n e u r o c i r u g i a .

2 0 1 8;2 9(3):122–130

NEUROCIRUGÍA

www.elsevier.es/neurocirugia

Review article

Headless compression screw in the

neuronavigation-guided and microscope-assisted
treatment of spondylolysis

Francisco Javier Goncalves-Ramírez a,∗ , Manel Tardaguila Serrano a , Sherman H. Lee b ,

Carlos Javier Dominguez a , Jordi Manuel-Rimbau a
a Departamento de Neurocirugía, Hospital Germans Trias i Pujol, Badalona, Spain
b Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong

a r t i c l e i n f o a b s t r a c t

Article history: Since 1968, many surgical techniques used in repairing the pars defect of the vertebra have
Received 7 April 2017 been reported. Technological advances are giving rise to new ways of obtaining the best
Accepted 29 July 2017 outcome using less invasive methods, which are more accurate, simple and effective. To treat
Available online 5 October 2017 cases of spondylolysis such as pseudarthrosis, we used neuro-navigation and microscopy
through a 2.5-cm skin incision to approach the pars defect, freshen the fracture and place a
Keywords: type of screw that, until now, has never been used for this purpose. This is a novel technique,
Buck’s technique which guarantees prolonged compression and sufficient stability to facilitate the prompt
Minimally invasive spinal surgery healing of the vertebra. We present 2 cases of L5 spondylolysis treated with our technique,
Headless compression screw a modification of Buck’s technique. A detailed description of the screw selection, surgical
Spondylolysis technical details, follow-up and outcome are discussed.
Neuronavigation © 2017 Sociedad Española de Neurocirugı́a. Published by Elsevier España, S.L.U. All rights
reserved.

Tornillo de compresión sin cabeza en el tratamiento de la espondilolisis

guiada por neuronavegación y asistida por microscopio

r e s u m e n

Palabras clave: Desde 1968 se han descrito muchas técnicas quirúrgicas utilizadas para reparar el defecto
Técnica de Buck en la pars de la vértebra. Los avances tecnológicos están dando lugar a nuevas formas de
Cirugía espinal minimamente obtener el mejor resultado utilizando métodos menos invasivos que son más precisos, sim-
invasiva ples y eficaces. Para tratar los casos de espondilolisis como una unión en seudoartrosis,
Tornillo de compresión sin cabeza se utilizó la neuronavegación y la microscopía a través de una incisión cutánea de 2,5 cm
Espondilolisis para abordar el defecto de la pars, refrescar la fractura y colocar un tipo de tornillo que
Neuronavegación no se ha utilizado previamente con ese fin. Esta es una técnica novedosa, que garantiza

∗
Corresponding author.
E-mail address: ncrfranc@gmail.com (F.J. Goncalves-Ramírez).
http://dx.doi.org/10.1016/j.neucie.2017.09.002
https://doi.org/10.1016/j.neucir.2017.07.008
2529-8496
1130-1473/© 2017 Sociedad Española de Neurocirugı́a. Published by Elsevier España, S.L.U. All rights reserved.
 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130 123

una compresión prolongada y suficiente estabilidad para lograr la curación oportuna de

la vértebra. Presentamos 2 casos de espondilolisis de L5 tratados con nuestra técnica, una
modificación de la técnica de Buck. Se realiza una descripción detallada de la selección del
tornillo, detalles técnicos quirúrgicos, seguimiento y resultado.
© 2017 Sociedad Española de Neurocirugı́a. Publicado por Elsevier España, S.L.U. Todos
los derechos reservados.

