Surgical Repair of Pars Interarticularis Fractures

Surgical Repair of Pars Interarticularis Fractures Overview

The surgical repair of pars interarticularis fractures is now possible with new technology. Internal fixation of the fracture has improved dramatically with new O-Arm and Stealth visualization (see website on this technology). A surgeon can safely place a screw directly across the fracture site, which rigidly fixes the fracture and significantly improves healing potential. The use of bone morphogenic protein (BMP), a synthetic protein that induces the patient’s own stem cells to turn into bone healing cells speeds up the healing process and increases success rate of fusion.

The surgical repair typically takes about 3-6 months to unite. There are rare patients that can take up to a year to heal. During that period of time, the patient will need to wear a brace and reduce normal activity. Bone healing uses the same mechanical principles with a surgical repair as with a fracture left to heal on its own. The difference is that with surgery, there is solid internal fixation to make the repair rigid while the bone attempts to heal.

The healing environment also has been significantly improved. Before surgery, cartilage and fibrous tissue existed in the fracture gap between the broken fragments that prevented healing. After surgery, the fractured bone ends are cleaned of the soft tissue debris and coopted end to end. Bone graft and BMP are both placed into and around the fracture gap to induce healing potential.

Are you a candidate for surgical repair of a pars interarticularis fracture?

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(Please keep reading below for more information on this treatment.)

Which patient is a candidate for surgical repair of pars interarticularis fractures? If the patient has significant degenerative disc disease or a significant slip of one vertebra on the other, he or she would most likely not be a candidate for fracture repair. What about the patients with pars fractures and no symptoms?

This is a treatment conundrum. Some adults with bilateral pars fractures do not develop lower back symptoms in their lifetime. The question then rises if surgeons should surgically repair the non-healed pars fractures in asymptomatic children. There is not a perfect answer to this question. Athletic children do seem to have a higher incidence of lower back pain with pars fractures which leads to repair but that does not necessarily mean that every athletic child needs a surgical repair.

Most individuals with bilateral pars fractures will develop degenerative disc disease. Many will also develop a slip of one vertebra on the other (an isthmic spondylolysthesis). A good percentage of patients will develop pain and some will have disabling pain. What would be the total percentage of disabled patients with an isthmic spondylolisthesis? That information is not fully known at this point.

It is predicted that a surgical repair in the child with a spondylolysis, no slip and no degenerative disc disease will prevent the degenerative cascade that so commonly proceeds after a non-healing pars fracture. The biomechanics of the repair makes sense and to see older patients with the symptoms of a painful isthmic spondylolisthesis requiring fusion makes prevention and repair a reasonable course of treatment. However, there have not been enough pars fractures repaired and followed out long enough to see if this prediction of degenerative prevention is correct. Pars repair could eventually become the standard of care in children.

If degenerative disc disease sets in or there is a significant slip (spondylolisthesis– not spondylolysis), the surgical repair of the pars fractures may be ineffective in relieving lower back pain. A fusion may be necessary to give pain relief. The tests to determine what course of action should be performed are an MRI and a subsequent discogram (see section on discogram on this website)

For more information on surgical repair of pars interarticularis fractures, please contact Dr. Donald Corenman, spine surgeon and back specialist offering diagnostic and surgical second opinions to patients in the USA and around the world.

Related Content

(Click to Enlarge Image) CT scan of pars fracture of L5. White arrow points to fracture. Thisadolescent had 4 months in brace and continued to have pain upon return toactivity.

(Click to Enlarge Image) CT scan of L5 pars fracture. White arrows point to bilateralfractures.

(Click to Enlarge Image) L5 axial CT scan of healed pars fractures.

(Click to Enlarge Image) CT scan of healed pars fracture. White arrow points to healed fractureWhite dot in bone is tip of screw used for repair.

(Click to Enlarge Image) X-ray of pars repair. Note the screw through one side of pars and thewire tightening the other side.

(Click to Enlarge Image) Lateral X-ray of pars interarticularis fractures of L3 and L5 in a 15year old boy who has fail. Black arrow points tominimal slip of L5 on S1. The MRI notes a normal disc at that level.

(Click to Enlarge Image) CT scan of pars fractures L3 and L5. White arrows point to fractures of pars interarticularis.

(Click to Enlarge Image) CT scan of healed pars fractures after surgery.

(Click to Enlarge Image) X-ray of pars repairs. White arrows point to screw placement across repaired pars.

Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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