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      Clinical and Radiologic Analysis of Posterior Apophyseal Ring Separation Associated with Lumbar Disc Herniation


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          We analyzed the clinical and radiologic features of posterior apophyseal ring separation (PARS) with lumbar disc herniation and suggest the proper management options according to the PARS characteristics.


          We reviewed case series of patients with PARS who underwent surgery of lumbar disc herniation. Preoperative symptoms, neurologic status, Body Mass Index, preoperative and postoperative Visual Analogue Scale (VAS) and Korean-Oswestry Disability Index (K-ODI) scores, operation types were obtained. PARS size, locations, the degree of resection were assessed.


          PARS was diagnosed in 109 (7.5%) patients among 1448 patients given surgical treatment for single level lumbar disc herniation. There were 55 (50.5%) small PARS and 54 (49.5%) large PARS. Among the large PARS group, 15 (27.8%) had lower endplate PARS of upper vertebra at the level of disc herniation. Thirty-nine (72.2%) were upper endplate PARS of lower vertebra. Among the group with upper endplate PARS of lower vertebra, unresected PARS was diagnosed in 12 (30.8%) cases and resected PARS was diagnosed in 27 (69.2%) cases. VAS and K-ODI scores changes were 3.6±2.9 and 5.4±6.4 in the unresected PARS group, 5.8±2.1 and 11.3±7.1 in the resected PARS group. The group with upper endplate PARS of lower vertebra showed significant difference of VAS ( p=0.01) and K-ODI ( p=0.013) score changes between unresected and resected PARS groups.


          The large PARS of upper endplate in lower vertebra should be removed during the surgery of lumbar disc herniation. High level or bilateral side of PARS should be widely decompressed and arthrodesis procedures are necessary if there is a possibility of secondary instability.

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          Most cited references 25

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          Overweight Japanese with body mass indexes of 23.0-24.9 have higher risks for obesity-associated disorders: a comparison of Japanese and Mongolians.

           K Shiwaku,  B Enkhmaa,  A Nogi (2003)
          The degree of obesity of Asians is less than that of Caucasians. It has been suggested that Japanese, categorized as having normal weight (BMI<25.0), as defined by WHO (2000), have a tendency toward increased incidences of dyslipidemia and diabetes. Our objective was to analyze parameters constituting obesity-associated disorders in overweight Japanese and Mongolians with a body mass index (BMI) of 23.0-24.9, and to assess the suitability for Asians of the Regional Office for Western Pacific Region of WHO criteria pertaining to obesity (WPRO criteria, 2000). Cross-sectional study in a workplace setting. A total of 386 Japanese men and 363 Japanese women, and 102 Mongolian men and 155 Mongolian women. Anthropometric measurements (weight, height, waist circumference, hip circumference and blood pressure) and metabolic measurements (plasma levels of total cholesterol, HDL cholesterol, triglyceride, glucose and insulin). Graded increases in BMI of Japanese and Mongolians were positively associated with body fat percent, waist circumference, hip circumference and waist/hip ratio. The Japanese were categorized as 22% overweight, 22% obese I, 3% obese II; the Mongolians rated as 18% overweight, 34% obese I, 19% obese II, based on the WPRO BMI criteria. The Mongolians had a higher prevalence of obesity and a higher body fat percent, but a lesser gradation of dyslipidemia, than did the BMI-matched Japanese groups. Overweight Japanese (BMI 23.0-24.9), in comparison to normal Japanese (BMI 18.5-22.9), had significant differences in systolic blood pressure, HDL-cholesterol and triglyceride in men, and in systolic and diastolic blood pressure, HDL-cholesterol, triglyceride, insulin and Homoeostasis model assessment-insulin resistance in women. In contrast, the Mongolians showed no significant differences in metabolic parameters between overweight and normal subjects, except for diastolic blood pressure. Since the relationship between abdominal fat mass and BMI is ethnic-specific, a universal BMI cutoff point is inappropriate for Asian populations such as the Japanese and Mongolians. The present investigation suggests that, while the WPRO criteria are suitable for Japanese, the WHO criteria are more appropriate for Mongolians.
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              Posterior ring apophysis separation combined with lumbar disc herniation in adults: a 10-year experience in the surgical management of 87 cases.

              The association of posterior ring apophysis separation (PRAS) with lumbar disc herniation (LDH) is uncommon and represents a true subgroup of disc herniation mainly seen in the adolescent population. The objective of this study was to describe a decade of experience in the care of adult patients with PRAS with LDH, giving particular attention to its diagnosis, surgical treatment, and outcome. This retrospective study focuses on a case series of adult patients with PRAS associated with LDH who underwent surgery for lumbar disc disease in the author's neurosurgical department between 1999 and 2008. Posterior ring apophysis separation was diagnosed in 87 (5.35%) of 1625 patients surgically treated for LDH; these patients made up the PRAS group. During a 6-month period in 2005, LDH without PRAS was diagnosed in 89 consecutive patients at the same facility; these patients constituted the control group. Presenting symptoms, physical examination findings, and preoperative imaging results were obtained from medical records. Immediate operative results were assessed, as were complications, long-term outcome, and the need for repeat surgery. This study is the first to document the distinguishing features between adult patients with and those without PRAS. The difference in average age was statistically significant (p < 0.001) between the study group (36.22 years) and the control group (44.30 years), as was the incidence of male patients (86.20% vs 71.91%, p = 0.020), incidence of military patients (74.71% vs 57.30%, p = 0.015), average duration of symptoms (16.13 vs 8.4 months, p = 0.016), and incidence of reactive scoliosis (19.54% vs 4.49%, p = 0.002). The most common anatomical location of disc herniation in the PRAS group was L5-S1 (51.72%) versus L4-L5 (53.93%) in the control group (p = 0.017). In terms of previous injury, motor deficits, back and/or leg pain, lateral or central location of LDH, mean anteroposterior diameter of disc herniation, hard or soft discs, and surgical complications, there was no statistical difference between the 2 patient groups. Similarly, there was no difference in recurrence rates and clinical outcomes between the patients with or without PRAS. Posterior ring apophysis separation with LDH is probably more common in adults than is generally recognized. It must be suspected when young male patients with persistent sciatic scoliosis and no history of injury show signs of calcified LDH. Computed tomography scanning with sagittal reconstructions is the procedure of choice for diagnosing. The L5-S1 intervertebral disc level is most commonly affected, especially the superior endplate of S-1. This condition needs more extensive surgical exposure and resection to relieve the nerve impingement. The occurrence of an apophyseal lesion was not associated with recurrent disc herniation or a fair outcome.

                Author and article information

                J Korean Neurosurg Soc
                J Korean Neurosurg Soc
                Journal of Korean Neurosurgical Society
                The Korean Neurosurgical Society
                March 2013
                31 March 2013
                : 53
                : 3
                : 145-149
                Department of Neurosurgery, Nanoori Hospital, Seoul, Korea.
                Author notes
                Address for reprints: Il-Tae Jang, M.D. Department of Neurosurgery, Nanoori Hospital, 63-8 Nonhyeon-dong, Gangnam-gu, Seoul 135-816, Korea. Tel: +82-2-3446-9797, Fax: +82-2-3448-0213, medmaxx@ 123456naver.com
                Copyright © 2013 The Korean Neurosurgical Society

                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.

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