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PubMed1987

Thoracic myelopathy secondary to ossification of the spinal ligament.

The authors describe their experience with 26 cases of thoracic myelopathy secondary to hypertrophic ossification of the spinal ligament (posterior longitudinal ligament and/or ligamentum flavum). The clinical manifestations of this condition and results of its surgical treatment are described. The commonest symptoms were numbness or tingling in the legs and feet and gait disturbance. Most of the patients with involvement of the upper thoracic spine showed typical features of thoracic myelopathy: that is, sensory and motor deficits in both the trunk and lower extremities, sphincter disturbance, and exaggerated tendon reflexes. Several patients with involvement of the thoracolumbar junction presented with atypical symptoms of thoracic myelopathy and were sometimes misdiagnosed and treated inappropriately. Surgical treatment, particularly laminectomy, was not always successful. Inconsistencies in the surgical outcome were caused by either operative complications or reversal of the initial improvement during the follow-up period. The results of anterior surgery for the condition were more favorable; however, use of this procedure was rarely indicated.

Adult↗
PubMed1987

Cervical spine stenosis secondary to ossification of the posterior longitudinal ligament.

Ossification of the posterior longitudinal ligament (OPLL) is a well-documented cause of cervical spine stenosis and myelopathy among Japanese patients. Reports of OPLL in North Americans are rare. Choices of diagnostic method and treatment for this entity remain controversial. The authors report the results of management of 20 patients in the United States with symptomatic OPLL of the cervical spine. These represented 10% to 20% of patients operated on over the last 3 years for myelopathy secondary to structural spinal compression. Most of these OPLL patients were Caucasian (60%), male (male:female 4:1), and middle-aged (median age 47.5 years). Six had previously undergone laminectomy or discectomy. Cervical roentgenograms and standard myelography occasionally suggested the diagnosis. Axial computerized tomography (CT) metrizamide myelography with small interslice intervals proved invaluable for diagnosis and operative planning. Magnetic resonance imaging was not necessary for diagnosis. Retrovertebral calcification extended over one to five bodies (mean 2.75). The mass ranged in size from 5 to 16 mm in anteroposterior diameter and reduced the residual canal diameter to a mean (+/- standard deviation) caliber of 9.42 +/- 2.41 mm (mean narrowing ratio 0.44 +/- 0.12). Anterior cervical decompression by medial corpectomy and discectomy with fusion uniformly reduced preoperative myelopathy. Complications were limited to transient neurological deterioration in two patients, recurrent laryngeal nerve palsy in one, and halo device pin site infections in two. At a mean postoperative interval of 15 months, improvement was seen in each category of deficit: extremity weakness, hypesthesia, hypertonia, and urinary dysfunction. All fusions produced solid unions. It is concluded that OPLL of the cervical spine is an unexpectedly prevalent cause of myelopathy among patients treated in the United States. Thin-section axial CT metrizamide myelography with small interslice intervals is essential for the investigation of patients who may have OPLL. Anterior decompression and stabilization by medial corpectomy, discectomy, removal of the calcified mass, and fusion is a safe and effective method of treatment.

Adult↗
PubMed1998

Magnetic resonance imaging findings in ossification of the posterior longitudinal ligament of the cervical spine.

OBJECT: Because of the lack of magnetic resonance (MR) signal from cortical bones, MR imaging is inadequate for diagnosing ossified lesions in the spinal canal. However, MR imaging provides important information on spinal cord morphology and associated soft-tissue abnormality. The purpose of this study is to determine the role of MR imaging in the diagnosis and treatment of patients with ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. METHODS: The authors reviewed MR imaging findings in 42 patients with cervical OPLL who were examined with a superconducting MR imaging system. The types of OPLL reviewed included eight cases of continuous, 21 cases of segmental, and 13 cases of the mixed type. All patients were treated surgically either by anterior (26 cases) or posterior decompression (16 cases). CONCLUSIONS: The T1-weighted images clearly demonstrated the spinal cord deformity caused by OPLL. Associated disc protrusion was found to be present at the maximum compression level in 60% of the patients in this series. The highest incidence of disc protrusion (81%) was found in patients with segmental OPLL. Intramedullary hyperintensity on T2*-weighted imaging was noted in 18 patients (43%). The neurological deficits observed in these 18 patients were significantly more severe than those observed in the other 24 patients. Postoperative MR imaging revealed improvement in the spinal cord deformity, although the intramedullary hyperintensity was still observed in most cases. The present study demonstrates the importance of associated disc protrusion in the development of myelopathy in patients with cervical OPLL. Magnetic resonance imaging findings may be used to help determine the actual levels of spinal cord compression and to suggest the method of surgical treatment.

