Percutaneous endoscopic lumbar discectomy in lumbar disc herniation with posterior ring apophysis fracture: A case report in a 15-year-old child

Abstract

Rationale: Lumbar disc herniation (LDH) with posterior ring apophysis fracture (PRAF) is rather rare in children, and in all age-stratified LDH patients, the incidence of RAF was 5.3% to 7.5%. Interestingly, the incidence of LDH with RAF in children (15%-32%) is several times higher than in adults, the mis-diagnosis of which may lead to delayed treatment.

Patient concerns: Here, we report a 15-year-old schoolboy who suffered from sudden low back pain and radiating pain in both lower limbs after sport activities. Symptoms persisted after 3 months of conservative treatment. Computer radiography and magnetic resonance imaging indicated central disc herniation with PRAF at L4-5.

Diagnosis: LDH with PRAF.

Interventions: The herniated disc and epiphyseal fragments were successfully excised by the percutaneous endoscopic lumbar discectomy minimal-invasive technique.

Outcomes: Surgery was successful. Symptoms were immediately relieved postoperatively with a wound of only about 7.0 mm. Discharged on the next day. No perioperative complications occurred. Moreover, the imaging and clinical outcomes were also more satisfactory during the post-operative 15 months outpatient follow-up.

Lessons: Pediatric LDH with PRAF is extremely uncommon, and there is a lack of training among physicians for such cases, which may lead to delayed diagnosis and treatment. Once a diagnosis for LDH with PRAF is established, percutaneous endoscopic lumbar discectomy is a safe and effective minimally invasive treatment to be considered, and we hope that this technique can provide more assistance in the future.

Figure 1.

Pre-operative lumbar spine anteroposterior, lateral, dynamic position views by X-ray. (A and B) Lumbar spine is anteroposterior and lateral (L-spine AP &LAT). (C and D) Lumbar spine dynamic position. The L4-5 level vertebral space was narrowed, fragments of PRAF at the lower L4 vertebral body were clearly visible.

Figure 2.

Pre-operative lumbar spine CT and MRI image features. (A–D/E and F) Pre-operative lumbar CT/MRI sagittal and axial planes showed L4-5 disc herniation (central type), fragments of PRAF with LDH at the lower L4 vertebral body were clearly visible, bilateral L5 nerve roots and the corresponding dural sac were compressed, and the spinal canal and bilateral lateral recess were both stenoses. CT = computer tomography, LDH = lumbar disc herniation. MRI = magnetic resonance imaging.

Figure 3.

Pre-operative C-arm fluoroscopy and post-operative follow-up CT image at 6 wk. (A–D) Pre-operative C-arm fluoroscopy image. (E–H) Lumbar spine CT at 6 wk after PELD showed that the L4-5 disc herniation and PRAF fragments were completely removed, the corresponding dural sac, adjacent nerve root compression, and spinal canal narrowing were significantly reduced compared with the pre-operative. CT = computer tomography. PELD = percutaneous endoscopic lumbar discectomy, PRAF = posterior ring apophysis fracture.