V-Rod Technique for Direct Repair Surgery of Pediatric Lumbar Spondylolysis Combined with Posterior Apophyseal Ring Fracture
A 16-year-old boy presented to his primary care physician complaints of strong back pain and leg pain. He was a very active member of a baseball team. Magnetic resonance imaging (MRI) taken at the hospital indicated a dural compression, and this patient was treated conservatively under diagnosis of the herniated nucleous pulposus. Despite 3 months of conservative treatment, his symptom did not improve. This patient and his parents decided to visit a special sports medicine clinic for a second opinion regarding the diagnosis and treatment.\nAt the next hospital, computed tomography (CT) was taken and a fracture of the posterior ring apophysis, not the herniated nucleous pulposus, was made. As the associated disorder, the lumbar spondylolysis at L5 in the terminal stage according to the previous report [] was also identified. Since no conservative treatment was effective to reduce his pain, the doctor felt this patient would require surgical intervention. He was referred to our sports clinic for surgical treatment including both the apophyseal bony fracture and the spondylolysis.\nAt the initial presentation in our clinic, this patient complained of strong back pain and right leg pain. The back pain was exacerbated with the motion of lumbar flexion. Finger to floor distance (FFD) was 10 cm at that time. Before he had this symptom, the FFD was approximately 0 cm. The tightness in FFD at that time may be due to back pain, which was 6/10 in the visual analogue scale (VAS) scale, and/or due to sciatic pain, which was 7/10 in the VAS scale. Tenderness was noted on Valleix point at the right side. The femoral nerve stretching sign was negative bilaterally; while, he showed the positive straight leg raising test for the right side. Deep tendon reflex, manual muscle testing and sensation of legs were all intact.\nOn the plain radiographs at the first presentation, the isthmic spondylolisthesis in 20% slippage is noted at the L5 vertebral level (). However, additional instability with dynamic motion was not obvious. CT scans indicated an apophyseal ring fracture at the caudal corner of the L5 vertebral body as well as the terminal stage lumbar spondylolysis (). MRIs demonstrate obvious compression of the intracanal neural tissue by the displaced bony fragments (). Based on these clinical and radiological findings, the diagnosis of the L5 nerve root radiculopathy due to the apophyseal bony ring fracture and bilateral terminal stage spondylolysis was made.