Adult↗
PubMed2002

Pathogenesis of myelopathy in patients with ossification of the posterior longitudinal ligament.

OBJECT: The goal of this study was to clarify the pathogenesis of myelopathy in patients with ossification of the posterior longitudinal ligament (OPLL) based on the relationship between static compression factors and dynamic factors. METHODS: There was a total of 247 patients, including 167 patients who were conservatively followed for a mean of 11 years and 2 months and 80 patients who had myelopathy at initial consultation and underwent surgery. The changes in clinical symptoms associated with OPLL in the cervical spine were examined periodically. During the natural course of OPLL in the cervical spine, 37 (22%) of 167 patients developed or suffered aggravated spinal symptoms. All of the patients with a space available for the spinal cord (SAC) less than 6 mm suffered myelopathy, whereas the patients with an SAC diameter of 14 mm or greater did not. No correlation was found between the presence or absence of myelopathy in patients whose SAC diameter ranged from 6 mm to less than 14 mm. In patients with myelopathy whose minimal SAC diameter ranged from 6 mm to less than 14 mm, the range of motion of the cervical spine was significantly greater. CONCLUSIONS: These results indicate that pathological compression by the ossified ligament above a certain critical point may be the most significant factor in inducing myelopathy, whereas below that point dynamic factors may be largely involved in inducing myelopathy.

Aged↗
PubMed2003

Ossification of the posterior atlantoaxial membrane. Case report.

The authors report a case of ossification of the posterior atlantoaxial membrane that led to the development of cervical myelopathy. Computerized tomography and magnetic resonance imaging were helpful in establishing the diagnosis, and decompressive laminectomy may be an appropriate intervention.

Atlanto-Axial Joint↗
PubMed2003

Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine.

OBJECT: Factors related to long-term surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) have not been fully investigated. To evaluate these factors, the authors reviewed medical records obtained in patients who had undergone decompressive surgery for thoracic OLF. METHODS: Thirty-four patients in whom decompressive surgery was performed for thoracic OLF (mean follow-up period 8 years) were recruited. Fourteen patients underwent simultaneous decompressive surgery for cervical or lumbar lesions. Patient age, duration of symptoms, OLF type, dural adhesion, neurological status classified by the Japanese Orthopaedic Association (JOA) scale before and after surgery (1 month postoperatively and at final follow up), and recovery rate were reviewed. The ossified ligamentum flavum was classified into five types according to Sato's classification by assessing preoperative computerized tomography scans. The mean preoperative JOA score (5) was significantly improved at 1 month after surgery (7.1) and at final follow up (7.9) (p < 0.05). Recovery rates at 1 month and at final follow up were 34.6 and 44.2%, respectively. No significant correlations were found between age, OLF type, and neurological status before and after surgery. In patients with dural adhesion, which was observed in cases of larger-type OLF (p < 0.02), lower JOA scores were observed compared with those in patients without dural adhesion both preoperatively and at 1 month after surgery (p < 0.05) but not at the final follow-up examination. Higher JOA scores and recovery rates were demonstrated in patients who had undergone simultaneous surgery than in those who had not undergone simultaneous surgery at 1 month (p < 0.05) but not at the final follow up. Using multiple regression analysis, the authors identified the duration of preoperative symptoms as the most important predictor of a high JOA score and recovery rate at the final follow up. CONCLUSIONS: Duration of preoperative symptoms represents the most important predictor of long-term surgery-related outcome in patients treated for thoracic OLF. The type of ossified ligamentum flavum, dural adhesion, and simultaneous surgery for coexistent cervical or lumbar lesions do not appear to influence the long-term postoperative prognosis.

