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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 244-246

Apophyseal ring fracture, posterior longitudinal ligament lift, case report

1 Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia
2 Medical Student, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication4-Oct-2019

Correspondence Address:
Waleed Mohammad Awwad
Orthopedic Spine and Scoliosis Consultant, Department of Orthopedic Surgery, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_12_19

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How to cite this article:
Awwad WM, Alwabel MS, Alsalih KA. Apophyseal ring fracture, posterior longitudinal ligament lift, case report. J Nat Sci Med 2019;2:244-6

How to cite this URL:
Awwad WM, Alwabel MS, Alsalih KA. Apophyseal ring fracture, posterior longitudinal ligament lift, case report. J Nat Sci Med [serial online] 2019 [cited 2023 Feb 9];2:244-6. Available from: https://www.jnsmonline.org/text.asp?2019/2/4/244/266072

  Introduction Top

Apophyseal ring fractures (ARF) are rare injuries that can occur without obvious symptoms.[1] These injuries are caused by trauma in adolescents and young adults whose apophyseal ring and vertebral body are incompletely fused before the age of 18 years.[2] It is reported that most affected sites are vertebral bodies L4 and L5.[3],[4],[5]

  Case Report Top

A 14-year-old boy, one of triplets, conceived after 15 years of infertility. This 14-year-old boy had an all-terrain vehicle accident 1 month before presentation. He was seen first by a general practitioner who told him that he has muscular pain; then, he was seen by orthopedic surgeon who diagnosed him with scoliosis [Figure 1]. Symptoms persisted with no relief; family decided to visit a neuro surgeon, who told them it is a simple disc hernia and it will resolve spontaneously [Figure 2]. Finally, he was presented to our clinic with persisted severe lower back pain, back deformity, bilateral sciatica (Left > Right), severe disability, and mobilizing by a wheelchair. He neither reported any neurological deficit nor any bowel or bladder symptoms.
Figure 1: Orthogonal scoliosis films showed trunk shift and loss of normal sagittal alignment

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Figure 2: Midsagittal lumbar magnetic resonance imaging T2 image and corresponding axial cut at L4–5

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At the initial physical examination, he had trunk shift to the right, crouched Gait but no feet equinus, severe back stiffness, positive straight leg raising test (direct and crossed leg), and no focal deficit.

Due to the persisted severe symptoms and the magnetic resonance imaging (MRI) finding, which showed clearly ARF with liftoff of the posterior longitudinal ligament [Figure 3], surgery was suggested to parents and agreed, underwent L4 partial laminectomy and excision of the fragment [Figure 4], which went uneventfully. The sciatic tension signs improved immediately postoperative, while gait and the painful scoliosis improved over 6 weeks. 4 years after surgery, the patient did well and had no complains, with MRI as shown in [Figure 5].
Figure 3: Midsagittal lumbar magnetic resonance imaging T2 image showed classic separation of cartilaginous growth plate and liftoff posterior longitudinal ligament

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Figure 4: The separated cartilaginous growth plate fragment after excision

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Figure 5: Midsagittal lumbar magnetic resonance imaging T2 image and corresponding axial cut at L4–5, postsurgical

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  What Is the Diagnosis? Top


ARF is a rare injury [6],[7] that affects the posterior region of vertebral body L4 and L5 in a>90% of the cases. It is more prevalent in male adolescents and young adults.[1],[3] However, a study done recently showed that this injury can be found also in adults, those patients most affected at level of L5-S1, and especially the upper plate of S1.[8] Sports-related trauma are considered to be the main etiology.[9] The most common symptom of ARF is lower back pain, with or without radiating pain due to nerve root irritation.[4],[8],[10],[11],[12] Other symptoms are paravertebral muscle spasm, decreased motor power in lower extremity or/and sensory defect, and loss of deep tendon reflexes according to the affected nerve. However, cauda equina syndrome is a rare symptom in the patients with ARF.[8],[10] In patients with scoliosis, the cause is largely unknown. A genetic link has been suggested, as 1 in 4 patients with scoliosis has a relative with the condition, but the inheritance pattern is variable.[13] A primary muscle disorder has been postulated as a possible etiology of idiopathic scoliosis. Recently, the cause is thought to be multifactorial with genetic predisposing factors.[13],[14]

Patients with ARF can present with painful scoliosis; while the common causes of painful scoliosis are: 1. Benign lesion like osteoid osteoma. 2. Nerve root compression commonly due to simple disc hernia, or less frequently ARF.[15],[16]

The diagnosis of the ARF requires a detailed history, physical examination, and investigations. The simple radiography gives few information and presents isolated accuracy that ranges from 29% to 69%.[3],[17],[18] Computed tomography (CT) scan is the modality of choice for the diagnosis of apophyseal fractures.[19] Almost all cases mentioned in literature were diagnosed with CT scan. It has the best performance for the demonstration of size, shape, and location of the fracture.[5],[19] However, the MRI enables fragment evaluation and also shows the quality of intervertebral disc and herniated disc without exposing the patients to ionizing radiation.[7]

Our patient had clearly separated cartilaginous growth plate and posterior longitudinal ligament liftoff which resample Salter–Harris Type II fractures.[19]

Takata et al.[18] proposed a classification for ARF, that is subdivided into three types based on tomographic findings. Type I corresponds to simple separation of posterior vertebral margin without bone defect. Type II is fracture by posterior margin avulsion of vertebral body. Type III consists in a more localized posterior vertebral larger than the vertebral rim. Epstein and Epstein [20] described Type IV with a complete dislocation of the vertebral body posterior wall.

