Introduction: Lumbar spondylolysis is highly prevalent in collegiate athletes involved in collision and endurance sports through frequent lumbar hyperextension. The authors present a clinical case series using percutaneous direct pars screw repair for lumbar spondylolysis with the use of a minimally-invasive tubular approach for curettage and bone grafting of the fracture defect.

Methods: A retrospective review for all patients treated surgically for lumbar spondylolysis via a minimally-invasive approach. Summary demographic information, clinical features of presentation, perioperative and intraoperative radiographic imaging, postoperative narcotic consumption, and visual analog scale back pain assessment were collected.

Results: Nine patients were identified (mean age 17.7 ± 3.42 years, range 14-20) 3 of which were female (33%). All patients presented with bilateral pars fractures and were distributed between the L4 (n= 4 of 9) and L5 (n = 5 of 9) levels (Table 1). The mean duration of preoperative symptoms was 17.22 ± 13.2 months (range 9-48). 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). Radiographic follow-up was available in 9 patients (100%) at a mean of 30.6 ± 23.6 months (range 1-59 m). The mean hospital length of stay was 1.13 ± 0.35 days (range 1-2 days). The mean VAS back score improved from 7.33 ± 2.35 to 0.11 ± 0.33 (Table 2). Both CT and radiographic evidence of fusion was noted in patients with greater than one year follow-up (n = 6, 66.7%). There were no intraoperative complications.

Conclusions: Lumbar spondylolysis treatment with a minimally invasive direct pars repair is a safe and technically feasible option whereby minimizing muscle and soft tissue dissection particularly benefits the adolescent population with a desire to return to a high level of physical activity.

Patient Care: This series provides vital clinical follow-up for the use of a minimally-invasive technique for the treatment of a lumbar spondylolysis in young athletes.

Learning Objectives: To describe the use of a minimally-invasive surgical treatment of lumbar spondylolysis in athletes by a fluoroscopically-guided direct pars screw with recombinant-human bone morphogenetic protein-2, with clinical and radiographic follow-up.