cation with pedicular screw. The direct approach showed a

Introduction
Spondylolysis is a fracture that occurs in the pars interarti-
cularis of the vertebra, frequently L5, and in 25% of cases it
tends to displaced.1–3 It is currently attributed to the over-
load phenomenon, which occurs mostly in sports, and has
been classified by different authors as: type I congenital or
dysplastic; type II isthmic; type III degenerative; type IV trau-
matic and type V pathological.4 Meyerding classified them
radiologically according to the displacement of the L5 body
over the first sacral vertebra: grade I displacement below 25%,
grade II displacement between 25 and 50%, grade III displace-
ment between 50 and 75% and grade IV displacement greater
than 75%.4 Clinically, spondylolysis is characterized by pain,
attributed to nerve stimulation, and instability produced in the
injured vertebral segment.5 It is usually treated conservatively,
with surgical criterion being met when the pain is disabling,
hinders activities of daily living, and does not respond to drug
therapy, physical therapy or orthoses.4,6
Many techniques have been proposed to repair the defect
in the pars interarticularis. In 1968 Kimura proposed repair-
ing the defect with bone graft, without any osteosynthetic
material, and confining the patient to bed rest for a period
of two months; with further use of a brace until full fusion
occurs.5–7 Scott first proposed the use of wires to provide sta-
bility to the fracture site while using autologous bone graft in
1968. He proposed cerclage, which required extensive spine
dissection to allow the wire to surround the vertebra, pass-
ing in front of the transverse processes and below the spinous
process of the same level.5,7 In 1970 Buck described an inter-
nal approach to the fracture, which involved less aggressive
dissection, debridement of the fracture focus, placement of a
4.5 mm cortical screw and placement of an autologous iliac
crest graft.6–10 In 1984 Morscher published a variation of the
Buck technique in which the screw is incorporated with a claw
which holds the lamina.5 In 1998 Songer proposed the place-
ment of pedicular screws in the lytic vertebra and a cerclage
system similar to the Scott technique that does not require
exposure of the transverse processes.5 In 1996 Tokuhashi and
Matsuzaki proposed the use of rod-hook associated pedicle
screws with an iliac crest autograft at the fracture focus.11
In 1999 Petit and Gillett described the placement of pedicle
screws associated with a “U” shaped rod that passes under
the spinous process at the relevant level.5
Few studies have biomechanically compared each of the
existing techniques and their outcome. Deguchi reported bet-
ter biomechanical behaviour in the screw-rod-hook technique
and Buck’s technique, where least movement is achieved at
the site of injury.11,12 Gadiucci compared Buck’s technique
with the Scott wiring technique and the Songer’s modifi-
better outcome in young patients, with Songer’s technique
resulting in the best outcome in the general population.7
J. Fan reported greater stability in the screw-rod-hook and
screw-rod techniques.13 Minimally invasive variants of Buck’s
technique, in which the screw is placed through neuronavi-
gation without fracture debridement have been described as
an alternative for young patients,3 including variants of the
technique described for young athletes that allow direct endo-
scopic observation while lysis repair is done.14,15 Traditionally,
cortical screws were used in the treatment of spondylolysis in
lumbar vertebrae,3,6,7,10,11 with the use of partially threaded
screws such as AO screws being reported by some authors.4,9,15
We propose a minimally invasive and effective treatment for
spondylolysis, using hardware that has never been previously
considered for this purpose.
Methods
Surgical planning
®
To plan our surgeries we used iPlanNet developed by Brain-
lab. This software allowed us to calculate the individual
morphometric parameters in each case, which was necessary
to find an optimal size, trajectory and location for the hard-
ware.
Screw selection
We believe that to achieve optimal repair of the injury, it is
necessary to use a trans-fracturary fixation technique with
compression at the focus of the structural lesion. Therefore
we decided to use the second generation of headless com-
pression screws, HCS 4.5 (Synthes). The superiority of this
screw has been clearly demonstrated when compared with
the Herbert–Whipple screw and traditional cortical screws for
treatment of small bone fractures and joints.16–19 We pre-
fer titanium to steel, not only for its hardness and strength,
but also for its better biocompatibility, osseo-integration, cor-
rosion resistance, and fewer artefacts in future MRIs. The
characteristics of the tip thread and head thread as well as the
length of the unthreaded shank is fully conditioned by indi-
vidual patient anatomy; specifically the size of the fragments.
We use the following basic principles:
1. The fracture focus must be crossed in a completely perpen-
dicular trajectory.
2. Pre-drilling of the trajectory should be avoided to achieve a
higher final compression force at the fracture focus.20 The
124 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130
Fig. 1 – Illustration showing the relation of the fracture and the different parts of the screw, trying to find the ideal location
for maximal compression in the fracture focus.
trajectory is therefore established by placing a Kirschner
wire.
3. The tip thread of the screw should be cancellous, not
cortical, and self-tapping/self-drilling to reduce resistance
to the screw when it comes into contact with the dis-
tal fragment. This reduces the possibility of pushing the
distal fragment, and ensures that the screw is contained
entirely in the distal fragment; slightly surpassing the cor-
tex of the distal fragment is an optimal position of the
screw.17
4. The fracture focus should coincide with the middle of the
screw, or failing that, in the proximal half, where in vitro
measurements have shown that there is a greater compres-
sive force,17
5. The head thread of the screw should be cortical to decrease
the natural tendency of the screw to pull out and reduce
the inevitable loss of compression commonly observed
when it is placed. The head of the screw should preferably