Adult↗
PubMed2004

Long-term results of expansive open-door laminoplasty for ossification of the posterior longitudinal ligament of the cervical spine.

OBJECT: Numerous surgical procedures have been developed for treatment of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine, and these can be performed via three approaches: anterior, posterior, or combined anterior-posterior. The optimal approach in cases involving OPLL-induced cervical myelopathy, however, remains controversial. To address this issue, the authors assessed the benefits and limitations of expansive open-door laminoplasty for OPLL-related myelopathy by evaluating mid- and long-term clinical results. METHODS: Clinical results obtained in 72 patients who underwent expansive open-door laminoplasty between 1983 and 1997 and who were followed for at least 5 years were assessed using the Japanese Orthopaedic Association (JOA) scoring system. The mean preoperative JOA score was 9.2 +/- 0.4; at 3 years postoperatively, the JOA score was 14.2 +/- 0.3 and the recovery rate (calculated using the Hirabayashi method) was 63.1 +/- 4.5%, both having reached their highest level. These favorable results were maintained up to 5 years after surgery. An increase in cervical myelopathy due to progression of the ossified ligament was observed in only two of 30 patients who could be followed for more than 10 years. Severe surgery-related complications were not observed. Preoperative JOA score, age at the time of surgery, and duration between onset of initial symptoms and surgery affected clinical results. CONCLUSIONS: Mid-term and long-term results of expansive open-door laminoplasty were satisfactory. Considering factors that affected surgical results, early surgery is recommended for OPLL of the cervical spine.

Adult↗
PubMed2004

Clinical course of patients with ossification of the posterior longitudinal ligament: a minimum 10-year cohort study.

OBJECT: Ossification of the posterior longitudinal ligament (OPLL) may produce quadriplegia. The course of future neurological deterioration in patients with radiographic evidence of OPLL, however, is not known. The authors conducted a long-term follow-up cohort study of more than 10 years to clarify the clinical course of this disease progression. METHODS: A total of 450 patients, including 304 managed conservatively and 146 treated by surgery, were enrolled in the study. All patients underwent neurological and radiographical follow-up examinations for a mean of 17.6 years. Myelopathy was graded using Nurick classification and the Japanese Orthopaedic Association scale. Fifty-five (17%) of 323 patients without myelopathy evident at the first examination developed myelopathy during the follow-up period. Risk factors associated with the evolution of myelopathy included greater than 60% OPLL-induced stenotic compromise of the cervical canal, and increased range of motion of the cervical spine. Using Kaplan-Meier analysis, the myelopathy-free rate in patients without first-visit myelopathy was 71% after 30 years. A significant difference in final functional outcome was not observed between nonsurgical and surgical cases in which preoperative Nurick grades were 1 or 2. In patients with Nurick Grade 3 or 4 myelopathy, however, only 12% who underwent surgery eventually became wheelchair bound or bedridden compared with 89% of those managed conservatively. Surgery proved ineffective in the management of patients with Grade 5 disease. CONCLUSIONS: Results of this long-term cohort study elucidated the clinical course of OPLL following conservative or surgical management. Surgery proved effective for the management of patients with Nurick Grades 3 and 4 myelopathy.

Aged↗
PubMed2004

Cough induced by ossification of the ligamentum flavum in the high cervical spine. Case report.

The authors report a very rare case of high cervical ossification of the ligamentum flavum (OLF) in a 40-year-old woman who developed an intractable cough after a traffic accident. The patient's symptoms subsided immediately after decompressive laminectomy and removal of the lesion. To the authors' knowledge, this is the first reported case of high cervical OLF in a patient who presented with a cough. The pathophysiological mechanism underlying the cough was determined to be symptomatic of high cervical spine OLF.

Accidents, Traffic↗
PubMed2005

Surgical experience with symptomatic thoracic ossification of the ligamentum flavum.