The initial treatment for acute injuries consists of analgesia, bed rest, changing the type of activity, non-steroidal antiinflammatory drugs and lumbar orthosis. The indication of surgical decompression is persistent lumbar pain, with or without neurologic deficit. In rare cases presented with neurological deficit, the surgical treatment is usually indicated without delay.[21]

The surgical intervention involves laminectomy and discectomy, but excision of bone fragment is controversial.[21],[22] In several situations, the fragment is not seen, and the injury could appear as a simple disk protrusion. However, a recent literature review highlighted that surgeons should consider the need of decompression, removal of the fragment, and fusion of the segment involved. In addition, it suggests that each case should be evaluated in an independent manner.[23]

  Clinicopathological Pearls Top

  1. ARF is a diagnosis of exclusion, especially in the presence of pain or nerve tension signs
  2. ARF mimics disc hernia clinical presentation, producing nerve tension signs according to the level. However, it cannot be treated the same way
  3. Posterior longitudinal ligament liftoff is a differentiation between soft disc hernia and ARF
  4. If ARF treated in a conservative way, it will lead to chronic spinal stenosis features.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Kurihara A, Kataoka O. Lumbar disc herniation in children and adolescents. A review of 70 operated cases and their minimum 5-year follow-up studies. Spine (Phila Pa 1976) 1980;5:443-51.  Back to cited text no. 1
Bick EM, Copel JW. The ring apophysis of the human vertebra; contribution to human osteogeny. II. J Bone Joint Surg Am 1951;33-A: 783-7.  Back to cited text no. 2
Dietemann JL, Runge M, Badoz A, Dosch JC, Beaujeux R, Bonneville JF, et al. Radiology of posterior lumbar apophyseal ring fractures: Report of 13 cases. Neuroradiology 1988;30:337-44.  Back to cited text no. 3
Laredo JD, Bard M, Chretien J, Kahn MF. Lumbar posterior marginal intra-osseous cartilaginous node. Skeletal Radiol 1986;15:201-8.  Back to cited text no. 4
Puertas EB, Wajchenberg M, Cohen M, Isoldi MN, Rodrigues LM, Souza PS. Avulsion fractures of apophysial ring (“limbus”) posterior superior of the L5 vertebra, associated to pre-marginal hernia in athletes. Acta Ortop Bras 2002;10:25-30.  Back to cited text no. 5
Yen CH, Chan SK, Ho YF, Mak KH. Posterior lumbar apophyseal ring fractures in adolescents: A report of four cases. J Orthop Surg (Hong Kong) 2009;17:85-9.  Back to cited text no. 6
Alvarenga JA, Ueta FT, Del Curto D, Ueta RH, Martins DE, Wajchenberg M. Apophyseal ring fracture associated with two levels extruded disc herniation: Case report and review of the literature. Einstein (Sao Paulo) 2014;12:230-1.  Back to cited text no. 7
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;14:475-83.  Back to cited text no. 8
Liquois F, Demay P, Filipe G. Sciatica caused by avulsion of the vertebral limbus in children. Rev Chir Orthop Reparatrice Appar Mot 1997;83:210-6.  Back to cited text no. 9
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.  Back to cited text no. 10
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;33:1750-4.  Back to cited text no. 11
Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine (Phila Pa 1976) 1992;17:1489-96.  Back to cited text no. 12
Miller MD, Thompson SR, Hart J. Review of Orthopaedics. US: Elsevier Health Sciences; 2012.  Back to cited text no. 13
Stirling AJ, Howel D, Millner PA, Sadiq S, Sharples D, Dickson RA. Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study. J Bone Joint Surg Am 1996;78:1330-6.  Back to cited text no. 14
Lin HH, Yu CT, Chang IL, Chen SJ. Painful scoliosis secondary to osteoid osteoma of the lumbar spine in adolescents. Int Surg 2008;93:32-6.  Back to cited text no. 15
Pinto FC, Poetscher AW, Quinhones FR, Pena M, Taricco MA. Lumbar disc herniation associated with scoliosis in a 15-year-old girl: Case report. Arq Neuropsiquiatr 2002;60:295-8.  Back to cited text no. 16
Krishnan A, Patel JG, Patel DA, Patel PR. Fracture of posterior margin of lumbar vertebral body. India J Orthop 2005;39:33-8.  Back to cited text no. 17
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.  Back to cited text no. 18
Salter RB, Harris WR. Injuries involving the epiphyseal plate. J Bone Joint Surg Am 1963;45:587-622.  Back to cited text no. 19
Epstein NE, Epstein JA. Limbus lumbar vertebral fractures in 27 adolescents and adults. Spine (Phila Pa 1976) 1991;16:962-6.  Back to cited text no. 20
Molina V, Court C, Dagher G, Pourjamasb B, Nordin JY. Fracture of the posterior margin of the lumbar spine: Case report after an acute, unique, and severe trauma. Spine (Phila Pa 1976) 2004;29:E565-7.  Back to cited text no. 21
Peh WC, Griffith JF, Yip DK, Leong JC. Magnetic resonance imaging of lumbar vertebral apophyseal ring fractures. Australas Radiol 1998;42:34-7.  Back to cited text no. 22
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;22:475-88.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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