Minimally invasive direct pars repair with cannulated screws and recombinant human bone morphogenetic protein: case series and review of the literature

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The objective of this study was to describe the use of a minimally invasive surgical treatment of lumbar spondylolysis in athletes by a fluoroscopically guided direct pars screw placement with recombinant human bone morphogenetic protein–2 (rhBMP-2) and to report on clinical and radiographic outcomes.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A retrospective review was conducted of all patients treated surgically for lumbar spondylolysis via a minimally invasive direct pars repair with cannulated screws. Demographic information, clinical features of presentation, perioperative and intraoperative radiographic imaging, and postoperative data were collected. A 1-cm midline incision was performed for the placement of bilateral pars screws utilizing biplanar fluoroscopy, followed by placement of a fully threaded 4.0-mm-diameter titanium cannulated screw. A tubular table-mounted retractor was utilized for direct pars fracture visualization and debridement through a separate incision. The now-visualized pars fracture could then be decorticated, with care taken not to damage the titanium screw when using a high-speed drill. Local bone obtained from the curettage was then placed in the defect with 1.05 mg rhBMP-2 divided equally between the bilateral pars defects.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Nine patients were identified (mean age 17.7 ± 3.42 years, range 14–25 years; 6 male and 3 female). All patients had bilateral pars fractures of L-4 (n = 4) or L-5 (n = 5). The mean duration of preoperative symptoms was 17.22 ± 13.2 months (range 9–48 months). The mean operative duration was 189 ± 29 minutes (range 151–228 minutes). The mean intraoperative blood loss was 17.5 ± 10 ml (range 10–30 ml). Radiographic follow-up was available in all cases; the mean length of time from surgery to the most recent imaging study was 30.8 ± 23.3 months (range 3–59 months). The mean hospital length of stay was 1.13 ± 0.35 days (range 1–2 days). There were no intraoperative complications.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Lumbar spondylolysis treatment with a minimally invasive direct pars repair is a safe and technically feasible option that minimizes muscle and soft-tissue dissection, which may particularly benefit adolescent patients with a desire to return to a high level of physical activity.</jats:p></jats:sec>

A comparison of the techniques of direct pars interarticularis repairs for spondylolysis and low-grade spondylolisthesis: a meta-analysis

“…In 4 series, the authors used a minimally invasive approach for the Buck repair. 10,12,21,51 Three studies used bone morphogenetic protein (BMP) to aid the fusion. Eight studies used pedicle screws with laminar hooks, and 4 studies used pedicle screws with a wiring technique.…”

“…BMP was used to aid fusion in 3 studies. 10,21,46 All of these studies reported good fusion rates. Analysis of the data from this study has shown that in patients with spondylolysis and low-grade spondylolisthesis in whom conservative treatment has failed, surgical management substantially improves the outcome and return to activity.…”

“…7,9,10,12,17,18,21,31,34 Ivanic et al 18 evaluated CT scans only in cases of doubtful fusion. The remaining studies did not mention the method used for assessing fusion.…”

Use of Recombinant Human Bone Morphogenetic Protein-2 With Iliac Crest Bone Graft Instead of Iliac Crest Bone Graft Alone in Lumbar Spondylolysis

“…37 In our cohort, based on previous literature, we only used 1 mg rhBMP-2 as a dual-use drug, which was much lower than the dose used in the previous study for intervertebral fusion. 28,31,32 This may explain the lack of complications. Our findings indicate that the use of 1 mg rhBMP-2 in pars repair is safe and effective.…”

Risk factor analysis of disc and facet joint degeneration after intersegmental pedicle screw fixation for lumbar spondylolysis

“…Goldstein et al used cortical screws and a spinous-process modular link in a minimally invasive fashion under intraoperative CT navigation [ 26 ]. Ghobrial et al treated lumbar spondylolysis via a minimally invasive direct pars repair with cannulated screws [ 27 ].…”