Name: BreakThrough™ With Christopher Adams, MD—Percutaneous Pars Fracture Repair Episode 2: Technique Play-by-Play
Uploaded: 2026-10-01T10:36:00Z
Channel: Arthrex
Description: In this episode, leading spine surgeons walk through key steps and share pearls for the percutaneous pars fracture repair technique using the fully threaded spine compression screw. Joining host Christopher Adams, MD, are in-studio guests Michael A. Gallizzi, MD (Vail, CO), and Saqib Hasan, MD (San Francisco, CA).

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<p>In this episode, leading spine surgeons walk through key steps and share pearls for the percutaneous pars fracture repair technique using the fully threaded spine compression screw. Joining host Christopher Adams, MD, are in-studio guests Michael A. Gallizzi, MD (Vail, CO), and Saqib Hasan, MD (San Francisco, CA).</p>

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VID1-009106-en-US | A | BreakThrough™ With Christopher Adams, MD—Percutaneous Pars Fracture Repair Episode 2: Technique Play-by-Play

Christopher Adams

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Michael Gallizzi

Saqib Hasan, MD

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BreakThrough™ With Christopher Adams, MD—Percutaneous Pars Fracture Repair Episode 2: Technique Play-by-Play

Speaker  Hello, welcome to BreakThrough. On today's episode, we have Michael Galis from Vail, Colorado, and Saqib Hasan from San Francisco, California to share their technique. Highlights when performing percutaneous pars fracture repair utilizing the fully threaded compression screw. Mike Saqib Take it away. So Mike, why don't. Speaker  We go through a play by play? Because I think it's very important that people understand exactly the step by step procedure for how to execute a great pars fixation. Speaker  Absolutely. Speaker  So I think the most important thing is setting yourself up for success. And that's patient positioning. So what tips do you have for patient positioning for us to make sure that we have the easiest time putting that pars screw in. Speaker  I think that's a great idea because essentially these patients have a high pelvic incidence. And so a lot of times that issue that lordosis is getting in your way. So whether you're doing this with fluoro navigation or robotics, you really want to make sure that you have the correct position for the patient on the table. Some people use a Wilson frame to help fix that. Some people use a flat top. Jackson. I think this is patient dependent or procedure dependent because they're both radiolucent. Speaker  So anytime we do anything minimally invasive, we draw a lot of lines on the body that helps us kind of orient ourselves. So why don't we start by showing some of the lines we draw. Speaker  So this lateral projection is really important. You want to be perpendicular to the fracture site, knowing that the terminal point of your implant should be near that pedicle vertebral body junction. Speaker  And that's that point right there. Speaker  So whether you're doing a single incision approach or two incision approach, making the X that you make going up and out from a center position is really important. If you're trying to keep this minimally invasive in a single incision, but you do have to be aware of that spinous process that can sort of get in your way. Speaker  The X that Mike is talking about is right here. So our incision would be kind of right around here. And that's if you're doing a single incision. But sometimes the pars may be wider. So you might have an incision here and here because you might have a wider part. Speaker  Absolutely. Speaker  So when I start, I like to use a spinal needle because it allows you to kind of see where your projects are going to be before you actually make your skin incision. Speaker  Absolutely. You know, and I think we do a lot of endoscopic procedures. And essentially, depending on the soft tissue envelope, we use the long 18 gauge spinal needle that we would do for a transforaminal approach. That's what I use here as well. And again, that lets you sort of get a little feel or preoperative before you make the incision template of the trajectory and making sure that you're in the right plane on both AP and lateral. Speaker  So, Mike, once you get your needle in, I think you can then move on to the jamshidi needle, which gives you a little bit more control, right? Speaker  Correct. And you know, the nice thing about the jamshidi needle, it's a more rigid structure. So now that when you're docking and you've made your incision, you've kind of planned it with that 18 gauge needle as you insert it, you can then get a good bite on that bone. And sometimes I give it a little tap just to insert it into the bone. And then I check it again on AP and lateral to make sure that we're actually in the planned trajectory. That gives you a little more control for the next step, which is placing the guidewire. Speaker  Before. Speaker  We put the guidewire in. We should have an idea of where we want to end up, right? Speaker  That's right. Speaker  So, Mike, where do you think we should end up if we're aiming our guidewire? Speaker  Yeah. As we were talking about before, that junction of where the pedicle sort of meets the vertebral body in that corner. And then on the AP view, aiming for the mid portion of the pedicle, knowing that you do not want to go medial. If you're going to error, you want to error to the lateral half of the pedicle on the AP projection. Speaker  That's an excellent point. I think in your head you should imagine the pedicle. And you know this here is a no no area. It's okay to error a little bit lateral here if you need to, but I think that you want to have it kind of right there. This is the pars right here. So you want to have it right in the middle if you could. Obviously again erring more laterally if you could. Speaker  Yeah. But once you have docked the jamshidi needle and you're advancing your wire, I like to advance it essentially to the fracture site on