Vertebral ring apophysis fracture should be considered as a rare cause of back pain in adolescents and can be associated with a disc prolapse. CT scanning is an indispensable investigation to correctly diagnose and properly delineate the relationship between the fractured fragment and herniated disc.
| Conclusion | | |
Vertebral ring apophysis fracture is an uncommon cause of back pain in adolescents and young adults and may be associated with disc herniation. A high degree of suspicion is necessary to differentiate these injuries from isolated disc herniations and to plan appropriate conservative or surgical management. Apart from MRI, CT is required for accurate diagnosis, classification, and proper management of these cases.
Ethics statement
Patient consent was obtained for the publication of this article.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 10. | Brown SH, Gregory DE, McGill SM. Vertebral end-plate fractures as a result of high rate pressure loading in the nucleus of the young adult porcine spine. J Biomech 2008;41:122-7. |
| 11. | Dake MD, Jacobs RP, Margolin FR. Computed tomography of posterior lumbar apophyseal ring fractures. J Comput Assist Tomogr 1985;9:730-2. |
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| 13. | Alvarenga JA, Ueta FT, Del Curto D, Ueta RH, Martins DE, Wajchenberg M, et al. Apophyseal ring fracture associated with two levels extruded disc herniation: Case report and review of the literature. Einstein (Sao Paulo) 2014;12:230-1. |
| 14. | Takata K, Inoue S, Takahashi K, Ohtsuka Y. Fracture of the posterior margin of a lumbar vertebral body. J Bone Joint Surg (Am) 1988;70:589-94. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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