What is the role of surgery in the treatment of acute pars interarticularis injury?

Updated: Jan 22, 2019
  • Author: Gerard A Malanga, MD; Chief Editor: Craig C Young, MD  more...
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During the acute phase, it is the general consensus in the medical community to attempt conservative management before implementing surgical intervention. Many studies support the nonsurgical approach.

Wiltse et al demonstrated that 12 of 17 young patients diagnosed with spondylolysis showed osseous healing with conservative treatment and no surgery. [27] Steiner and Micheli demonstrated radiologic healing in 18% of 67 patients with symptomatic spondylolysis or grade I spondylolisthesis. [57] Furthermore, Blanda et al examined 62 patients with spondylolysis and found 52 patients had excellent results with conservative treatment, with an average follow-up of 4.2 years. [25] In a longitudinal study of young athletes with early detected spondylolysis who were treated with conservative management, 29 of 32 respondents had good to excellent low back outcome scores at an average follow-up interval of 9 years. [67]

Early diagnosis is an important factor for a good prognosis in bone healing. Ciullo and Jackson studied gymnasts and found that the longer symptoms were present before treatment, the more likely that surgical intervention was needed. [68] Jackson also examined 7 athletes with positive bone scans and negative lumbosacral plain films. [62] Jackson discovered that if the bony reaction was recognized early, healing at the subroentgenographic level could occur with conservative treatment.

Furthermore, Morita et studied 185 adolescents with spondylolysis and classified the pars defects into early, progressive, and terminal stages. [11] Conservative management produced healing in 73% of the early stage cases, in 38.5% of the progressive stage cases, and in 0% of the cases with terminal defects.

These studies suggest that spondylolysis can successfully be treated using conservative treatment if diagnosed at an early stage.

Sairyo et al described a new minimally invasive technique to repair pars interarticularis defects in 2 adults, in which they modified the established pedicle screw and hook-rod system technique. [69] Percutaneous insertion of bilateral pedicle screws was performed with the Sextant system; then, an illuminated tubular retractor was inserted through a small skin incision into the pars defect, and the nearby bursa and fibrocartilaginous mass were removed. The pseudoarthrosis at the spondylolytic level was decorticated, followed by implantation of bone grafts and attachment of the hook portion of the hook-rod system to the lamina. The rod was secured at the pedicle screws' tulip head. [69] Sairyo et al reported resolution of the patients' low back pain immediately postsurgery, with postoperative return to their work or sports activities by 3 months.

Gillis et al described an application of a minimally invasive surgery pars repair technique on 8 athletes which attempts to recreate the normal anatomy rather than fusing across a motion segment. The study reported that minimally invasive surgery advantages include less muscle tissue disruption and restoration of the natural anatomy which leads to a more rapid recovery, decreased perioperative pain, minimal blood loss, earlier mobilization and decreased hospital length of stay. At one year follow-up, 6 of the 8 athletes had been able to return to their previous sport activity level. [70]

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