References: REFERENCES 1. Askar Z, Wardlaw D, Koti M: Scott wiring for direct repair of lumbar spondylolysis. Spine (Phila Pa 1976) 28:354-357, 2003 2. Bach K, Ahmadian A, Deukmedjian A, Uribe JS: Minimally invasive surgical techniques in adult degenerative spinal deformity: a systematic review. Clin Orthop Relat Res 472:1749-1761, 2014 3. Beutler WJ, Fredrickson BE, Murtland A, Sweeney CA, Grant WD, Baker D: The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976) 28:1027-1035; discussion 1035, 2003 4. Bradford DS, Iza J: Repair of the defect in spondylolysis or minimal degrees of spondylolisthesis by segmental wire fixation and bone grafting. Spine (Phila Pa 1976) 10:673-679, 1985 5. Buck JE: Direct repair of the defect in spondylolisthesis. Preliminary report. J Bone Joint Surg Br 52:432-437, 1970 6. Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD: Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg 14:417-424, 2006 7. Crawford CH, 3rd, Ledonio CG, Bess RS, Buchowski JM, Burton DC, Hu SS, et al: Current Evidence Regarding the Etiology, Prevalence, Natural History, and Prognosis of Pediatric Lumbar Spondylolysis: A Report from the Scoliosis Research Society Evidence-Based Medicine Committee. Spine Deform 3:12-29, 2015 8. Debnath UK, Freeman BJ, Gregory P, de la Harpe D, Kerslake RW, Webb JK: Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg Br 85:244-249, 2003 9. Debnath UK, Freeman BJ, Grevitt MP, Sithole J, Scammell BE, Webb JK: Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine (Phila Pa 1976) 32:995-1000, 2007 10. Deguchi M, Rapoff AJ, Zdeblick TA: Biomechanical comparison of spondylolysis fixation techniques. Spine (Phila Pa 1976) 24:328-333, 1999 11. Dreyzin V, Esses SI: A comparative analysis of spondylolysis repair. Spine (Phila Pa 1976) 19:1909-1914; discussion 1915, 1994 12. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP: The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 66:699-707, 1984 13. Gillis CC, Eichholz K, Thoman WJ, Fessler RG: A minimally invasive approach to defects of the pars interarticularis: Restoring function in competitive athletes. Clin Neurol Neurosurg 139:29-34, 2015 14. Goldstein MJ, Bruffey J, Eastlack RK: New Minimally Invasive Technique for Direct Pars Interarticularis Osteosynthesis Using Cortical Screws and Spinous-Process Modular Link. Spine (Phila Pa 1976) 41:E1421-E1424, 2016 15. Grob D, Rubeli M, Scheier HJ, Dvorak J: Translaminar screw fixation of the lumbar spine. Int Orthop 16:223-226, 1992 16. Halvorsen TM, Nilsson S, Nakstad PH: [Stress fractures. Spondylolysis and spondylolisthesis of the lumbar vertebrae among young athletes with back pain]. Tidsskr Nor Laegeforen 116:1999-2001, 1996 17. Hambly M, Lee CK, Gutteling E, Zimmerman MC, Langrana N, Pyun Y: Tension band wiring-bone grafting for spondylolysis and spondylolisthesis. A clinical and biomechanical study. Spine (Phila Pa 1976) 14:455-460, 1989 18. Hardcastle PH: Repair of spondylolysis in young fast bowlers. J Bone Joint Surg Br 75:398-402, 1993 19. Harvey J, Tanner S: Low back pain in young athletes. A practical approach. Sports Med 12:394-406, 1991 20. Hefti F: Direct repair of spondylolysis with the hook screw. Orthopade 26:769-773, 1997 21. Hefti F, Seelig W, Morscher E: Repair of lumbar spondylolysis with a hook-screw. Int Orthop 16:81-85, 1992 22. Heggeness MH, Esses SI: Translaminar facet joint screw fixation for lumbar and lumbosacral fusion. A clinical and biomechanical study. Spine (Phila Pa 1976) 16:S266-269, 1991 23. Henderson ED: Results of the surgical treatment of spondylolisthesis. J Bone Joint Surg Am 48:619-642, 1966 24. Jackson DW: Low back pain in young athletes: evaluation of stress reaction and discogenic problems. Am J Sports Med 7:364-366, 1979 25. Jackson DW, Wiltse LL, Cirincoine RJ: Spondylolysis in the female gymnast. Clin Orthop Relat Res:68-73, 1976 26. Jackson DW, Wiltse LL, Dingeman RD, Hayes M: Stress reactions involving the pars interarticularis in young athletes. Am J Sports Med 9:304-312, 1981 27. Jeanneret B: Direct repair of spondylolysis. Acta Orthop Scand Suppl 251:111-115, 1993 28. Johnson GV, Thompson AG: The Scott wiring technique for direct repair of lumbar spondylolysis. J Bone Joint Surg Br 74:426-430, 1992 29. Kakiuchi M: Repair of the defect in spondylolysis. Durable fixation with pedicle screws and laminar hooks. J Bone Joint Surg Am 79:818-825, 1997 30. Koreckij T, Park DK, Fischgrund J: Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus 37:E11, 2014 31. Kujala UM, Kinnunen J, Helenius P, Orava S, Taavitsainen M, Karaharju E: Prolonged low-back pain in young athletes: a prospective case series study of findings and prognosis. Eur Spine J 8:480-484, 1999 32. Kujala UM, Salminen JJ, Taimela S, Oksanen A, Jaakkola L: Subject characteristics and low back pain in young athletes and nonathletes. Med Sci Sports Exerc 24:627-632, 1992 33. Leone A, Cianfoni A, Cerase A, Magarelli N, Bonomo L: Lumbar spondylolysis: a review. Skeletal Radiol 40:683-700, 2011 34. Markwalder