Transforaminal endoscopic discectomy with temporary percutaneous pedicle screw fixation as a fusion-sparing approach for giant recurrent L4/5 disc herniation and iatrogenic pars fracture in a young female: a case report

Introduction

Microdiscectomy is the gold standard procedure for removal of lumbar disc herniation when radicular pain is refractory to conservative care or if there is associated neurological deficits. However, reoperation can occur in up to 14% of cases (1), with recurrent disc herniation at the same index level being the primary indication in up to 62% of these cases (2). Apart from recurrent disc herniation, there are also risks of durotomy, nerve damage, and spinal instability from iatrogenic bony injuries, especially in cases of significant thecal effacement.

One such bony injury is an iatrogenic pars fracture or ‘spondylosis’ (3-5), which may cause post-operative lumbar pain that worsens with activity (particularly spinal extension), or occult radiculopathy from displacement of fracture fragment (6-8). These fractures can progress to contralateral pedicular stress fracture and unstable spondylolisthesis (4,9-11), especially in the iatrogenic setting where biomechanical forces involved may be higher than typical stress fractures in athletes.

Direct repair of a pars fracture may be favored over posterolateral fusion particularly in younger patients due to its motion-preserving advantages (12). However, depending on the morphology of the remnant pars, direct repair may not be feasible. Furthermore, risks of spinal instability in the re-operation setting (following laminectomy and discectomy) can necessitate fusion of the lumbar spine. However, spinal fusion carries significant risks of adjacent segment degeneration (ASD), with 36% of patients who undergo posterior fusion requiring additional surgery at 10 years postoperatively due to ASD (13). Whilst bracing is an option, including in cases of spondylolysis, its use has not been reported in cases such as ours, where the posterior tension band (via midline laminectomy) and the disc space have also suffered significant disruption.

We therefore present an alternative surgical strategy in the form of temporary percutaneous pedicle screw posterior fixation followed by hardware removal 6 months post-operatively after successful fracture union. There are few reports of this clinical approach, which has previously only been described in cases of Chance fractures (14) and bilateral pars fractures (15,16). To the best of our knowledge, this treatment strategy has not been previously explored in literature for the management of iatrogenic pars fractures. We present this article in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-192/rc).

Case presentation

A 37-year-old female flying trapeze instructor presented with a cauda equina syndrome following L4/5 laminectomy and left sided discectomy 1 month prior at an outside institution for left L5 radiculopathy, that was disabling and limiting her ability to stand. Despite activity modification, previous trial of physiotherapy and commencement of multi-modal analgesia including Lyrica she re-presents 1 month after her index surgery. She reports awakening with saddle numbness and paraesthesia, with ‘electric shocks’ and ‘cramps’ in the buttocks and calves bilaterally, as if she had ‘ran a marathon’. Additionally, she admitted to ‘not knowing when she has finished’ her urinary stream, along with intermittent wound swelling for the past 2 weeks. She denied any postural headaches or any signs of intracranial hypotension. This was on the background of a chronic and asymptomatic thoracolumbar kyphotic deformity due to T12 compression fracture following a fall while performing flying trapeze in 2019, managed non-operatively.

On examination, she required a single-point walking stick for stability. Straight leg raises were positive bilaterally at 60 degrees. Strength remained 5/5 throughout, including ankle dorsi- and plantar-flexion. However, ankle jerks were depressed bilaterally, associated with reduced sensation from the S1 dermatome down, including in the saddle region.

All procedures performed in this study were in accordance with the ethical standards of the institutional committee. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Imaging

Magnetic resonance imaging (MRI) demonstrated a large remnant and/or recurrent central disc protrusion causing severe compression of the cauda equina nerve roots, with complete obliteration of cerebrospinal fluid (CSF) (Figure 1). In addition, there were CSF intensity epidural and subcutaneous collections, and a chronic T12 compression fracture. Computed tomography (CT) demonstrated a fracture through the left L4 pars (Figure 2).

Figure 1 MRI of lumbosacral spine demonstrating L4/5 laminectomy with giant remnant/recurrent disc protrusion and postoperative seroma. (A) T2 weighted sagittal MRI sequence. (B) T2 weighted axial MRI sequence of L4/5 intervertebral level showing critically compressed thecal sac outlined in green [1]. MRI, magnetic resonance imaging.

Figure 2 Sagittal CT bone window of lumbosacral spine demonstrating fracture of the left L4 pars (arrow). CT, computed tomography.

Surgical planning

In order to avoid the previous midline scar, including possible previous unintended durotomy with CSF leak, and given the central location of the recurrent disc herniation, and to expedite the recovery of a young fit and healthy female, a transforaminal endoscopic approach was taken. Given the patients’ young age, occupation and reluctance towards fusion, and the unfavorable morphology of the remnant pars to accommodate a direct repair due to the large amount of bone that had been removed, a shared decision was made for temporary percutaneous pedicle screw fixation, with view to hardware removal 6 months post-operatively following fracture union to re-mobilise that segment of the spine.

