A Novel Technique for Spondylolysis Repair With Pedicle Screws, Rod and Polyester Band

Case Report With Technical Note and Systematic Literature Review

Pedro Berjano, MD, PhD; Gabriele Ristori, MD; Maryem-Fama Ismael Aguirre, MD; Francesco Langella, MD; Marco Damilano, MD; Riccardo Cecchinato, MD; Alvin Pun, MD; Claudio Lamartina, MD

Disclosures

Spine. 2020;45(24):E1682-E1691. 

In This Article

Results

Study Selection

We identified 982 studies through database searching. No additional eligible studies were identified through other sources. After screening titles and abstracts of all remaining unique articles, 26 full-text articles needed to be assessed to verify their eligibility for the inclusion in the present study. Ultimately, five of them were excluded for various reasons (two preliminary studies: Roca in 1989 and Songer in 1988; three studies presented the same procedure of Buck and Morscher techniques), resulting in the inclusion of 21 studies.

Levels of Evidence and Types of Study

The literature research reached level of evidence (LoE) IV as the best result. The review included 28.6% (6/21) technical note or biomechanical studies (LoE V)[20–25] and 71.4% (15/21) case series (LoE IV).[17,26–39] All papers were included if they presented original surgical methods. All the techniques of spondylolysis direct repair are summarized and grouped on the basis of the main implant used in Table 1.

Data From Studies

Isthmic Direct Screwing. In 1970, Buck[30] first introduced a surgical technique aimed to create a direct fixation of the pars defect. The original method places the screws from the ipsilateral lamina directly through the pars interarticularis defect. Intending to increase the accuracy and safety of screw placement, in 2008, Brennan et al[21] introduced a variation based on the O-arm (3D) navigation. In 2016, Wilson et al[24] proposed the percutaneous pars fixation combined with the use of compression screws.

Wiring. In 1987, Scott proposed the first wiring technique.[17] The loose posterior arch is fixed by cerclage wiring of the transverse process to the spinous process of the involved vertebra with the defect fusion.

Hambly proposed a variation in 1989.[22] He described an intersegmental wiring technique, where one end of the loop is tightened under the spinous process of the same vertebra and the other end is tightened under the spinous process of the segment below.

Salib and Pettine[29] described another modification of the original wiring technique: a tension band wiring around the spinous process combined with pedicle screws of the same vertebra.

Songer and Rovin[40] replaced the wire for a cable passing underneath the lamina, fixed on a pair of pedicle screws. Later, Bozart et al[28] proposed to pass a cable around a pedicle screw on each side, rather than the transverse process, and modified the Songer technique to pass the cable around the base of the spinous process and not beneath the lamina.

Butterfly Plate. In the 1980s, a segmental fixation of spondylolytic vertebra and the vertebra below was proposed by Louis.[34] The author developed a properly designed butterfly plate to fix temporarily the lumbosacral junction and the pars interarticularis defect. The plate offered a wide area for bone graft and not required the application of compressive forces across the pars interarticularis with the possible consequences of pars shortening.

Hook-screw Construct. In 1984, Morscher et al[41] described a new repair technique that used a laminar hook positioned in the defect and a compressive force placed upon it with a spring held against a screw within the articular process to achieve approximation of the pars defect.

Several modifications of this technique were proposed based on different instrumentation used. Tokuhashi and Matsuzaki[27] used the Isola pediculolaminar system; Kakiuchi[35] used the Texas Scottish Rite Hospital (TSRH) system, with a variable-angle pedicle screw; Roca et al[32] used the Diapason system that presents a hook bent at an angle of 30° to grasp the lamina in a very close-fitting way; Debusscher and Troussel[37] used the Bone and Joint Research (BJR) system, which was made up of a standard pedicle screw and a rod-laminar hook complex.

Shaped Rod. In 1999, Gillet and Petit[31] described direct repair by placing screws on the pedicles of the involved vertebra and fixing the loose posterior arch with a solid rod bent into a V-shape, taking purchase on the spinous process and laminae. In 2006, Ulibarri et al[23] reported a minimal variation of the Gillet technique using a U-shaped modular linkage in association with multiaxial pedicle screws. In 2012, Mohi[26] presented a minimally invasive variation with image-guided screw positioning.

Laminar Screw. In 2012, Patel et al[25] introduced a combination of the pedicle screw and laminar screw system to fix the posterior arch and the anterior portion of the spondylolytic vertebra. The compressive forces are applied across the pars without the reduction of the fusion surface. Furthermore, the surgical procedure is performed entirely outside the spinal canal and preserves the spinal motion.

Combination Techniques. Some papers presented a combination of various techniques.

In 2002, Tan et al[33] introduced a combination of Buck and Scott techniques: a lag screw is placed across the pars defect and a tension band cerclage is performed between this screw and the transverse process.

In 2016, Goldstein et al[36] combined the Buck and Gillet techniques. Cortical bone trajectory screws were placed across the fracture lines using navigation. A rod was contoured in a curvilinear fashion, passed through the inferior interspinous ligament, and finally connected to the screw tulip heads.

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