not be buried beyond 2 mm below the proximal cortex19
(Fig. 1).
Surgical details
The patient is put under general anaesthesia and placed in
a prone position with slight flexion of the spine. Through a
2.5–3.0 cm midline incision at the lower edge of the spinous
process of L5, bilateral paravertebral access is gained to the
spinous base of L5; lamina and pars interarticularis must be
exposed. By neuronavigation, Kirschner wire is placed to a
depth of 4.0 cm, exact depth depending on the anatomy of
the patient. The wire passes through the fracture focus with
a medial to lateral trajectory (15–18◦ ) and in the sagittal plane
with a caudal to cranial trajectory, parallel to the plane of the
spinous process. The next step is the removal of the outer wall
of the fibrous pseudocapsule and decortication of the inner
side of the fracture and the outer surface of the pars interarti-
cularis with a carbide mill/drill, and further percutaneous HCS
4.5 (Synthes) screws are laid. During this procedure, which is
performed by direct microscope visualization, the screw can
be seen passing through the fracture. Once the fracture has
been debrided, the selected bone substitute is placed and final
tightening of the screw is done. Finally, the fascia and skin are
sutured (Fig. 2).
Case report
Case 1
History and examination
An otherwise healthy 49-year-old male athlete presented with
a 13-month history of lower back pain, EVA 6, which did not
respond to medical treatment, typically worsening with sud-
den movements, Valsalva manoeuver and sudden changes in
posture. Once diagnosed, the patient was treated medically,
with physiotherapy, postural hygiene, and his condition was
monitored.
Complementary tests
Static and functional lumbar radiographs did not show
spondylolisthesis. Lumbar spine MRI revealed mild degenera-
tion of intervertebral discs in the last three lumbar segments.
The scanner showed spondylolysis in L5, without spondylolis-
thesis.
Operation
The patient’s bone fragments were almost equal, so both
screws had the same measurements: total length 38 mm,
tip length 7 mm self-tapping, self-tapping head with 3.5 mm
length, 27.5 mm stem length, diameter 4.5 mm, thread pitch of
the tips and head of the screw, cancellous and cortical respec-
tively, titanium alloy material.
The patient was operated on in a time of 93 min, blood loss
was estimated at less than 30 cc, minimal skeletonisation was
done.
Case 2
History and examination
A 54-year-old gentleman, a smoker with dyslipidaemia, whose
job required strenuous weight-lifting, had been suffering from
severe lower back pain (EVA 5) for longer than 5 years with
occasional referred pain in the gluteal region. The pain was
resistant to conservative treatment and had worsened in the
past year.
 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130
Fig. 2 – Surgical pictures showing: (A) Kirschner wire insertion through the fracture focus, (B) use of neuronavigation to
guide the procedure, (C) screw insertion guided by neuronavigation and the Kirschner wire and (D) screw tightening.
Complementary tests
CT scan revealed L5 spondylolysis without spondylolisthesis.
There was mild foraminal stenosis of L5-S1 with no lum-
bar canal stenosis. Although a functional radiograph did not
reveal any instability, MRI showed mild disc degeneration.
Operation
The features of the screw in this case were different: total
length 38 mm, tip length 14 mm self-tapping, self-tapping
head with 3.5 mm length, 20.5 mm stem length, diameter
4.5 mm, thread pitch of the tips and head of the screw, can-
cellous and cortical respectively, titanium alloy material.
The patient was operated on in a time of 85 min, blood loss
was estimated at less than 20 cc, the skin wound reach was
2.5 cm (Fig. 3).
Postoperative course
Both of our patients had post-operative pain controlled by oral
analgesics and were discharged one day after surgery. There
was good wound healing of the incision at first follow up
(14 days). A lumbar support girdle was given to the patients
from the first day, X-ray showed the correct position of the
implants. Six months after surgery, a follow up CT scan was
performed (Figs. 4 and 5), in which the screws were observed
crossing the fracture focus in concurrence with preoperative
planning, and although no fusion was observed, ossification
points began to appear and there was no increase in the
degree of spondylolisthesis. Three months post-surgery, case
1 improved to a lumbar EVA of 3, remaining on analgesics. 7
months post-surgery the EVA was 2 with eventual episodes
of pain that resolved easily with analgesics. Case 2 presented
125
with improvement of the lumbar EVA at the third month in
3 points, 7 months post-surgery the EVA was 2 with sporadic
pain. Both patients have returned to work, and resumed their
usual activities of daily life.
Discussion
Different techniques have been designed for the repair of
spondylolysis: the simple placement of a bone graft with-
out osteosynthetic material, fusing one or more vertebrae to
achieve stability and fusion through cerclage, a screw placed
in the pars interarticularis defect, pedicle screws or laminar
hooks, or a rod-screw construct amongst others.3,5,6,9,11,21–23
All these techniques involve a large skin incision and deep
tissue exposure with its concomitant comorbidities.23 Other
authors have described percutaneous placement of a pedicle
screw systems with rods and hooks, achieving excellent clini-
cal results.23,24 In the era of minimally invasive spinal surgery,
the microscope allows direct observation of the fracture focus,
its curettage, bone graft and osteosynthetic material place-
ment with minimal dissection.14,15 Neuronavigation has also
been described as a resource for screw placement trans pars
interarticularis.3
We believe that after conservative treatment with a pru-
dent follow up time, the cause of refractory pain probably
comes from a non-union fracture characterized by inter-
fragmentary movement and reduced local blood flow. Repair of
this injury aims to resolve the focus of pseudarthrosis. Histor-
ically it has been considered a bone healing disorder requiring
mandatory surgical treatment.25,26 Fracture of the pars is often
not initially considered a surgical lesion, but after the fail-
126 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130

