Procedure 29 Spondylolysis Repair

Manish K. Kasliwal, Brian Walsh, Ernest Found, Vincent C. Traynelis

Indications

• Pars defect must be source of pain

• No instability on imaging

• Minimal disk degeneration present

• Patient 30 years of age or younger

• Nonsmoker

Indications Pearls

• Young healthy patients with normal sagittal alignment, no significant instability, and a positive bone scan who have failed to improve with a course of nonoperative management are the best candidates for this procedure.

Examination/Imaging

• Anteroposterior and lateral lumbar radiographs

• Flexion and extension lateral lumbar radiographs (Figure 29-1, A and B)

• Lumbosacral computed tomography (Figure 29-2)

• Bone scan

FIGURE 29-1, A-B

FIGURE 29-2

Treatment Options

• Arthrodesis with or without instrumentation

• Direct screw fixation of defect

Surgical Anatomy

• The affected lamina

• The affected pars interarticularis

• The pedicle of the affected vertebra

Positioning

• Prone on Wilson frame, laminectomy rolls, or Jackson table

Positioning Pearls

• Strive to position patient in normal lumbar lordosis. This is best accomplished by extending the hips.

Positioning Pitfalls

• Avoid significant lumbar flexion. Although this may facilitate the surgical exposure, it is not associated with optimal postoperative sagittal balance or outcome.

Positioning Equipment

• Jackson table, laminectomy rolls

Portals/Exposures

• A standard posterior lumbar exposure is used to access the affected vertebra. The lamina, facets, and proximal transverse process should be exposed (Buck, 1970; Askar, 2003; Chung, 2007; Debusscher, 2007).

• Recently, minimally invasive techniques of repair have been described using percutaneous screws and of tubular retractors (Nichol, 1986; Morscher, 1988).

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