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      Repair of symptomatic bilateral L5 spondylolysis with autogenous iliac crest graft and temporary intersegmental pedicle screw fixation in youth

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          Abstract

          Background

          When symptomatic spondylolysis fail to respond to nonoperative treatment, surgical management may be required. A number of techniques have been described for repair by intrasegmental fixation with good results; however, there are still some problems. We reported a repair technique with temporary intersegmental pedicle screw fixation and autogenous iliac crest graft. The aim of present study is to assess the clinical outcomes of L5 symptomatic spondylolysis with this technique.

          Methods

          A retrospective analysis of 128 patients with L5 spondylolysis treated with this method was performed. According to CT scan, the spondylolysis were classified into 3 categories: line, intermediate, and sclerosis type. The diagnostic block test of L5 bilateral pars defect was done in all patients preoperatively. The sagittal and axial CT images were used to determine the bone union. The healing time, complications, number of spina bifida occulta, Japanese Orthopedic Association (JOA) score, and VAS for back pain were recorded. After fixation removal, the rate of ROM preservation at L5S1 was calculated.

          Results

          There were 97 patients (194 pars) followed with mean follow-up of 23 months (range, 12–36 months). The union rate of pars was 82.0% at 12 months and 94.3% at 24 months postoperatively. Low back pain VAS significantly (P < 0.05) improved from preoperative mean value of 7.2 to 1.3 at the final follow-up postoperatively (P < 0.05). JOA score increased significantly postoperatively (P < 0.05) with average improvement rate of 79.3%. The rates of L5S1 ROM preservation were 79.8% and 64.0% after fixation removal at 1 and 2 years postoperatively. There were 3 patients of delayed incision healing without other complications.

          Conclusions

          Although sacrificing L5S1 segment motion temporarily, more stability was obtained with intersegmental fixation. This technique is reliable for spondylolysis repair which has satisfactory symptom relief, high healing rate, low incidence of complications, and preserve a large part of ROM for fixed segment.

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          Most cited references 25

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          The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation.

          A prospective study of spondylolysis and spondylolisthesis was initiated in 1955 with a radiographic and clinical study of 500 first-grade children. To determine the natural history of spondylolysis and spondylolisthesis. Most studies on the natural history of spondylolysis and spondylolisthesis are based on patient populations presenting with pain. Critical to any natural history investigation is the study of a population of affected individuals, whether symptomatic or not, from onset of the condition through their lives. By study of a population from the age of 6 years to adulthood, 30 individuals were identified to have pars lesions. Data collection at a 45-year follow-up assessment included magnetic resonance imaging, a back pain questionnaire, and the SF-36 Survey. No subject with a pars defect was lost to follow-up evaluation once a lesion was identified. Subjects with unilateral defects never experienced slippage over the course of the study. Progression of spondylolisthesis slowed with each decade. There was no association of slip progression and low back pain. There was no statistically significant difference between the study population SF-36 scores and those of the general population the same age. This report is the only prospective study to document the natural history of spondylolysis and spondylolisthesis from onset through more than 45 years of life in a population unselected for pain. Subjects with pars defects follow a clinical course similar to that of the general population. There appears to be a marked slowing of slip progression with each decade, and no subject has reached a 40% slip.
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            Lumbar spondylolysis: a review.

            Spondylolysis is an osseous defect of the pars interarticularis, thought to be a developmental or acquired stress fracture secondary to chronic low-grade trauma. It is encountered most frequently in adolescents, most commonly involving the lower lumbar spine, with particularly high prevalence among athletes involved in certain sports or activities. Spondylolysis can be asymptomatic or can be a cause of spine instability, back pain, and radiculopathy. The biomechanics and pathophysiology of spondylolysis are complex and debated. Imaging is utilized to detect spondylolysis, distinguish acute and active lesions from chronic inactive non-union, help establish prognosis, guide treatment, and to assess bony healing. Radiography with satisfactory technical quality can often demonstrate a pars defect. Multislice CT with multiplanar reformats is the most accurate modality for detecting the bony defect and may also be used for assessment of osseous healing; however, as with radiographs, it is not sensitive for detection of the early edematous stress response without a fracture line and exposes the patient to ionizing radiation. Magnetic resonance (MR) imaging should be used as the primary investigation for adolescents with back pain and suspected stress reactions of the lumbar pars interarticularis. Several imaging pitfalls render MR imaging less sensitive than CT for directly visualizing the pars defects (regional degenerative changes and sclerosis). Nevertheless, the presence of bone marrow edema on fluid-sensitive images is an important early finding that may suggest stress response without a visible fracture line. Moreover, MR is the imaging modality of choice for identifying associated nerve root compression. Single-photon emission computed tomography (SPECT) use is limited by a high rate of false-positive and false-negative results and by considerable ionizing radiation exposure. In this article, we provide a review of the current concepts regarding spondylolysis, its epidemiology, pathogenesis, and general treatment guidelines, as well as a detailed review and discussion of the imaging principles for the diagnosis and follow-up of this condition.
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              The Pfirrmann classification of lumbar intervertebral disc degeneration: an independent inter- and intra-observer agreement assessment.

              Grading inter-vertebral disc degeneration (IDD) is important in the evaluation of many degenerative conditions, including patients with low back pain. Magnetic resonance imaging (MRI) is considered the best imaging instrument to evaluate IDD. The Pfirrmann classification is commonly used to grade IDD; the authors describing this classification showed an adequate agreement using it; however, there has been a paucity of independent agreement studies using this grading system. The aim of this study was to perform an independent inter- and intra-observer agreement study using the Pfirrmann classification.
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                Author and article information

                Contributors
                fangl6722@vip.sina.com
                Journal
                J Orthop Surg Res
                J Orthop Surg Res
                Journal of Orthopaedic Surgery and Research
                BioMed Central (London )
                1749-799X
                2 July 2021
                2 July 2021
                2021
                : 16
                Affiliations
                GRID grid.414252.4, ISNI 0000 0004 1761 8894, Department of Orthopedic, , The Seventh Medical Center of Chinese PLA General Hospital, ; Beijing, 100700 China
                Article
                2534
                10.1186/s13018-021-02534-y
                8252200
                34215290
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                Funding
                Funded by: PLA logistics special project
                Award ID: 20WQ036
                Funded by: General Hospital of People’s Liberation Army (CN)
                Award ID: QNC19026
                Funded by: Capital Health Research and Development of Special Funding
                Award ID: 2020-2-5091
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2021

                Surgery

                lumbar spondylolysis, repair, internal fixation, motion segment

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