A surgeon at the University of Miami Miller School of Medicine has pioneered a new, minimally invasive surgical technique for treating pars fractures, a painful and debilitating back injury that can stop adolescent athletes in their tracks.
A pars fracture is a break in the pars interarticularis, a small connecting bone in the lumbar spine, which is caused by repetitive stress on the lower back – most often in young, physically active patients.
Once imaging confirms a pars fracture, most physicians recommend that patients stop playing sports and, to promote healing, they prescribe conservative therapies such as targeted physical therapy or bracing. Cases with severe pain resistant to conservative treatment require open back surgery consisting of fusion of one vertebrae to another, which often entails a longer and more difficult recovery.
“If bracing or casting will heal the fracture, patients can heal on their own,” said Allan D. Levi, M.D., Ph.D., chairman of neurological surgery at UHealth–the University of Miami Health System. “However, if they don’t show improvement after four to six months, physicians and patients can consider surgical options.”
The new technique developed by Dr. Levi facilitates healing of pars fractures by placing two percutaneous screws across the break in the bone. According to Dr. Levi, this minimally invasive approach uses intraoperative biplanar fluoroscopy with CT confirmation of guide wire placement to increase the precision of screw position.
Dr. Levi and his colleagues have made this surgery even less invasive by obviating the need to take bone grafts from the hip, as they place recombinant human bone morphogenic protein (rhBMP-2) and bone shavings into each defect to encourage healing.
In a 2017 study of nine patients published in the Journal of Neurosurgery, Dr. Levi and his colleagues demonstrated the efficacy of their surgical technique.
“All but one participant reported fully improved back pain, and fusion was confirmed by imaging for six of nine patients more than one year post-procedure,” Dr. Levi said.
One patient who has benefitted from the Levi Surgical Technique is Nick Mucerino, 24, who was an avid hockey player in high school when he first started having physical problems. He recalls not knowing what was wrong as he quickly went from playing hockey six days a week to being in so much pain that some days he couldn’t even get out of bed.
Four different orthopedic physicians could not confirm a diagnosis, and a series of x-rays and MRI scans offered no conclusive answers. Despite wearing a back brace and going through physical therapy, Mucerino’s back pain returned, and he was benched from the hockey team during his freshman year in college.
That’s when his mother decided to take him to see Dr. Levi. Thanks to the innovative surgery, which was followed by physical therapy, Mucerino was back on the ice in just five months. Seven years later, he’s now in law school at Barry University and plays in the Junior Hockey League for the Palm Beach Hawks.
“When you get to play the sport you love, it’s like getting back to normal,” he said.
UHealth is a leader in using the technique to repair pars fractures, according to Dr. Levi.
“We’re the only ones doing this – it’s not being done anywhere else,” he said. “People now come to Miami from across the country and around the world for this treatment.”
One such patient is Aiden Tu, a soccer and volleyball player in California who started to experience back pain in ninth grade. It worsened over time and his father, Mark Tu, M.D., a radiologist, took his son to 11 different spine specialists in a search for answers.
Dr. Tu realized open back surgery would likely leave a large scar, so he researched other treatments and learned of Dr. Levi’s minimally invasive approach. He interviewed several parents whose children had had success with the surgery and then flew to Miami to meet with Dr. Levi.
Dr. Levi performed Aiden Tu’s surgery in April 2017. After three months of initial recovery, Dr. Tu took his son hiking. By five months, Aiden was playing soccer again.
“He had no pain at all,” Dr. Tu said. “We saw a CT scan of the area that was operated on, and it showed a complete fusion of the pars defect.”
A minimally invasive approach to pars defects is both feasible and favorable, according to Dr. Levi.
“Direct pars repairs with placement of intralaminar instrumentation across the defect with rhBMP-2 supplementation offers an alternative methodology with equivalent fusion and pain-free success rates,” Dr. Levi said. “This is particularly true in young patients with a high desire to return to competitive sports and activity.”