29: Spondylolysis Repair

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Procedure 29 Spondylolysis Repair

Manish K. Kasliwal, Brian Walsh, Ernest Found, Vincent C. Traynelis

Indications

• Pars defect must be source of pain

• No instability on imaging

• Minimal disk degeneration present

• Patient 30 years of age or younger

• Nonsmoker

Indications Pearls

• Young healthy patients with normal sagittal alignment, no significant instability, and a positive bone scan who have failed to improve with a course of nonoperative management are the best candidates for this procedure.

Examination/Imaging

• Anteroposterior and lateral lumbar radiographs

• Flexion and extension lateral lumbar radiographs (Figure 29-1, A and B)

• Lumbosacral computed tomography (Figure 29-2)

• Bone scan

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FIGURE 29-1, A-B

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FIGURE 29-2

Treatment Options

• Arthrodesis with or without instrumentation

• Direct screw fixation of defect

Surgical Anatomy

• The affected lamina

• The affected pars interarticularis

• The pedicle of the affected vertebra

Positioning

• Prone on Wilson frame, laminectomy rolls, or Jackson table

Positioning Pearls

• Strive to position patient in normal lumbar lordosis. This is best accomplished by extending the hips.

Positioning Pitfalls

• Avoid significant lumbar flexion. Although this may facilitate the surgical exposure, it is not associated with optimal postoperative sagittal balance or outcome.

Positioning Equipment

• Jackson table, laminectomy rolls

Portals/Exposures

• A standard posterior lumbar exposure is used to access the affected vertebra. The lamina, facets, and proximal transverse process should be exposed (Buck, 1970; Askar, 2003; Chung, 2007; Debusscher, 2007).

• Recently, minimally invasive techniques of repair have been described using percutaneous screws and of tubular retractors (Nichol, 1986; Morscher, 1988).

Procedure

Step 1

• Curettage of the pars defect is performed.

• A burr is used to freshen fracture surfaces (Figure 29-3). Note that the burr and exposure of the defect margins are enlarged in Figure 29-3 to illustrate the technique. The actual débridement should disrupt as little bone as possible.

• The soft tissue between the fracture surfaces is removed (Figure 29-4).

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FIGURE 29-3

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FIGURE 29-4

Step 1 Pearls

• A small curette or cutting burr may be used for this step. Great care should be exerted to avoid excessive bone removal. If the defect is large, an autologous bone graft should be placed.

• Do not aggressively dissect the facet joint capsule.

Step 2

• A pedicle screw with a hole through its post is inserted using standard techniques.

• A cable is threaded through the hole in the pedicle screw post and around the spinous process (Figure 29-5, A and B).

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FIGURE 29-5, A-B

Step 2 Pearls

• The pars defect should be inspected carefully while tightening the cable. Once the cable is tight, the fracture edges should be well approximated (Figure 29-6, A and B).

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FIGURE 29-6, A-B

Step 2 Instrumentation/Implantation

• Pedicle screw

• Cable

Step 3

• An alternative technique uses a hook/rod construct (Figure 29-7).

• A pedicle screw is inserted using standard techniques.

• A sublaminar hook is placed, connected to the pedicle screw with a rod, and secured after compression force is applied.

• Minimal access techniques can be used to perform the same.

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FIGURE 29-7

Step 3 Pitfalls

• Care should be taken to avoid superior distraction of the lamina, which may result in suboptimal fracture alignment.

Step 3 Instrumentation/Implantation

• Pedicle screw

• Sublaminar hook

Postoperative Care and Expected Outcomes

• A camp brace is used for 6 weeks.

Evidence

Askar Z, Wardlaw D, Koti M. Scott wiring for direct repair of lumbar spondylolysis. Spine. 2003;28:354-357.

Grade B description of the Scott wiring technique in 14 patients.

Buck JE. Direct repair of the defect in spondylolisthesis: preliminary report. J Bone Joint Surg Br. 1970;52:432-437.

Grade B description of a direct screw fixation technique across the pars defect.

Chung CH, Chiu HM, Wang SJ, Hsu SY, Wei YS. Direct repair of multiple levels of lumbar spondylolysis by pedicle screw laminar hook and bone grafting: clinical, CT, and MRI-assessed study. J Spinal Disord Tech. 2007;20:399-402.

Grade B prospective study of ten patients with multiple-level lumbar spondylolysis treated with segmental pedicle screw hook fixation and autogenous bone graft. Follow-up confirmed a union rate of 75% (18 pars/24 pars) on CT scans.

Debusscher F, Troussel S. Direct repair of defects in lumbar spondylolysis with a new pedicle screw hook fixation: clinical, functional and CT-assessed study. Eur Spine J. 2007;16:1650-1658.

Grade B study of 23 patients who were treated with a pedicle hook and screw system with good clinical outcome in 20, and 91% fusion rate as assessed on a CT scan.

Morscher E, Gerber B, Fasel J. Surgical treatment of spondylolisthesis by bone grafting and direct stabilization of spondylolysis by means of a hook screw. Arch Orthop Trauma Surg. 1988;103:178-188.

Grade B description of a hook screw fixation technique in 12 patients, 10 of whom had an excellent or good outcome.

Nichol RO, Scott JHS. Lytic spondylolysis repair by wiring. Spine. 1986;11:1027-1030.

Grade C retrospective review of a wiring technique.

Noggle JC, Sciubba DM, Samdani AF, et al. Minimally invasive direct repair of lumbar spondylolysis with a pedicle screw and hook construct. Neurosurg Focus. 2008;25:E15.

Grade B review of minimally invasive pedicle screw and hook-rod technique in five patients.

Sairyo K, Sakai T, Yasui N. Minimally invasive technique for direct repair of pars interarticularis defects in adults using a percutaneous pedicle screw and hook-rod system. J Neurosurg Spine. 2009;10:492-495.

Grade C description of minimally invasive direct spondylolysis repair in two adults.

Songer MN, Rovin R. Repair of the pars interarticularis defect with a cable-screw construct: a preliminary report. Spine. 1998;23:263-269.

Grade B report with an excellent description of the technique. The outcomes of seven patients are retrospectively reviewed.

Tokuhasi Y, Matsuzaki H. Repair of defects in spondylolysis by segmental pedicular screw hook fixation: a preliminary report. Spine. 1996;21:2041-2045.

Grade B report of six patients treated with a screw-hook technique.

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