Spondylolysis repair with impaction grafting and rigid fixation: prospective outcome study Matthew D Hepler, MD* Matthew T Walker, MD Eugene Lautenschlager, PhD *Vero Orthopaedics and Vero Neurology Departments of Orthopaedic Surgery and Neuroradiology Northwestern Memorial Hospital Chicago, IL mdhepler@hotmail.com

Introduction Spondylolysis is common diagnosis (6%) Chronic lesions alter lumbar biomechanics progress to spondylolysthesis or DDD cause back pain and disability Surgical treatment Pars repair high failure rate fusion sacrifices motion no consensus The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.

Treatment Controversy M Schaefer L2 Spondylolysis: Surgical vs non surgical treatment Spine Universe 6/12/2008

Purpose Prospective evaluation of clinical and radiologic outcomes of spondylolysis treated with fracture debridement, impaction grafting, and rigid fixation.

Methods Inclusion Surgery F/U (3, 6, 12, 24 mo) Lysis on MRI/CT Failed non-operative Tx Dx inj. if other pathology Surgery Fx debridement ICBG Pedicle screw/hook F/U (3, 6, 12, 24 mo) SF-36, ODI, RM, VAS Xray (incl. flex/ext) +/-CT The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.

Demographics 18 consecutive patients First 11 (12 lesions) L5 (8), L4 (2), L3 (2) 2 females, 9 males Av age: 28 (range 17-50) Extension based BP (11) Leg pain (4) Neurologix Sx (2)

Concomitant Dx Adjacent spondylolysis(2) 1 healed non operatively Spondylolisthesis (3) DDD (5) HNP (3) Schmorl nodes (2) The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate. DDD L4 Pars defect

Pars defect debridement Pannus before debridement Defect after debridement The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.

Pars repair: ICBG Bone graft The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate. Bone graft

Rigid Fixation: Pedicle-laminar claw The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.

Postoperative Treatment Discharge 1.5 days (0-3) TLSO 2-3 months PT @ 2-3 months Sport specific rehabilitation @ 3-4 months The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.

Clinical Follow-up No infections No revision surgery All patients returned to unrestricted activities @ 6 months 1 fusion for DDD @ 3 yr f/u

Outcome Measures Preop 3 mo 6 mo 1 yr 2 yr ODI 32.5 17.8 6.7 5.3 RM   Preop 3 mo 6 mo 1 yr 2 yr ODI 32.5 17.8 6.7 5.3 RM 10.6 2.0 2.4 2.8 VAS 8.3 1.3 0.9 0.7 SF-36(PCS) 34.6 (6.5) 44.7 (7.6) 51.5 (11.5) 53.3 52.5 (9.7) The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate. Statistical analysis by repeated measures ANOVA Values in parentheses are standard deviations

Radiographic Results Xray (fl/ext @ 6 mo. n=11) CT @ 6-18 mo (n=6) No defects No loosening No motion CT @ 6-18 mo (n=6) 4/6 residual unilateral defect osseous integration on repeat CT The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.

Conclusion Pars repair with impaction grafting and rigid fixation has excellent clinical and radiologic outcome Rapid return to full activities including contact sports Provides motion preservation Restores normal biomechanics Can be treated in presence of other pathology (spondylolisthesis, HNP, DDD) The fusion of the adult spine to the sacrum is fraught with difficulties and complications. Combined anterior and posterior approaches to the lumbosacral junction lessens the Pseudarthrosis rate.