Apophyseal ring fracture associated with two levels escoliosis derecha extruded disc herniation case report and… – europe pmc article – europe pmc

Apophyseal ring fractures is a rare injury ( 11) that affects the posterior region of vertebral body L4 and escoliosis derecha L5 in more than 90% of cases. It is more prevalent in male adolescents and young adults. ( 1, 12) however, a recent retrospective study showed that this injury is also escoliosis derecha found in adults and, in those patients, the most affected level was the L5-S1, especially the upper plate of S1. ( 13) in all cases reviewed in the literature, the apophyseal injury caused a single disc herniation. Our case is the unique reported in the literature because escoliosis derecha the apophyseal ring injury caused two extruded disc herniation in escoliosis derecha the adjacent levels. The most common symptoms are low back pain and radicular escoliosis derecha pain, but neurologic deficit is rare. ( 14) other symptoms include limp, paravertebral muscle spasm and shortening of ischiotibial muscle.

Sports-related microtraumas are considered the main etiology, ( 15) because they lead to progressive avulsion of apophyseal ring and escoliosis derecha cause the deviation of the fragment in direction to vertebral escoliosis derecha canal. There is no consensus concerning the injury associated with intervertebral escoliosis derecha disc. ( 10, 11)

This disease physiopathology is explained by ossification of apophyseal ring escoliosis derecha between 4-6 years of age and its fusion at roughly 18 escoliosis derecha years of age. This is firmly adhered to fibrous annulus by sharpey’s fibers and to some fibers of posterior longitudinal ligament. Therefore, microtraumas due to repetitious activities can lead to extraction of escoliosis derecha the apophyseal ring that is incompletely fused so that causing escoliosis derecha the injury.

The diagnosis of the apophyseal ring fracture requires a detailed escoliosis derecha physical exam, associated with complementary exams. The simple radiography gives few information and presents isolated accuracy escoliosis derecha that ranges from 29% to 69%. ( 12, 16, 17) the computed tomography is the ideal exam to visualize the escoliosis derecha avulsed bone fragment. However, the magnetic resonance also enables fragment evaluation, besides showing the quality of intervertebral disc and herniated disc, without the need to expose the patient to ionizing radiation.

Takata et al. ( 17) proposed a classification that is subdivided in three types based escoliosis derecha in tomographic findings. The type I corresponds to simple separation of posterior vertebral escoliosis derecha margin without bone defect; type II is the fracture by posterior margin avulsion of escoliosis derecha vertebral body; and type III consists in the small posterior fracture to escoliosis derecha a cartilaginous irregularity of motor plate. Epstein and epstein ( 18) described the type IV with a complete dislocation of the escoliosis derecha vertebral body posterior wall.

The initial treatment consists in analgesia, change of activities or interruption of physical activity, non-steroids anti-inflammatory and lumbar orthosis. When the fragment is reabsorbed or whether it will cause escoliosis derecha an extensive ossification is unknown. The indication of surgical decompression consists the gap in the escoliosis derecha conservative treatment with persistent lumbar pain that affects the functional escoliosis derecha ability of patient, with or without neurologic deficit. In rare cases with neurologic deficit the surgical treatment is escoliosis derecha indicated with no delay. ( 14)

The surgical proposed involves laminectomy and discectomy, but excision of bone fragment is controversial. ( 14, 19) in several situations, the fragment is not seen and the injury could appear escoliosis derecha as a simple disk protrusion. ( 19) if the bone fragment does not cause compression, there is no need for excision because it will increase escoliosis derecha the time and surgical risk because the mentioned fragment is escoliosis derecha located ventrally to dural sac, and its approach will cause more harm than good. In addition, the resection of the fragment does not influence the clinical escoliosis derecha results and it is not always necessary to achieve satisfactory escoliosis derecha outcomes. ( 9) epstein emphasized that when the fragment is fused, only the decompression can be conducted. ( 20)

A recent literature review ( 21) 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 escoliosis derecha independently manner.