OBJECT: Symptomatic thoracic ossification of the ligamentum flavum (OLF) is rare, and its prognostic factors remain unclear. The authors retrospectively studied 24 patients with surgically treated thoracic OLF to delineate its prognostic factor. METHODS: The clinical manifestations, radiological studies, surgical records, and pathological findings were reviewed. Preoperative and postoperative neurological data were reappraised using the American Spinal Injury Association and modified Japanese Orthopaedic Association (JOA) scoring systems. Spearman rank-correlation coefficients and nonparametric tests were used to analyze the correlations between the variables of patient characteristics, preoperative duration of symptoms, preoperative neurological status, associated spinal disorder(s) other than thoracic OLF, and the final functional outcome. CONCLUSIONS: Decompressive surgery is indicated in patients in whom symptomatic thoracic spinal cord compression is caused by intruding OLF. Magnetic resonance imaging can provide sufficient clues for the diagnosis of thoracic OLF. Higher preoperative modified JOA scores of 3 and 4 are positively correlated with better postoperatiVe functional recovery than lower scores. Surgery should be performed as soon as possible before independent ambulatory function is impaired.

Aged↗
PubMed2005

Image-guided surgery for thoracic ossification of the posterior longitudinal ligament. Technical note.

The authors describe an anterior decompression procedure for thoracic ossification of the posterior longitudinal ligament (PLL) in which they used an image guidance system in three cases. To make registration possible in anterior thoracic surgery, they devised a surgical reference frame that could be connected to a rod and attached to an external fixation device, which was then attached to the thoracic VB. The mean fiducial error at the registration was acceptable (range 0.5-0.8 mm). They were able to confirm the success of decompression on postoperative computerized tomography scans. In the removal of an ossified thoracic PLL, an image guidance system has been shown to be a useful tool.

Decompression, Surgical↗
PubMed2005

Long-term results after expansive open-door laminoplasty for the segmental-type of ossification of the posterior longitudinal ligament of the cervical spine: a comparison with nonsegmental-type lesions.

OBJECT: The segmental-type of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine is distinct from other types in its morphological features. Whether the results of expansive open-door laminoplasty for the segmental-type are different from those for other types remains unclear. To clarify this issue, the long-term results after surgical treatment of segmental-type OPLL were compared with those of other types. METHODS: Clinical results were documented in 57 patients who underwent expansive open-door laminoplasty and were followed for a minimum of 7 years, results were quantified using the Japanese Orthopaedic Association (JOA) scoring system to determine function. Segmental-type OPLL was observed in 10 patients (Group 1) and other types in 47 patients (Group 2). Preoperative JOA scores were not significantly different between the two groups. As many as 5 years after surgery, clinical results were favorable and maintained in both groups, and no significant intergroup difference in postoperative JOA scores was observed; however, after 5 years postoperatively, JOA scores decreased in both groups. The decrease was greater in Group 1, and a significant intergroup difference in JOA scores was demonstrated when analyzing final follow-up data. In Group 1, the authors found that the degree of late-onset deterioration relating to cervical myelopathy positively correlated with the cervical range of motion. CONCLUSIONS: The long-term results of expansive open-door laminoplasty in the treatment of segmental-type OPLL were inferior to those for other types. Cervical mobility may contribute to the development of late deterioration of cervical myelopathy.

Adult↗
PubMed2005

Surgical treatment of lumbar ossification of the posterior longitudinal ligament. Report of two cases and description of surgical technique.

The authors report two cases of patients with lumbar ossification of the posterior longitudinal ligament (OPLL). One patient underwent surgery via the single posterior approach, and the other patient underwent combined anterior-posterior surgery. The authors consider the anterior approach for excision of the ossified lesion to be the most reasonable for treatment of lumbar OPLL. It is extremely important, however, to select the surgical procedure according to the individual patient's condition.

Adult↗
PubMed2006

Surgical treatment of 40 patients with thoracic ossification of the ligamentum flavum.