Procedure

A standard outside-in transforaminal endoscopic approach was taken. Targeting was performed under fluoroscopic guidance (Figure 3) using a spinal needle, guidewire, sequential dilators followed by passage of the bevelled retractor and endoscopic system (Joimax TESSYS, California, USA). Multiple large disc fragments were removed (Figure 4), with the thecal sac seen to gradually drop into anatomic position, regaining pulsatility by the conclusion of the procedure (Figure 5). This was followed by percutaneous insertion of L4 and L5 pedicle screws using standard ‘bull’s eye’ technique under fluoroscopic control (K2M Everest XT, Virginia, USA, 7.5 mm × 45 mm at L4 and 8.5 mm × 45 mm at L5), followed by connection with rods and set screws, compression applied to the left side (side of pars fracture) prior to final tightening (Figure 3).

Figure 3 AP and lateral intraoperative fluoroscopic views showing endoscopic and probe advanced past midline as well as percutaneous posterior instrumentation. AP, anteroposterior.

Figure 4 Fragments from disc herniation totaling 20 cm in length.

Figure 5 Intraoperative transforaminal endoscopic camera views of pre- (left) and post- (right) decompression of thecal sac.

Post-operative course

Our patient made an excellent post-operative recovery with minimal remnant numbness in the lateral aspect of her left foot, with occasional ‘twitches’ and ‘tight calves’ in the morning, all improving over time. Her saddle and urinary sensation had returned to normal and she no longer had significant back or leg pain. Six-week post-operative MRI showed complete excision of the disc herniation, resolution of cauda equina compression without any complication features (Figure 6A). Six-month CT imaging demonstrated union of the pars fracture (Figure 6B). Following this her hardware was removed, with 6-week post-operative flexion-extension X-rays showing preserved motion at the L4/5 segment (Figure 7).

Figure 6 Post-operative MRI and CT imaging of lumbosacral spine. (A) 6-week post-operative T2 weighted sagittal and axial MRI views showing resolution of cauda equina compression. (B) 6-month post-operative sagittal bone window CT of lumbosacral spine showing union across previous pars fracture site. CT, computed tomography; MRI, magnetic resonance imaging.

Figure 7 Six-week post-operative flexion-extension X-rays following hardware removal showing preserved segmental motion.

Discussion

Our case highlights the risks of iatrogenic injuries during spine surgery, and highlights a novel minimally invasive approach to management. Recurrent disc herniations following open surgery can be hazardous to re-approach via the midline due to scar formation, need for neural retraction, especially when the disc herniation is large or its location is central, particularly in cases of previous unintended durotomy, as was likely in our patient.

Transforaminal endoscopy offers an alternative approach through virgin anatomy (i.e., the neural foramen), and may be an ideal alternative in such cases as demonstrated by Ruetten et al. (17). Percutaneous pedicle screw placement provides advantages over open instrumentation in the form of minimized muscle and soft tissue dissection, reduced blood loss, lower complication rates and shortened hospital stays (18-20), and offers an alternative to direct pars repair (such the Buck’s technique) when such a repair is precluded by the patient’s post-operative anatomy, as was seen in our case with risk of progression to spondylolisthesis (4,21). In our case, intraoperative blood loss was 100 cc, operative time 191 minutes, and length of hospital stay three days with minimal analgesic requirements (≈100 mg tapentadol/day), contrasting with reported averages for open transforaminal lumbar interbody fusion surgery (650 cc blood loss, 210 minutes, and 8-day length of stay) (22).

Our case highlights the synergy between two minimally invasive surgery techniques, and offers an alternative solution to fusion in the form of temporary fixation and delayed hardware removal. However, this approach requires a second procedure with prolonged post-operative recovery that may not be preferred by some young patients. But in most young patients, the potential to avoid fusion and preserve segmental motion may justify the added cost and inconvenience, particularly when guided by shared decision-making between surgeon and patient. Previously not explored in literature, this surgical strategy may be favourable in younger, athletically active patients, restoring lumbar mobility and reducing the long-term risks of ASD following fusion and the potential need for additional spinal surgeries over the patient’s lifetime. However, our findings are limited by sample size as a singular case report and a larger series with comparator cohorts would be necessary to demonstrate generalisability.

Conclusions

We present a case of recurrent lumbar disc herniation with cauda equina syndrome, following open laminectomy complicated by an iatrogenic pars interarticularis fracture. Management through an endoscopic transforaminal approach highlights the advantages of minimally invasive techniques in a difficult case of re-operation where complications associated with traditional open laminectomy was present. Additionally, percutaneous pedicle screw fixation followed by hardware removal after radiological healing, suggests this may be a promising a motion-preserving alternative to fusion in select cases involving younger patients where fusion may be less desirable. Surgeons should consider minimally invasive, motion-preserving approaches in similar complex revision cases.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-192/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-192/prf

Funding: Lifehealthcare Pty provided funding for covering of APC expenses for the publication of this manuscript.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-aw-192/coif). P.N. serves as an unpaid managing editor of Journal of Spine Surgery. Both authors report that Lifehealthcare Pty provided funding for covering of APC expenses for the publication of this manuscript. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional committee. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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