Percutaneous endoscopic-assisted direct repair of pars defect without general anesthesia could be a satisfying treatment alternative for young patient with symptomatic lumbar spondylolysis: a technique note with case series

Rate and Duration of Bone Union for Conservative Treatment in Pediatric Lumbar Spondylolysis

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To report the detailed bone fusion rates and duration of treatment in unilateral and bilateral cases of pediatric lumbar spondylolysis (LS).

SUMMARY OF BACKGROUND DATA

Early diagnosis and optimal conservative management for LS are crucial for achieving bony healing without surgery. However, existing research on the conservative treatment of pediatric LS, particularly regarding bone union rates and treatment duration for each stage of bilateral spondylolysis, is limited.

METHODS

We retrospectively analyzed 590 pediatric patients (522 boys and 68 girls) under 18 years of age diagnosed with LS and treated conservatively from 2015 to 2021. The diagnosis was based on computed tomography scans and magnetic resonance imaging findings, with stages classified as very early, early, progressive, or terminal. Patient background, sports history, level and stage of spondylolysis, presence of spina bifida occulta, bone union rate, duration of conservative treatment, and recurrence rate were retrospectively analyzed.

RESULTS

The overall bone union rate was 81.9%, with a mean conservative treatment duration of 53.7 days. Unilateral LS cases showed decreased bone union rates with stage advancement (very early; 98.2%, early; 96.0%, progressive; 64.3%). Bilateral LS cases with progressive or terminal stage demonstrated low bone union rates (very early/very early; 100%, early/very early; 94.1%, progressive/very early; 66.7%, early/early; 82.9%, progressive/early; 32.3%, progressive/progressive; 23.7%, very early/terminal; 0%, early/terminal; 50.0%, progressive/terminal; 11.1%). The duration of conservative treatment extended as the stage of the main and contralateral lesions progressed, ranging from 39.1 days (very early/none) to 105 days (progressive/terminal). The recurrence rate after bone fusion was 16.6%, with no differences based on lesion stage.

CONCLUSIONS

In this series of 590 patients, conservative treatment yielded high bone union rates for pediatric LS. However, union rates decreased with stage advancement, especially in bilateral cases. These findings provide valuable insights for prognosticating natural history and outcome regarding LS treatment, bone union, and return to activity.

Biportal endoscopic bone graft repair and percutaneous screw fixation for lumbar spondylolysis-technical note and clinical outcomes

BACKGROUND

Lumbar spondylolysis involves a bony defect in the vertebral pars interarticularis, predominantly affecting the lower lumbar spine. This condition is a significant etiological factor in lumbar instability and recurrent lower back pain, particularly in young individuals. While conservative treatments are the primary intervention, they often fail to provide relief, necessitating surgical approaches. Notwithstanding, executing bone grafting and fixation in the pars interarticularis defect simultaneously through minimally invasive surgery remains challenging.

METHOD

This study elucidates the biportal endoscopic spinal surgery (BESS) technique, innovatively applied for bone graft repair and percutaneous cannulated screw fixation in a patient with lumbar spondylolysis. We offer a detailed walkthrough of the technical procedures supplemented with follow-up radiographic evidence.

RESULTS

The BESS technique facilitated meticulous clearance of the defect site, coupled with bone grafting and cannulated screw fixation, effectively addressing lumbar spondylolysis through a minimally invasive approach. This method holds promise for achieving substantial osseous fusion at the vertebral pars interarticularis defect site.

CONCLUSION

The BESS procedure for lumbar spondylolysis ensures a clean and prepared defect site for grafting and encourages successful osseous fusion, spotlighting its potential as a viable surgical strategy in managing this condition.

Endoscopic-assisted fusion for lumbar pars fracture repair in an adolescent patient

Minimally invasive repair of pars defects can be achieved via means of cannulation followed by tubular decortication. Given these injuries typically occur in pediatric and adolescent patients, minimal disruption to surrounding tissue during the repair is ideal. The use of an endoscopic approach to assist with repair and fusion across the pars defect is a novel consideration in the pediatric demographic, and in this case report we highlight our experience and rationale for this in treating a 14-year-old male athlete with lumbar 5 pars fracture. Radiographic evidence of bony fusion was seen by the third postoperative month. In this case report we demonstrate the invasive nature of this repair can be minimized further than current convention with successful radiographic and clinical outcomes.

Is there a place for surgical repair in adults with spondylolysis or grade-I spondylolisthesis-a systematic review and treatment algorithm

OBJECTIVES

Pars repair is less explored in adults due to associated disc degeneration with advancing age. The aim of our systematic review was to define optimal characteristics of adults with spondylolysis/grade-I spondylolisthesis suitable for pars repair and evaluate the feasibility, effectiveness, and safety of standard repair techniques in these adults.

METHODS

This systematic review is reported in line with PRISMA-P and protocol is registered with PROSPERO (CRD42020189208). Electronic searches were conducted in PubMed, Embase, Scopus, and Web of Science in June 2020 using systematic search strategy. Studies involving adults aged ≥18-years with spondylolysis/grade-1 isthmic spondylolisthesis treated with standard pars repair techniques were considered eligible. A two-staged (titles/abstracts and full-text) screening was conducted independently by three authors followed by quality assessment using the Joanna Briggs Institute critical appraisal checklist for selection of final articles for narrative synthesis.

RESULTS

A total of 5,813-articles were retrieved using systematic search strategy. First screening followed by removal of duplicates resulted in 111-articles. Second (full-text) screening resulted in exclusion of 64-articles. A final 47-articles were considered for data extraction after quality assessment. A total of 590-adults were enrolled across 47-studies; 93% were 'young adults' (18-35 years); 82% were males. Persistent low back pain was the common presenting complaint. Lysis defect was primarily bilateral (96.4%) and L5 was the most involved level (68.5%). Majority had no disc degeneration (83.5%) and had spondylolysis as the primary diagnosis (86%); only 14% had grade-I spondylolisthesis. Pars infiltration test was conducted in 22-studies and discography in 8-studies. Duration of prior conservative therapy was 3 to 72-months. Buck's repair was the commonest technique (27-studies, 372-adults). Successful repair was reported in 86% of patients treated with Buck's and ≥90% treated with Scott's, Morscher's and pedicle-screw-based techniques. Improvement in pain/functional outcomes, union rate and rate-of-return to sports/activity was high and comparable across all techniques. Intraoperative blood loss was low with minimally invasive versus traditional repair. The overall complication rate was 11.9%, with implant failure being the major complication.

CONCLUSIONS

Our systematic review establishes a definite place for lysis repair in carefully selected adults with spondylolysis/grade-I spondylolisthesis. We propose a treatment algorithm for optimizing patient selection and outcomes. We conclude that adults with age 18 to 45 years, no/mild disc or facet degenerative changes, positive diagnostic infiltration test, and normal preoperative discography will have successful outcomes with pars repair, regardless of the technique.

Lumbosacral Spondylolysis and Spondylolisthesis

Repetitive stress on the lumbosacral spine during sporting activity places the athletic patient at risk of developing symptomatic pars defect. Clinical history, physical examination, and diagnostic imaging are important to distinguish spondylolysis from other causes of lower back pain. Early pars stress reaction can be identified with advanced imaging, before the development of cortical fracture or vertebral slip progression to spondylolisthesis. Conservative management is first-line for low-grade injury with surgical intervention indicated for refractory symptoms, severe spondylolisthesis, or considerable neurologic deficit. Prompt diagnosis and management of spondylolysis leads to good outcomes and return to competition for most athletes.