Repair Of Pars Interarticularis Research Articles

Pars Interarticularis Fractures Treated with Minimally Invasive Surgery: A Literature Review.

Recurrent stress on the isthmic pars interarticularis often leads to profound injury and symptom burden. When conservative and medical management fail, there are various operative interventions that can be used. The current review details the common clinical presentation and treatment of pars injury, with a special focus on the emerging minimally invasive procedures used in isthmic pars interarticularis repair. PubMed and Google Scholar database literature reviews were conducted. The keywords and phrases that were searched include but were not limited to; "history of spondylolysis", "pars interarticularis", "pars defect", "conventional surgical repair of pars", and "minimally invasive repair of pars". The natural history, conventional presentation, etiology, risk factors, and management of pars interarticularis injury are discussed by the authors. The surgical interventions described include the Buck's repair, Morscher Screw-Hook repair, Scott's Wiring technique, and additional pedicle screw-based repairs. Minimally invasive techniques are also reviewed, including the Levi technique. Surgical intervention has been proven to be safe and effective in managing pars interarticularis fractures. However, minimally invasive techniques often provide additional benefit to patients such as reducing damage of surrounding structures, decreasing postoperative pain, and limiting the time away from sports and other activities.

Multiple-level lumbar spondylolysis and spondylolisthesis.

Lumbar spondylolysis and isthmic spondylolisthesis occur most commonly at only one spinal level. The authors report on 13 cases of lumbar spondylolysis with spondylolisthesis at multiple levels. During July 2007-March 2012, multiple-level spondylolysis associated with spondylolisthesis was diagnosed in 13 patients (10 male, 3 female) at Qilu Hospital of Shandong University. The mean patient age was 43.5 ± 14.6 years. The duration of low-back pain was 11.7 ± 5.1 months. Spondylolysis occurred at L-2 in 2 patients, L-3 in 4 patients, L-4 in all patients, and L-5 in 5 patients. Spondylolysis occurred at 3 spinal levels in 3 patients and at 2 levels in 10 patients. All patients had spondylolisthesis at 1 or 2 levels. Japanese Orthopaedic Association and visual analog scale scores were used to evaluate preoperative and postoperative neurological function and low-back pain. All patients underwent pedicle screw fixation and interbody fusion or direct pars interarticularis repair. Both low-back pain scores improved significantly after surgery (p < 0.05). Postoperative radiographs or CT scans showed satisfactory interbody fusion or pars interarticularis healing. No breakage, dislodging, or loosening of the pedicle screw hardware was observed for any patient. Multiple-level lumbar spondylolysis and spondylolisthesis occurred more often in men. Most multiplelevel lumbar spondylolysis occurred at 2 spinal levels and was associated with sports, trauma, or heavy labor. Multiplelevel lumbar spondylolysis occurred mostly at L3-5; associated spondylolisthesis usually occurred at L-4 and L-5, mostly at L-4. The treatment principle was the same as that for single-level spondylolisthesis.

Back pain in the under 20s would appear to be a ‘red flag’ of dubious significance: Results of a retrospective case note analysis

Purpose To assess whether being under the age of 20 is a significant ‘red flag’ in the presentation of first time low back pain. Method Retrospective case note analysis of patients under 20 years of age, referred into a secondary care service with pain (not deformity) over a 1-year period. Results The case notes of 86 new patients were reviewed. One patient with a serious pathology was identified, an eosinophilic granuloma. Fifty-six patients presented with non-specific mechanical spinal pain. Nine patients presented with a spondylolysis with or without associated spondylolisthesis and seven with disc degeneration/prolapse with nerve root pain. Thirteen patients (15%) received invasive treatment, six undergoing surgery (pars inter-articularis repair and discectomies), and seven had an injection (pars inter-articularis blocks, facet joint injections, transforaminal nerve root blocks or caudal epidural). Conclusion This study does not support the hypothesis that being aged under 20 years at the time of pres...

Repair of pars interarticularis defect utilizing a pedicle and laminar screw construct: a new technique based on anatomical and biomechanical analysis

The theoretical advantage of pars interarticularis repair over spinal fusion to correct pars defects is that the treatment is a direct osteosynthesis that preserves motion at the involved functional spinal unit. Several techniques and constructs have been used to achieve greater rigidity, but these techniques may risk entry into the spinal canal, and adverse events are common. A pedicle and laminar screw construct placed entirely outside the spinal canal may offer greater stiffness and achieve higher pars defect healing rates. The purpose of this study was to biomechanically assess an intralaminar screw construct in cadaveric lumbar spines in comparison with other types of constructs typically used in pars repair and to quantify the sizes of screws that can be placed safely in both normal and spondylolytic vertebrae. The L-4 and L-5 laminae in patients with spondylolysis and in controls who underwent CT (n = 41, each group) were measured by analysis of conventional axial CT images and multiplanar reformations constructed on a Vitrea workstation to determine the feasibility of translaminar fixation with a 4.5-mm-diameter screw. Biomechanical tests for torsion and flexion-extension were performed on 8 fresh human cadaveric lumbar spines before and after modeling for bilateral spondylolytic defects. Three pars repair techniques were tested at each level and in the following sequence: pedicle screw-cable, pedicle screw-rod-hook, and pedicle screw-intralaminar screw. The majority of laminae can accept 4.5 × 25-mm screws. The cable construct allowed the greatest motion and least stability across the defect in all biomechanical tests. The hook and laminar screw constructs performed similarly in all tests and exhibited no significant difference in stiffness. A surgically placed intralaminar screw construct may be a safe and effective alternative to current pars repair methods.

