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Apophyseal ring fractures on adolescents at a single center: mid- to long-term follow-up study
Arthrosc Orthop Sports Med 2023;10:67-72
Published online November 1, 2023;  https://doi.org/10.14517/aosm23010
© 2023 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine.

Byung Ho Kim, Sung Tan Cho, Oh Jun Yu, Jin Hwan Kim

Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
Correspondence to: Jin Hwan Kim, https://orcid.org/0000-0001-8695-3547
Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170, Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea. Tel: +82-31- 910-7828, Fax: +82-31-910-7967, E-mail: oskim@paik.ac.kr
Received April 6, 2023; Revised October 2, 2023; Accepted October 6, 2023.
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
Background: Apophyseal ring fractures (ARFs) are a rare disease typically found in adolescents and caused by microtraumas due to repetitious activities, especially in young active athletes. This study aimed to analyze our experience in the treatment and outcome of the disease at a single center for mid- to long-term follow-up.
Methods: This study retrospectively analyzed 649 patients < 18 years old who presented with lower back pain between 2001 and 2022. Clinical symptoms and patient characteristics were recorded along with functional outcomes. The diagnosis was confirmed by radiologic evaluation with magnetic resonance imaging and/or computed tomography. Surgical treatment was performed after conservative treatment failure.
Results: Twenty-eight (4.3%) patients with ARF were diagnosed, with a mean age at diagnosis of 14.9 years. Male patients (21 cases, 75.0%) were three times more prevalent than female patients (7 cases, 25.0%). The mean follow-up period was 39.7 months. Radiating pain was the most common symptom (15 cases). Ten cases presented neurologic symptoms (motor weakness). The most affected sites were the L5 upper endplate (13 cases) and S1 upper endplate (13 cases). There were 8 cases (28.5%) preceded by sports-related trauma. Patients who did not respond to conservative treatment or showed worsening neurologic symptoms underwent surgery, including chemonucleolysis (6 cases) and discectomy (6 cases). All patients showed improvement in subjective symptoms, including pain, until the final follow-up. There were no cases of neurologic sequelae after treatment.
Conclusion: ARF is a potentially prevalent cause of lower back pain in adolescents. ARF can be reliably treated with conservative and operative methods. Practitioners should be aware of ARF to ensure accurate diagnosis and proper treatment.
Keywords : Apophysis; Lower back pain; Adolescents; Sports
References
  1. Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (Phila Pa 1976) 2007;32:2630-7.
    Pubmed CrossRef
  2. 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.
    Pubmed CrossRef
  3. 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.
    CrossRef
  4. King L, Mior SA, Devonshire-Zielonka K. Adolescent lumbar disc herniation: a case report. J Can Chiropr Assoc 1996;40:15-8.
  5. 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.
    Pubmed KoreaMed CrossRef
  6. Huang PY, Yeh LR, Tzeng WS, et al. Imaging features of posterior limbus vertebrae. Clin Imaging 2012;36:797-802.
    Pubmed CrossRef
  7. Bae JS, Rhee WT, Kim WJ, Ha SI, Lim JH, Jang IT. Clinical and radiologic analysis of posterior apophyseal ring separation associated with lumbar disc herniation. J Korean Neurosurg Soc 2013; 53:145-9.
    Pubmed KoreaMed CrossRef
  8. Wu XY, Ma W. Posterior lumbar ring apophysis fracture. Orthop Surg 2011;3:72-7.
    Pubmed KoreaMed CrossRef
  9. Martínez-Lage JF, Poza M, Arcas P. Avulsed lumbar vertebral rim plate in an adolescent: trauma or malformation? Childs Nerv Syst 1998;14:131-4.
    Pubmed CrossRef
  10. Kazemi M. Adolescent lumbar disc herniation in a Tae Kwon Do martial artist: a case report. J Can Chiropr Assoc 1999;43:236-42.
  11. Sairyo K, Goel VK, Masuda A, et al. Three-dimensional finite element analysis of the pediatric lumbar spine. Part I: pathomechanism of apophyseal bony ring fracture. Eur Spine J 2006;15:923-9.
    Pubmed KoreaMed CrossRef
  12. Faizan A, Sairyo K, Goel VK, Biyani A, Ebraheim N. Biomechanical rationale of ossification of the secondary ossification center on apophyseal bony ring fracture: a biomechanical study. Clin Biomech (Bristol, Avon) 2007;22:1063-7.
    Pubmed CrossRef
  13. Kadam G, Narsinghpura K, Deshmukh S, Desai S. Traumatic lumbar vertebral ring apophysis fracture with disk herniation in an adolescent. Radiol Case Rep 2017;12:427-30.
    Pubmed KoreaMed CrossRef
  14. Albeck MJ, Madsen FF, Wagner A, Gjerris F. Fracture of the lumbar vertebral ring apophysis imitating disc herniation. Acta Neurochir (Wien) 1991;113:52-6.
    Pubmed CrossRef
  15. Yang IK, Bahk YW, Choi KH, Paik MW, Shinn KS. Posterior lumbar apophyseal ring fractures: a report of 20 cases. Neuroradiology 1994;36:453-5.
    Pubmed CrossRef
  16. Epstein BS. The spine: a radiological text and atlas. 3rd ed. Philadelphia: Lea & Febiger; 1969. p.35-36, 69-71.
  17. 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.
    Pubmed CrossRef
  18. Palliyil NS, Rai RR, Deogaonkar K. Limbus vertebral fracture presenting as cauda equina syndrome masquerading an acute disc prolapse - a rare case report and review of literature. J Orthop Case Rep 2018;8:38-40.
  19. Deleo T, Merotto S, Smith C, D’Angelo K. A posterior ring apophyseal fracture and disc herniation in a 21-year-old competitive basketball player: a case report. J Can Chiropr Assoc 2015;59:373-82.
  20. 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.
    Pubmed CrossRef
  21. Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine (Phila Pa 1976) 1992;17:1489-96.
    Pubmed CrossRef
  22. 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.
    Pubmed CrossRef
  23. Savini R, Di Silvestre M, Gargiulo G, Picci P. Posterior lumbar apophyseal fractures. Spine (Phila Pa 1976) 1991;16:1118-23.
    Pubmed CrossRef
  24. 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;145:461-6; discussion 466.
  25. 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. French.
  26. Ikata T, Morita T, Katoh S, Tachibana K, Maoka H. Lesions of the lumbar posterior end plate in children and adolescents. An MRI study. J Bone Joint Surg Br 1995;77:951-5.
    Pubmed CrossRef
  27. Dang L, Liu Z. A review of current treatment for lumbar disc herniation in children and adolescents. Eur Spine J 2010;19:205-14.
    Pubmed KoreaMed CrossRef
  28. Okada E, Suzuki S, Nori S, et al. The effectiveness of chemonucleolysis with condoliase for treatment of painful lumbar disc herniation. J Orthop Sci 2021;26:548-54.
    Pubmed CrossRef
  29. Higashino K, Sairyo K, Katoh S, Takao S, Kosaka H, Yasui N. Long-term outcomes of lumbar posterior apophyseal endplate lesions in children and adolescents. J Bone Joint Surg Am 2012;94:e74.
    Pubmed CrossRef
  30. Sairyo K, Nagamachi A. State-of-the-art management of low back pain in athletes: instructional lecture. J Orthop Sci 2016;21:263-72.
    Pubmed CrossRef

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