Fig. 3 – Post-operative X-ray, (A and B): (Case 1), (C and D): (Case 2), in an anterior-posterior view and lateral view
respectively, showing the correct position of the screw, crossing the fracture focus.

ure of conservative treatment and having reached the bone
healing time with union failure, a more aggressive strategy
must be adopted,3,5–9,11 There have been some reports in liter-
ature of rapidly progressive spondylolisthesis which requires
two-level fusion,27 while more insidious cases allow timely
planning of less aggressive techniques. Bilateral pars defects
not only biomechanically compromises a fracture’s level but
a level overlying this could also be affected.6,9,22 We agree
with some authors that fixation screws through the fracture
without intervertebral fusion theoretically preserves segment
mobility and the vitality of the intervertebral disk.4 Planned
surgery for this case includes the use of minimally invasive
techniques, microscope to approach the focus of non-union
and the placement of a HCS percutaneous compression screw
 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130 127

Fig. 4 – Case 1 six-month follow up CT scan. The first two images are an axial view of L5, and the rest of the images are in
the sagittal view showing the left screw (on the left sided images) and the right screw (on the right sided images).

guided by neuronavigation; in an attempt to optimize the tech-
nique first described by Buck in 1970. En nuestra experiencia,
los pacientes que presentan espondilolisis sin espondiloliste-
sis, con dolor refractario a tratamiento conservador, podrían
ser candidatos a esta técnica, menos invasiva y costosa que
la arthrodesis transpedicular típica, la reparación de la frac-
tura evita la progression de la listesis, degeneración del disco
intervertebral de dicho nivel y produce alivio efectivo del el
dolor, en nuestra serie el control del dolor y grado de fusion
tras un año de seguimiento es satisfactorio, aunque sera nece-
sario un número mayor de pacientes para valorar a mediano
y largo plazo el grado de fusion y evolución clínica tras la
intervención.
In our experience, patients who present with spondylo-
lysis without spondylolisthesis and with pain refractory to
conservative treatment may be candidates for this technique.
It is less invasive and costly when compared with a typical
transpedicular arthrodesis. The repair of the fracture prevents
further progression of the listhesis, further degeneration of
the intervertebral disc of the same level and provides effec-
tive relief of pain. In our series, control of pain and degree
of fusion after one year of follow-up is satisfactory, however,
128 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130

