A review of current treatment of lumbar posterior ring apophysis fracture with lumbar disc herniation

Abstract

Purpose: Lumbar posterior ring apophysis fracture (PRAF) is an uncommon disorder frequently accompanied by lumbar disc herniation (LDH). Over the years, there have constantly been published studies concerning this disorder. Due to its rarity, there is lack of an agreed treatment strategy, and lots of different opinions exist, including the choice of decompressive modalities, whether removal of apophyseal fragments or/and disc material, and the necessity of additional spinal fusion. The purpose of this review is to provide a collective opinion on the treatment of PRAF with LDH.

Methods: A MEDLINE search in the English language literature was performed from 1980 to 2012. To be included in the study, it was strictly necessary for each clinical article to provide information about the description of apophyseal fracture such as location, treatment methods and clinical outcome. The studies were mainly analyzed for general features, the related classifications and treatments.

Results: The literature searching yielded 19 articles reporting 366 patients experiencing 380 sites of fractures. All of them were case reports or case series. The classification systems of PRAF were various based on the morphology, mobilization, size or localization, and relationship between disc and fragment. The most used surgical options were posterior discectomy simultaneous excision of apophyseal fragments without spine fusion. Surgical treatment for PRAF with LDH had equally excellent clinical outcome compared with LDH alone.

Conclusions: The diverse features of apophyseal fracture lead to various modalities of classifications and operation options. Prior to operation, the surgeons should carefully make a plan to consider decompressive scope, removal of apophyseal fragment or/and disc and fusion or not. Because of methodological shortcomings in publications, it is not possible to definitively conclude what treatment modality is the best for the treatment of PRAF. More high-quality clinical studies are needed to draw more confirmable conclusions.

Fig. 1

Plain radiograph shows a bony fragment displaced into spinal canal at the lower endplate of L4 vertebra

Fig. 2

CT scan clearly demonstrates posterior detached bony fragment at the border of the posterior endplate of L4 and a round defect in the bone adjoining the fracture site

Fig. 3

Sagittal section of T2-weighted (a) and axial section (b) of MRI demonstrate that the dual sac is severely compressed, but it is difficult to distinguish that the compressive material is apophyseal fragments or/and disc material

Fig. 4

Classification of PRAF. a Type I, an arcuate simple avulsion of the posterior cortex of the endplate without osseous defect. b Type II, an avulsion fracture of the central cortical and cancellous rim of posterior vertebra. c Type III, a more lateral localized fracture involving a larger amount of the vertebral body, resulting that osseous defect anterior to the fragment is larger than the fragment. d Type IV, a fracture spans full length of vertebral bodies between the endplates (schematic drawing was cited in Talha et al. [22], with reprint permission of Eur Spine J)

Fig. 5

Flow chart of the process to treat a patient with PRAF and LDH