OBJECT: The authors evaluated different surgical methods used to treat thoracic ossification of the ligamentum flavum (OLF). METHODS: Data obtained in 40 patients who underwent posterior decompression for thoracic myelopathy caused by thoracic OLF were studied retrospectively. There were 32 men and eight women. All patients underwent posterior decompression in which laminoplasty was performed or laminectomy combined with lateral fusion. Every surgical specimen was stained with H & E, and scanning electron microscopy was performed in 20 cases. The mean follow-up period was 28 months. Postoperative outcomes were evaluated using a recovery scale based on the Japanese Orthopaedic Association classification. There were a total of 168 ossified segments in this series, 77.4% of which were located in the lower thoracic spine. Marginal osteophyte formation was found in 36 patients; in 32 of the 36 patients, these marginal osteophytes were located at the intervertebral space either higher or lower than the ossified segment. Scanning electron microscopy showed elastic fiber breakdown, proliferation of collagenous fibers, calcification, and OLF in the same microscopy region. Laminoplasty was performed in four patients. In three cases surgery resulted in unchanged or worse outcome (increased kyphotic deformity in two), and in one it resulted in good outcome. Laminectomy combined with lateral fusion was performed in 36 patients, in 30 cases of which it resulted in a good or fair outcome, and increased kyphotic deformity in only one. Of these 36 laminectomy-treated patients, an en bloc laminectomy-treated procedure was performed in 16 patients; in 11 of the 12 patients with lateral or diffuse-type lesions the surgery resulted in a good or fair outcome. En bloc laminectomy, however, seems ineffective in the treatment of patients with thickened, nodular-type thoracic OLF, as the procedure resulted in worse outcome in two of the four patients. The authors have thus developed a new modality of laminectomy that they have termed "separating laminectomy," which they performed in 16 patients with thickened, nodular-type OLF; in 13 cases it resulted in a good or fair outcome, and in only one case did it result in a worse outcome. CONCLUSIONS: The pathogenesis of thoracic OLF is mainly due to the localized mechanical stress on the ligament. Laminectomy combined with lateral fusion is the treatment of choice for thoracic OLF; furthermore, in terms of the configuration of the ossified lesion, en bloc laminectomy is suitable for the treatment of lateral-type and diffuse-type OLF, and the separating laminectomy is suitable for the thickened, nodular-type OLF.

Aged↗
PubMed2006

Thoracic myelopathy caused by ossification of the ligamentum flavum: clinical features and surgical results in the Japanese population.

OBJECT: Data obtained in patients with thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) were retrospectively reviewed to clarify clinical features and surgical outcomes in the Japanese population. METHODS: Seventy-two patients who underwent surgery for OLF-induced myelopathy in the Miyagi Prefecture, Japan, between 1988 and 2002 were observed for at least 2 years. Clinical data were collected from medical and operative records. The patients were evaluated pre- and postoperatively using the modified Japanese Orthopaedic Association (JOA) scale (maximum score 11). The relationships among various factors (age, sex, and preoperative duration of symptoms) affecting the preoperative severity of myelopathy and postoperative improvement were also examined. CONCLUSIONS: In this series the surgical outcome was relatively good and depended on the severity of myelopathy; thus early and correct diagnosis is required to avoid poorer results. The male/female ratio was 3:2 and the mean patient age at surgery was 61 years for men and 68 for women. The patients commonly noticed numbness or pain in their lower legs or gait disturbances. In a total of 104 decompressed intervertebral disc levels, more than 80% of the ossified ligaments were at the T9-10 level or lower. The mean preoperative JOA score of 5.1 improved to 7.9 after an average of 46 months. The postoperative results statistically depended on the preoperative severity of myelopathy. Among studies of patients with OLF-related myelopathy, the present study had the largest sample size, which should help clarify the clinical features of OLF myelopathy.

Aged↗
PubMed2007

Ossification of ligamentum.