Fig. 5 – Case 2 six-month follow up CT scan. The first two images axial view of L5, and the rest of the images are in the
sagittal view showing the left screw (on the left sided images) and the right screw (on the right sided images).

a greater number of patients will be necessary to assess the
degree of fusion and clinical evolution after intervention.
Regarding the selection of the screw, we decided to use the
second generation headless compression screw at the fracture
focus, as its design provides increased stability, compression
and regeneration.18 Some studies of the second genera-
tion screws support better performance in partially threaded
screws,28 while others prefer fully threaded ones.16,18,19 It is
important to note that the use of this screw for this pur-
pose has not been previously reported. When assessing the
potential risks of the chosen device, there is no literature
available that reveals fracture or rupture of the material used.
We found reports of proximal migration of the screw when it
was used to repair scaphoid fractures.29 In our case, the ten-
dency of the screw to pull out, would theoretically result in
loss of compression on the fracture focus and cause screw
migration in an extreme case, therefore the selection of our
screw threads ensures resistance to pull-out on the tip of 178 N
(18 kg) and head 274 N (27 kg). In odontoid screws or classic cor-
tical screws, over fastening produces structural lesions of the
bone matrix that is in contact with the thread, which results
in a loss of screw attachment, loss of pull out resistance, and
 n e u r o c i r u g i a . 2 0 1 8;2 9(3):122–130
loss of compression. The HCS screw with a concealable head
does not involve this risk.20
When considering the placement technique, we decided
to avoid pre-drilling to ensure maximum compression force
and reduce the possibility of hardware movement.20 The bib-
liographic data for the HCS 4.5 screw, demonstrates that peak
compression is achieved 1.5 mm from the proximal cortex, and
it is recommended to deepen it to −2 mm.19 We consider 0 mm
to −2 mm to be the ideal range relative to the cortex of the
distal fragment, because this depth allows the screw head to
be hidden, thus reducing the possibility of damage to nearby
structures. Additionally the cortical thread is contained in the
place where it better fulfils its function of conserving forces.
We know that the compressive force on the fracture focus,
described in literature to be around 90 N, can be up to one third
of the initial compression force just minutes after completion
of the implementation.16 Some studies report the final force
as half the registered compressive force when implanting the
screw.18 However, this screw still exceeds the compression
force produced by the cortical screw or AO cortical bone screw,
traditionally used to repair L5 spondylolysis.30–34
For the election of the graft, we agree with most
authors that the ideal graft should be preferably autologous
iliac crest.26 However, in designing a minimally damag-
ing technique, we decided that synthetic HAp provides an
easy-to-implement and effective presentation to achieve con-
solidation of the fracture focus. Once the bone surfaces in
pseudarthrosis have been debrided and fibroids removed, HAp
has the theoretical ability to induce osteoid formation during
the second week, achieving maximum proliferation until the
4th week. Nevertheless in our case the pars interarticularis
being a poorly vascularized structure and sclerosed by the scar
of a fracture in pseudarthrosis, could lengthen the fusion pro-
cess. The placement of an autologous graft will be reserved for
any future rescue surgery if needed. The possibility of future
surgery is not ruled out. In fact, the position of our hardware
does not hinder the best trajectory of pedicle screws in that
vertebra, the final trajectory trans pars interarticularis in this
case, remains at least 2.8 mm away from the nearest point of
the ideal path of a transpedicular screw.
Conclusion
Spondylolysis refractory to conservative treatment is pre-
sented as pseudarthrosis. Surgical treatment should be aimed
at the removal of the fibrous tissue and curettage of edges at
the fracture focus, with bone grafting and compression appli-
cation also at the focus.
The HCS second generation implant is an easy and effective
alternative in the treatment of spondylolysis without spondy-
lolisthesis.
The use of neuronavigation and microscope optimises the
surgery in terms of invasiveness, recovery time, hospital stay,
post-surgical recovery and reduces the possibility of compli-
cation.
Conflict of interests
The authors declare that they have no conflict of interest.
129
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