the lateral projection. And then I flip back to AP just to confirm that I'm going in that direction that you discussed. Mid pedicle to lateral edge of the pedicle, and then finish advancing the guidewire to get it to that corner where the pedicle meets the vertebral body. Speaker  And that's the corner that Mike is talking about. So you want to end up in that corner because one, it has the strongest bone in the body. And two it's pretty safe area to be in. Speaker  Yes. Speaker  So once you have your guidewire in that's when you start to over drill. Correct. Speaker  Correct. Yep. And once you've placed that, you have your drill sleeve that you can advance. And really it's critical to make sure that that sleeve is all the way on the bone itself. You dilate through the soft tissue, and then you advance the sleeve over the soft tissue that docks on the bone. And you want to make sure that that sleeve is all the way to the bone right there. You can see we've dilated through the soft tissue, and now the drill guide and depth gauge sleeve is against our starting point on the bone right there. Speaker  So you can see these tines are what you should be focused on, on the lateral view. And again, we emphasize how important the lateral view is when you're doing all your work is because when you're putting your guidewire, your drill over drilling all, all the steps, you have to be cognizant of the nerve root here. Obviously the nerve root here. So you need to make sure you're always dorsal not ventral correct. Speaker  Just like you'd want to air lateral on the AP. You want to be more dorsal on the lateral. Once you have the wire in you got the sleeve. Now we're over drilling on the wire again. It's really important to stay coaxial with the wire itself because you don't want to bend it or move it in any way. And this is, you know, you can have your assistant hold it or whatever you need to have that held to make sure as you're drilling and advancing. Again, I do this under lateral fluoroscopy. I don't do it live or anything like that, but I do take periodic shots. And as you're drilling, you got to let the drill do the work. So your drilling, drilling, drilling, you may feel depending on how big that pars GAP is, you may feel it come across and then start drilling again. And that's okay to feel that, but you have to anticipate that. So you're not surprised as you cross the fracture site. Speaker  You know, a little tip that I use is that before I put my drill down, I kind of go back and forth a little bit, make sure I'm not getting bound up. And it's a nice, cool linear trajectory. That's a kind of basic orthopedic principle that we all should utilize. But I think you're right. I think the critical point here is when we're drilling, which is probably the most dangerous part of the surgery, you have to make sure you're getting lateral fluoroscopy. Still, I think the AP is important when you're first starting because you know where your goalpost is. Yes. And then the lateral just to make sure you're safe. Yes. So once you've drilled the correct directory, then you place a screw. It's pretty straightforward. Speaker  Yep. And again you want to let the screw do the work. Right. So you're advancing it under the lateral. And the reason why we keep it under the lateral is we also want to make sure that we're not pushing that guidewire anywhere, that we don't want it to go. And again, being right down the pipe, that guidewire really shouldn't move a lot. Speaker  I think it's an important point. You can see that the guidewire did move a little bit there. You see that? But that's okay, because it's still in a safe spot. Speaker  Correct. Speaker  This is our final trajectory, and you can see that I really like the way the screws placed. I think it kind of hits everything we talked about. Right. So how would you rate this screw. 0 to 10. Speaker  I'd give it a nine. Five. Speaker  Okay, I'll take that. Speaker  It's maybe a little proud on the back end, but I think for me, ending up at that corner is so important at the tip of the screw, because that really guarantees that you're going to have really good bone. And the different thread pitches are what's going to compress that fracture site that allows this to actually get a good union. Speaker  So just to kind of highlight, again, that's the pedicle. We've done a nice job of bisecting the pedicle, right? Again, criticisms, you know, maybe we could have put this in a little bit further back here and maybe end up right around here. What do you think? Speaker  Yeah. Nine. Five. Speaker  Nine. Five. We'll take it, guys. Speaker  Yeah. Speaker  Gentlemen, that was incredible. Now, when would you decide to incorporate endoscopy into your pars surgical repair? Speaker  Excellent question Chris. Utility of an endoscope really depends on the actual pathology. If it's chronic, if the edges are sclerotic, if there's large amount of gapping, I think it behooves you to actually do something more than just put a screw across it, because there's gonna be a lot of scar tissue in that fracture site, right, Mike? Speaker  Yeah, absolutely. And you bring up a great point when we're able to do this minimally invasive, not only on the insertion of the screw, but over the top debridement of the fracture site. So using the endoscope to do that endoscopic drill, being able to deliver biologics directly to the fracture site itself is another game changer to making this a true percutaneous, minimally invasive repair. Speaker  Again, that was an excellent demonstration with insightful surgical pearls. Thank you both for joining us today. Now, to learn more about fully threaded compression screws for the treatment of pars fractures, be sure to tune in to our other breakthrough episodes, including innovative solutions making the case. Lessons learned and the patient experience. Thank you for joining us.

BreakThrough™ With Christopher Adams, MD—Percutaneous Pars Fracture Repair Episode 2: Technique Play-by-Play

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