QJM Advance Access published April 23, 2014 Q J Med doi:10.1093/qjmed/hcu074
Advance Access Publication 8 April 2014
Clinical picture Giant limbus vertebra mimicking a vertebral fracture of L3 was diagnosed. With pain control therapy and conservative treatment, she felt better and then was discharged 6 h latterly. Limbus vertebra represents a marginal herniation of nucleus pulposus through a defect through the vertebral endplate and beneath the ring apophysis.1,2 The anterosuperior corner of a single vertebral body in the middle lumbar spine is most frequently affected, whereas the inferior and posterior margin and other regions are less frequently affected.1–3 The anterior herniation of the nucleus pulposus may cause a separation of a smooth triangular bone fragment which apparently represents the ring
Figure 1. The radiography of the lumbar spine (1a) revealed a large bony fragment over the anterosuperior portion of the third lumbar vertebral body (arrow). 3D volume rendering imaging of sagittal computed tomography (1b) showed one large well-corticate with sclerotic margin, triangular bone fragment on anterior and superior endplate of L3 vertebrae (arrowhead), a finding that is compatible with limbus vertebra.
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A 24-year-old woman was sent to our emergency department because of a traffic accident. She presented with transient loss of consciousness and low back pain. Physical examination revealed no neurologic deficit, but tenderness over the lower back region. The radiography of the lumbar spine revealed a large bony fragment over the anterosuperior portion of third lumbar vertebral body (Figure 1a). As a result, CT of the lumbar spine was arranged. It showed a separation of a smooth large triangular bone fragment without displacement over anterosuperior corner of L3 and adjacent Schmorl’s node (Figure 1b). Anterior limbus vertebra
Clinical picture apophysis. This apophysis then remains separate from the body. Anterior limbus vertebra is typically asymptomatic, while posterior limbus vertebra has been reported to cause nerve compression and be associated with back pain. The limbus vertebra is often misdiagnosed as a fracture, which may result in unnecessary invasive procedures. The clue for radiographic differentiation of the limbus vertebra from fracture is the sclerotic margin of the triangular fragment. It can be differentiated from an acute fracture because fractures will not have sclerotic margins, but limbus vertebra will. It is important to consider limbus vertebra in the differential diagnosis, especially when a patient presents with back pain after trauma.2 Conflict of interest: None declared.
Photographs and text from: Y. Yen and F.-Z. Wu, Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. email:
[email protected];
[email protected]
References 1. Ghelman B, Freiberger RH. The limbus vertebra: an anterior disc herniation demonstrated by discography. AJR Am J Roentgenol 1976; 127:854–5. 2. Sanal HT, Yilmaz S, Simsek I. Limbus vertebra. Arthritis Rheum 2012; 64:4011. 3. Mupparapu M, Vuppalapati A, Mozaffari E. Radiographic diagnosis of Limbus vertebra on a lateral cephalometric film: report of a case. Dentomaxillofac Radiol 2002; 31:328–30.
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