Direct repair of defects in lumbar spondylolysis with a new pedicle screw hook fixation: clinical, functional and Ct-assessed study

Spondylolysis is a common entity, a minority of people affected by this disease need medical care, and only a few require surgery. Reconstruction of the pars interarticularis is an interesting alternative to segmental fusion; this technique has the advantage of preserving segmental motion. Most authors report good results for young patients without intervertebral disk or facet degenerative changes. Moreover Louis also showed good to excellent results with his technique carried out among people who presented a satisfactory disk height (equal to two thirds of normal height). This could extend the number of patients for whom pars interarticularis repair could be proposed. In this study, the limit of reconstruction was set at grade 3 of the Pfirrmann's classification. The fixation of the isthmus was done with a new kind of pedicle screw hook system. This stable and strong device is easy to use, allows an anatomic pars interarticularis reconstruction of spondylolysis and avoids a postoperative bracing. Twenty-three patients were assessed in this study, the mean age at operation was 34 (range 16-52 years) and the average follow-up was for 59 months (range 6-113 months). Eight patients showed moderate degenerative disk disease before the surgery and 12 patients had a grade 1 spondylolisthesis. The visual analogical scale, the Oswestry disability index (ODI) and the modified Prolo score were used for assessment of pain and clinical outcome before and after surgery. The results were from "excellent" to "good" for twenty patients (87%) and "fair" for three of them (13%). The consolidation of the isthmus was assessed at the end of the study (CT-scan); the fusion rate was observed in 91%. Among patients aged less than 30 years results are from "good", to "excellent" in all cases and consolidation was always observed. All of them showed normal disc signal before the surgery. In the group aged more than 30 years, the results varied from "good" to "excellent' in 73% and fusion of the defect was discovered in 82% of cases. Eight of them (73%) had moderate disk signal modification before the surgery. All people with fair results displayed moderate disk degeneration signs at MRI before surgery; but two of those three patients had a failure of defect consolidation too and it is also associated with poor results by several authors. No complication was found in this series. According to the good results reported by Louis and upto the current finding, the authors believe that pars interarticularis repair can be carried out on patients with moderate degenerative disk disease; the stage 3 of Pfirrmann's classification seems a good limit. The Bone and joint research (B.J.R. system) is readily usable by any surgeon using pedicle screw systems and having a short learning curve. No device failure has been observed in this series.

Direct Repair of the Pars interarticularis for Spondylolysis and Spondylolisthesis

Spondylolysis and spondylolisthesis can be associated with significant low back pain, especially in physically active adolescents. Non-operative management is usually successful in improving symptoms, but surgical intervention is occasionally required for those that fail reduction of activity and bracing. In a subpopulation of these patients, direct repair of the pars interarticularis defect can be an effective modality of treatment. The advantage of direct pars repair over intertransverse fusion with or without segmental instrumentation is the preservation of the anatomic integrity and motion of the affected segment. We describe our experience in 5 patients (aged 15–18 years) managed by direct pars interarticularis repair after failing multimodality non-operative treatment. The length of stay averaged 3.2 days (range 3–4 days). All 5 patients were able to return to full activity with either no (60%) or minor (40%) symptoms. No immediate or delayed complications were noted. Patients were followed a minimum of 30 months (range 30–78 months). All 5 patients demonstrated evidence of bony fusion by radiographic criteria. This demonstrates that direct pars repair is a safe and effective modality to treat select groups of patients with spondylolysis and low-grade spondylolisthesis.

Direct repair of spondylolysis without spondylolisthesis, using a rod-screw construct and bone grafting of the pars defect.

A retrospective study of patient outcome after pars repair using an original technique in patients with spondylolysis without spondylolisthesis and degenerative disk disease. To assess the results of a new technique of internal fixation that avoids penetration of the spinal canal, temporary fixation of the lumbosacral junction, and postoperative bracing owing to stable instrumentation consisting of pedicle screws and a V-shaped rod resting against the inferior aspect on the spinous process and the posterior aspects of the laminas. Previously described techniques for direct repair of a pars defect often require postoperative bracing and can require intracanal penetration of wires or hooks; screws passing directly through the defect, thereby lessening the bone surface available for bone grafting; and temporary fixation of the lumbosacral junction with a plate that must be removed. Patients with painful pars defect not responding to conservative therapy and interfering with everyday life, sports, or work were considered to be eligible for direct repair of the spondylolysis rather than lumbosacral fusion, if there was no associated degenerative disk disease or spondylolisthesis. The surgical technique involves placement of screws on the pedicles of the involved vertebra and the fixation of the loose posterior arch with a solid rod bent in a V shape, taking purchase on the spinous process and laminas. A bone graft is placed under compression in the pars defect before the rod-screw construct is tightened. The first 10 patients who underwent this technique had an average follow-up of 35 months (range, 7 months to 5.3 years); mean age at operation was 26 years (range, 16-48 years). Six patients had an excellent result, returned to normal everyday life and work, and participated in sports when desired. The outcome in one patient was rated good and in one, fair. The procedure in one was considered a failure, although bone fusion seemed to have been obtained. Seven patients would recommend the operation, one would hesitate. No complications were encountered because of the specific design of the construct. This new technique offers the advantage of being easy and fast, it can be performed using a great number of available spinal instrumentations using rods and pedicle screws. There is no violation of the neural canal except in the case of a misplacement of pedicle screws. No postoperative brace was used, return to everyday life avoiding low back stress was immediate, and return to work or sports was possible 3 to 6 months after the procedure. This technique seems safe and effective but needs careful selection of patients, as do all other techniques for direct repair of pars interarticularis.