Allan D Levi MD, PhD, FACS, Professor and Chairman of Neurosurgery at the University of Miami Miller School of Medicine talks about a pars fracture and a procedure that’s offering help for some patients.
Interview conducted by Ivanhoe Broadcast News in September 2019.
What is a pars fracture and who might be affected by something like this?
LEVI: The pars is a part of your spine or part of your vertebrae. It is in the back of the spine. It can be fractured after repetitive stress and strain, particularly after sports or sporting-related injuries. The age group that’s most susceptible to it is the young adolescent ranging in age anywhere from around 10 to 22 years old.
Is it a common injury that you see? Or, because you mostly see it in young athletic adolescents, is it rare?
LEVI: It’s relatively common, the actual injury. Many patients get better with conservative treatment. And in fact, some of the fractures will heal on their own. Some will not heal on their own but become asymptomatic or not produce symptoms. Then later in life, the patient will have symptoms when they’re 40, 50, 60. There are certain patients who are adolescents who have the fracture who don’t get better after six months or so of conservative treatment, which usually includes bracing. Those are the patients that end up getting the surgery.
If it is severe and surgery seems to be the best option, what are the standard treatments? Then, let’s talk a little bit about what you’re doing and Nick.
LEVI: Patients who fail all forms of conservative treatment would have one of two approaches. One is what we would call an indirect approach, meaning that you would fuse two vertebrae together. That fracture bridges those two vertebrae. Fusing two vertebrae in a young kid is not ideal. Typically, those procedures are done what we call open, meaning you must make an incision and move muscles around. Another approach is to put a screw through the fracture. And that is typically done open. So again, opening the muscles, somewhat higher blood loss, somewhat higher risk of infection, somewhat higher recovery time and more pain. The procedure that we described and then published over time is a technique where you basically use a minimally invasive approach to put screws across the fracture site.
When you met Nick, he was playing hockey. How long ago did he come to you and how bad was his pars fracture?
LEVI: Nick was around 17 years old and in college. He aspired to be in the big show, as they call it, and was talented. He had sustained this pars fracture while playing hockey and had six months of conservative treatment and could not go back to playing. Every time he laced on the skates, he just had severe back pain. So, he’s the kind of person that you would consider doing surgery on. We met and we talked about what were the standard approaches and what might be considered somewhat experimental. He was all in. We told him that he’d be the first person that would undergo this. And, the worst that could happen is it could fail, and we end up doing the standard approach.
Is this normally a career-ending injury for a young athlete?
LEVI: It can be for sure.
Is there a special name for the technique that you do?
LEVI: It’s basically a minimally-invasive pars fracture screw repair.
Tell us about the procedure itself, what you do, how long it takes, and the difference in recovery.
LEVI: The surgery is done under general anesthesia and the patients are lying on their stomach, so their back is exposed to us. Essentially, we make two small incisions and use X-ray – or fluoroscopy – to localize where the fracture is. We put a pin through the fracture, then get an intraoperative CAT scan to make sure the pin is exactly where we want it to be across the fracture site. We put a screw across the fracture site along the pin. Then, the other thing we do is that the screws are only good to stabilize the fracture. You really must have a bone union – or fusion, we call it. And to do that, we add some protein to help fusion, as well as some bone graft inside the fracture. That’s done through another tiny separate incision.
How long does all this take?
LEVI: People sometimes think that minimally-invasive surgery means shorter surgery. That’s not necessarily true. Actual surgical time takes us at least two to three hours to do even though the actual putting the screw in may take a couple of minutes, because it takes a lot of planning just to make sure that it’s going in the right place.
It seems very precise.
LEVI: It’s precise. The actual fracture itself is relatively small. And you’re dealing with kids, too, who tend to be small as well. So, there isn’t a lot of room for error.
So, you’re saying it would be the same result as the open, more traditional surgery?
LEVI: The same end result, but the advantage would be, less blood loss and less dissection of the spine muscles so we have less pain and then shorter length of stay in the hospital.
How long do patients normally stay compared to the other procedure?
LEVI: If they had an open fusion – indirect fusing of two vertebrae together – at least a couple of days. Most of these patients went home the next day after surgery.
And, are they walking?
LEVI: They’re walking. Our goal is not only to have them walk, of course, but to get back to competitive sports. Essentially, all of them but one has gotten back to competitive sports.
Nick had the minimally-invasive procedure, was out the next day, and returned to the ice?
LEVI: He returned to the ice about six or seven months after the surgery. In the first three months, they wear a brace. And, he had a great college career in hockey and still plays hockey. But instead of going to the big leagues, he ended up fantastically going to law school. And that’s where he’s at now.
How many procedures like this do you do a year?
LEVI: We’ve had people come from all over the country – from California to Florida to Idaho – lots of different places. We’ve even had someone come from Israel! I think it’s getting out there, and as we get the word out, mostly through publications, this will grow. We’re certainly ready to take on any new patients who might be the right patients.
How young could a patient be essentially who might get this injury?
LEVI: The youngest patient we’ve ever done was about 13 years old, and the oldest that we’ve ever done has been 25. There are certainly patients who are not candidates. For example, anybody who has significant leg pain is not a candidate. These are patients with back pain only. If they have a lot of arthritis or misalignment of the fracture, they’re unfortunately not a candidate.
When a person does sustain this injury, or this fracture, what are the symptoms that they might be feeling?
LEVI: They have severe back pain. Sometimes the fracture is on one side, but most of the time it’s on both sides. So, they usually feel it on both sides of their lower back. Sometimes they’ll get better with conservative treatment only to get recurrent pain when they start trying to push it. But I would say every case is relatively unique.
Is this something they would have to redo years later?
LEVI: As long as they fused then that should be it for them.
Since the population for the procedure is so young and their bones aren’t as developed, you’re still able to do this? Can you explain that?
LEVI: It’s been known for years and years and years that that is likely when the fracture starts, at a young age. Some people have described it in even younger patients. It is most likely the fact that because of their growing spine and the repetitive stress and kids are more active, that’s the likely reason why it happens to them. It can happen to adults as well. But typically, it’s sort of a higher velocity trauma that produces it rather than just repetitive stress and strain of sports.
Can you talk more about the diagnosis?
LEVI: The diagnosis can be difficult because you cannot diagnose it just on history or physical. You really need imaging studies. And X-rays may miss it. It’s a small fracture. Unless the views are done correctly, it’s not difficult to miss it. The best way to diagnose it is with a CAT scan. A CAT scan is able to look at fractures much better than X-rays and actually much better than an MRI scan. We often do an MRI scan to make sure that there isn’t any nerve impingement. But the test that really establishes the diagnosis is a CAT scan.
Can it get worse over time?
LEVI: It can get worse. And not knowing is always very frustrating for the patient and the parents. So that is one difficult aspect and why a lot of patients can go for months and months and months and not really know what’s going on.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Kai Hill, University of Miami Miller School of Med. PR
305-243-3249
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