OBJECT: The authors evaluated different surgical methods used to treat thoracic ossification of the ligamentum flavum (OLF). METHODS: Data obtained in 40 patients who underwent posterior decompression for thoracic myelopathy caused by thoracic OLF were studied retrospectively. There were 32 men and eight women. All patients underwent posterior decompression in which laminoplasty was performed or laminectomy combined with lateral fusion. Every surgical specimen was stained with H and E, and scanning electron microscopy was performed in 20 cases. The mean follow-up period was 28 months. Postoperative outcomes were evaluated using a recovery scale based on the Japanese Orthopaedic Association classification. There were a total of 168 ossified segments in this series, 77.4% of which were located in the lower thoracic spine. Marginal osteophyte formation was found in 36 patients; in 32 of the 36 patients, these marginal osteophytes were located at the intervertebral space either higher or lower than the ossified segment. Scanning electron microscopy showed elastic fiber breakdown, proliferation of collagenous fibers, calcification, and OLF in the same microscopy region. Laminoplasty was performed in four patients. In three cases surgery resulted in unchanged or worse outcome (increased kyphotic deformity in two), and in one it resulted in good outcome. Laminectomy combined with lateral fusion was performed in 36 patients, in 30 cases of which it resulted in a good or fair outcome, and increased kyphotic deformity in only one. Of these 36 laminectomy-treated patients, an en bloc laminectomy-treated procedure was performed in 16 patients; in 11 of the 12 patients with lateral or diffuse-type lesions the surgery resulted in a good or fair outcome. En bloc laminectomy, however, seems ineffective in the treatment of patients with thickened, nodular-type thoracic OLF, as the procedure resulted in worse outcome in two of the four patients. The authors have thus developed a new modality of laminectomy that they have termed "separating laminectomy," which they performed in 16 patients with thickened, nodular-type OLF; in 13 cases it resulted in a good or fair outcome, and in only one case did it result in a worse outcome. CONCLUSIONS: The pathogenesis of thoracic OLF is mainly due to the localized mechanical stress on the ligament. Laminectomy combined with lateral fusion is the treatment of choice for thoracic OLF; furthermore, in terms of the configuration of the ossified lesion, en bloc laminectomy is suitable for the treatment of lateral-type and diffuse-type OLF, and the separating laminectomy is suitable for the thickened, nodular-type OLF.

Adult↗
PubMed1986

Para osteo arthropathy--ectopic ossification of healing tendon about the rodent ankle joint: histologic and type V collagen changes.

Ectopic bone formation, or para osteo arthropathy (POA), is commonly seen in humans following lesions to the central nervous system. The condition also occurs after severe trauma, burns, or tetanus, and, rarely, after poliomyelitis or cauda equina lesions. The lack of a suitable laboratory animal model has hampered study of its etiology and treatment. The lesion occurs just above the rodent ankle joint 7 weeks after repair of the severed achilles tendon. Tendon repair using a single silk suture resulted in ectopic calcification in 22 of 23 animals. Ectopic ossification, with extensive mineralization, occurred in 11 animals, 5 of which showed bone marrow. Ectopic mineralization was moderate in 8 others, minimal in 4, and absent in one. Collagen typing thrice during healing indicated that type V collagen increased by one-third at 10 days, doubled at 20 days, and returned to near normal amounts at 50 days. Since type V collagen is a major component of the nonfibrous collagen of blood vessels, increased amounts of type V collagen are consistent with the presence of many new blood vessels in the granulation tissue at 10 and 20 days. Vascularity is less dense at 50 days when ectopic mineralization and new bone formation are observed. These findings suggest that POA and the degree of maturation of healing tendon may be linked to reduced amounts of type V collagen. It is concluded that the sutured tendon of the rodent ankle joint offers an animal model by which to study ectopic bone formation, or para osteo arthropathy.

Achilles Tendon↗
PubMed2000

Radiation therapy for heterotopic ossification in a patient with traumatic brain injury.

Radiation therapy has been known to have a prophylactic effect for heterotopic ossification (HO), but until now it has not been known to have a therapeutic effect for established HO. We report a case of established HO compounded with a sudden increase in activity, that was improved with radiation therapy. A patient with traumatic brain injury had HO in both hips and thighs two months after the initial trauma. The existing level of HO activity suddenly increased seven months after the initial trauma, and was accompanied by severe pain that was refractory to indomethacin. We assumed that the pain was caused by the increased activity of HO on the basis of clinical symptoms and laboratory results. Initially, the patient received radiation therapy to the left lower extremity, with a total dose of 20 Gy in ten fractions. Next, the patient received radiation therapy at the same dosage to the right lower extremity, after which the pain and level of serum alkaline phosphatase significantly decreased. The patient experienced a mild pancytopenia as a side effect of the radiation therapy, but it was not severe enough to stop the radiation therapy, given the patient's suffering from the increased HO activity.

Adult↗