|Year : 2019 | Volume
| Issue : 4 | Page : 244-246
Apophyseal ring fracture, posterior longitudinal ligament lift, case report
Waleed Mohammad Awwad1, Muhannad Saleh Alwabel2, Khalid Abdulrazzak Alsalih1
1 Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia
2 Medical Student, King Saud University, Riyadh, Saudi Arabia
|Date of Web Publication||4-Oct-2019|
Waleed Mohammad Awwad
Orthopedic Spine and Scoliosis Consultant, Department of Orthopedic Surgery, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
|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
| Introduction|| |
Apophyseal ring fractures (ARF) are rare injuries that can occur without obvious symptoms. 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. It is reported that most affected sites are vertebral bodies L4 and L5.,,
| Case Report|| |
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?|| |
ARF is a rare injury , 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., 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. Sports-related trauma are considered to be the main etiology. The most common symptom of ARF is lower back pain, with or without radiating pain due to nerve root irritation.,,,, 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., 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. 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.,
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.,
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%.,, Computed tomography (CT) scan is the modality of choice for the diagnosis of apophyseal fractures. 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., However, the MRI enables fragment evaluation and also shows the quality of intervertebral disc and herniated disc without exposing the patients to ionizing radiation.
Our patient had clearly separated cartilaginous growth plate and posterior longitudinal ligament liftoff which resample Salter–Harris Type II fractures.
Takata et al. 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  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.
The surgical intervention involves laminectomy and discectomy, but excision of bone fragment is controversial., 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.
| Clinicopathological Pearls|| |
- ARF is a diagnosis of exclusion, especially in the presence of pain or nerve tension signs
- ARF mimics disc hernia clinical presentation, producing nerve tension signs according to the level. However, it cannot be treated the same way
- Posterior longitudinal ligament liftoff is a differentiation between soft disc hernia and ARF
- 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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]