TheLimbus Vertebra: AnAnterior DiscHerniation Demonstrated ...

The Limbus Vertebra:

An Anterior Disc Herniation Demonstrated by Discography

BERNARD GHELMAN’ AND ROBERT H. FREIBERGER’

Limbus vertebra results from an intrabody herniation of Case Report

Downloaded from www.ajronline.org by 50.116.19.84 on 01/29/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved disc material. It can be mistaken for a fracture, infection, A 28-year-old woman was hospitalized because of low back

or tumor, resulting in unnecessary invasive diagnostic pain and increasing bilateral leg weakness. The admitting diag-
nosis was herniation
procedures. A case is presented in which the lesion was of the L4-L5 disc with root compression.

diagnosed by dis#{244}ography.Most radiologists are unfamiliar Pelvic traction was instituted for 3 to 4 weeks with improvement

with discograms, yet they are useful because they opacify of back pain but without relief of the pain radiating to the left
lower extremity.
the anteriorly herniated portion of the nucleus pulposus.

The anterior intraosseous herniation of the nucleus pul- Review of radiographs revealed mild levoscoliosis of the mid-

lumbar spine. The disc spaces between L2-L3 and L4-L5 were

posus producing a limbus vertebra was first described by minimally narrowed and the third lumbar vertebra had a limbus

Schmorl [1 1 in 1927 and later in detail by Niedner [2]. vertebra deformity (fig. 1A). Her x-rays had been interpreted

Despite the long interval since its first description, the previously as showing “severe arthritic changes” and “collapse

abnormality is often misdiagnosed as a fracture, infection, of the third lumbar vertebra.”
A lumbar myelogram performed
or tumor, and unnecessary surgical investigative pro- with a water soluble contrast

cedures may be undertaken for diagnosis. It is possible agent demonstrated posterior bulging of the L4-L5 disc but

to prove the nature of this lesion by discography which gave no convincing evidence of root compression. Because of

opacifies the anteriorly herniated portion of the nucleus these equivocal findings. the patient was further evaluated by

pulposus. lumbar discography. Discograms were performed using a pos-

.Fig. 1 -A. Limbus vertebra at L3 level B. Discogram of L2-L3 disc showing opacification of nucleus pulposus with evidence of opacified nucleus
Discogram
pulposus herniated between fragments of limbus vertebra at L4-L5 is normal.

Received May 10. 1976; accepted after revision June 30. 1976.

1 Department of Radiology. Hospital for Special Surgey. New York. New York 10021

Am J Roentgenol 127:854-855, 1976 854

CASE REPORTS 855

Discussion

A limbus vertebra or, in the child, a defect in the anterior

margin of the vertebral body is a common radiologic

finding. The anterosuperior corner of a single vertebral

body in the midlumbar spine is most frequently affected.

The inferior and posterior margin and other regions are

Downloaded from www.ajronline.org by 50.116.19.84 on 01/29/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved less frequently affected. Most investigators accept

Schmorl’s opinion [1 1 that the limbus vertebra results

from an intrabody herniation of disc material. Schmorl’s

nodule is a more central herniation into the vertebral end

plate (fig. 2), while the limbus vertebra is caused by a

marginal herniation. The anterior herniation of the nucleus

pulposus may cause a separation of a triangular smooth
bone fragment which apparently represents the ring apo-

physis. This apophysis then remains separate from the

body.

It has been suggested that the anterosuperior margin

of the vertebral body is more frequently affected because

of the difference in size of the adjacent vertebral bodies,

the upper one being smaller. As a result, during flexion,
the anterior portion of the disc would be forced into the

superior end plate of the large inferior vertebra [3].

Diagnosis of the limbus vertebra may be less difficult in

adults since a well formed triangular fragment is present;

in children or adolescents, only an irregular destructive-

appearing process is present on the vertebral margin.

Even when the radiologist is knowledgeable of this con-

dition, it may be difficult to persuade the referring phy-

sician that no further investigative procedures such as

open or trochar biopsies are necessary.

A discogram furnishes proof of the anterior disc hernia-

tion with less trauma and expense than a vertebral biopsy.

However, such proof should not be necessary in most

cases [4].

permission from Bone

of Radiology)

tenor midline approach. Using biplane fluoroscopy, 25-gauge
needles were
L4-L5 discs. placed in the center of the L2-L3. L3-L4. and REFERENCES

The injection of a small amount of contrast agent

(Renografin 60) into the center of the L2-L3 disc resulted in 1 . Schmorl G, Junghanns H: The Human Spine in Health and

immediate opacification of the gap between the separated mar- Disease, 2d ed, New York, Grune & Stratton, 1971

ginal fragment and the body of L3 (fig. 1 B), proving the existence 2. Niedner F: Zur Kenntnis der normalen und pathologischen
of an anterior herniation of the nucleus pulposus. Minimal non-
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radicular pain in the upper abdomen was apparently caused by

anterior extravasation of the contrast agent. 3. Hellstadius A: A contribution to the question of the origin of

The L3-L4 disc was normal. Injection of a minimal amount anterior paradiscal defects and so-called persisting apophyses
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She recovered uneventfully. 12-16, 1951

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