TM, Reulen HJ: Translaminar screw fixation in lumbar spine pathology. Technical note. Acta Neurochir (Wien) 99:58-60, 1989 35. Menga EN, Jain A, Kebaish KM, Zimmerman SL, Sponseller PD: Anatomic parameters: direct intralaminar screw repair of spondylolysis. Spine (Phila Pa 1976) 39:E153-158, 2014 36. Micheli LJ, Wood R: Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 149:15-18, 1995 37. Morita T, Ikata T, Katoh S, Miyake R: Lumbar spondylolysis in children and adolescents. J Bone Joint Surg Br 77:620-625, 1995 38. Nazarian S: Spondylolysis and spondylolytic spondylolisthesis. A review of current concepts on pathogenesis, natural history, clinical symptoms, imaging, and therapeutic management. Eur Spine J 1:62-83, 1992 39. Nicol RO, Scott JH: Lytic spondylolysis. Repair by wiring. Spine (Phila Pa 1976) 11:1027-1030, 1986 40. Nourbakhsh A, Preuss F, Hadeed M, Shimer A: Percutaneous Direct Repair of a Pars Defect Using Intraoperative Computed Tomography Scan: A Modification of the Buck's Technique. Spine (Phila Pa 1976), 2016 41. Oh T, Scheer JK, Fakurnejad S, Dahdaleh NS, Smith ZA: Minimally invasive spinal surgery for the treatment of traumatic thoracolumbar burst fractures. J Clin Neurosci 22:42-47, 2015 42. Ohmori K, Suzuki K, Ishida Y: Translamino-pedicular screw fixation with bone grafting for symptomatic isthmic lumbar spondylolysis. Neurosurgery 30:379-384, 1992 43. Pavlovcic V: Surgical treatment of spondylolysis and spondylolisthesis with a hook screw. Int Orthop 18:6-9, 1994 44. Pedersen AK, Hagen R: Spondylolysis and spondylolisthesis. Treatment by internal fixation and bone-grafting of the defect. J Bone Joint Surg Am 70:15-24, 1988 45. Purcell L: Causes and prevention of low back pain in young athletes. Paediatr Child Health 14:533-538, 2009 46. Purcell L, Micheli L: Low back pain in young athletes. Sports Health 1:212-222, 2009 47. Rossi F: Spondylolysis, spondylolisthesis and sports. J Sports Med Phys Fitness 18:317-340, 1978 48. Rossi F, Dragoni S: Lumbar spondylolysis: occurrence in competitive athletes. Updated achievements in a series of 390 cases. J Sports Med Phys Fitness 30:450-452, 1990 49. Seldomridge JA, Phillips FM: Minimally invasive spine surgery. Am J Orthop (Belle Mead NJ) 34:224-232; discussion 232, 2005 50. Singh K, Ahmadinia K, Park DK, Nandyala SV, Marquez-Lara A, Patel AA, et al: Complications of spinal fusion with utilization of bone morphogenetic protein: a systematic review of the literature. Spine (Phila Pa 1976) 39:91-101, 2014 51. Snyder LA, Shufflebarger H, O'Brien MF, Thind H, Theodore N, Kakarla UK: Spondylolysis outcomes in adolescents after direct screw repair of the pars interarticularis. J Neurosurg Spine 21:329-333, 2014 52. Songer M: Repair of the pars interarticularis defect with a cable-screw construct. Spine (Phila Pa 1976) 23:284, 1998 53. Songer MN, Rovin R: Repair of the pars interarticularis defect with a cable-screw construct. A preliminary report. Spine (Phila Pa 1976) 23:263-269, 1998 54. Spoor AB, Oner FC: Minimally invasive spine surgery in chronic low back pain patients. J Neurosurg Sci 57:203-218, 2013 55. Suh PB, Esses SI, Kostuik JP: Repair of pars interarticularis defect. The prognostic value of pars infiltration. Spine (Phila Pa 1976) 16:S445-448, 1991 56. Sutton JH, Guin PD, Theiss SM: Acute lumbar spondylolysis in intercollegiate athletes. J Spinal Disord Tech 25:422-425, 2012 57. Sys J, Michielsen J, Bracke P, Martens M, Verstreken J: Nonoperative treatment of active spondylolysis in elite athletes with normal X-ray findings: literature review and results of conservative treatment. Eur Spine J 10:498-504, 2001 58. Tallarico RA, Madom IA, Palumbo MA: Spondylolysis and spondylolisthesis in the athlete. Sports Med Arthrosc 16:32-38, 2008 59. Tokuhashi Y, Matsuzaki H: Repair of defects in spondylolysis by segmental pedicular screw hook fixation. A preliminary report. Spine (Phila Pa 1976) 21:2041-2045, 1996 60. Tonino A, van der Werf G: Direct repair of lumbar spondylolysis. 10-year follow-up of 12 previously reported cases. Acta Orthop Scand 65:91-93, 1994 61. Ulibarri JA, Anderson PA, Escarcega T, Mann D, Noonan KJ: Biomechanical and clinical evaluation of a novel technique for surgical repair of spondylolysis in adolescents. Spine (Phila Pa 1976) 31:2067-2072, 2006 62. van der Werf GJ, Tonino AJ, Zeegers WS: Direct repair of lumbar spondylolysis. Acta Orthop Scand 56:378-379, 1985 63. Widi GA, Williams SK, Levi AD: Minimally invasive direct repair of bilateral lumbar spine pars defects in athletes. Case Rep Med 2013:659078, 2013 64. Wilson L, Altaf F, Tyler P: Percutaneous pars interarticularis screw fixation: a technical note. Eur Spine J 25:1651-1654, 2016 65. Wiltse LL: The etiology of spondylolisthesis. J Bone Joint Surg Am 44-A:539-560, 1962 66. Wiltse LL, Widell EH, Jr., Jackson DW: Fatigue fracture: the basic lesion is inthmic spondylolisthesis. J Bone Joint Surg Am 57:17-22, 1975 67. Winter RB: The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 67:823, 1985