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Rujeedawa T, Mowforth OD, Davies BM, Yang C, Nouri A, Francis JJ, Aarabi B, Kwon BK, Harrop J, Wilson JR, Martin AR, Rahimi-Movaghar V, Guest JD, Fehlings MG, Kotter MR. Degenerative Thoracic Myelopathy: A Scoping Review of Epidemiology, Genetics, and Pathogenesis. Global Spine J 2024; 14:1664-1677. [PMID: 38146739 DOI: 10.1177/21925682231224768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
STUDY DESIGN Literature Review. OBJECTIVE Myelopathy affecting the thoracic spinal cord can arise secondary to several aetiologies which have similar presentation and management. Consequently, there are many uncertainties in this area, including optimal terminology and definitions. Recent collaborative cervical spinal research has led to the proposal and subsequent community adoption of the name degenerative cervical myelopathy(DCM), which has facilitated the establishment of internationally-agreed research priorities for DCM. We put forward the case for the introduction of the term degenerative thoracic myelopathy(DTM) and degenerative spinal myelopathy(DSM) as an umbrella term for both DCM and DTM. METHODS Following PRISMA guidelines, a systematic literature search was performed to identify degenerative thoracic myelopathy literature in Embase and MEDLINE. RESULTS Conditions encompassed within DTM include thoracic spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, calcification of ligaments, hypertrophy of ligaments, degenerative disc disease, thoracic osteoarthritis, intervertebral disc herniation, and posterior osteophytosis. The classic presentation includes girdle pain, gait disturbance, leg weakness, sensory disturbance, and bladder or bowel dysfunction, often with associated back pain. Surgical management is typically favoured with post-surgical outcomes dependent on many factors, including the causative pathology, and presence of additional stenosis. CONCLUSION The clinical entities encompassed by the term DTM are interrelated, can manifest concurrently, and present similarly. Building on the consensus adoption of DCM in the cervical spine and the recent proposal of degenerative cervical radiculopathy(DCR), extending this common nomenclature framework to the terms degenerative spinal myelopathy and degenerative thoracic myelopathy will help improve recognition and communication.
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Affiliation(s)
- Tanzil Rujeedawa
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Oliver D Mowforth
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cylene Yang
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Aria Nouri
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Jibin J Francis
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Brian K Kwon
- Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - James Harrop
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Allan R Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Michael G Fehlings
- Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mark R Kotter
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Yoshida S, Nakamura S, Saita K, Oya S, Ogihara S. Differences in the Demographics and Clinical Characteristics between the Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum in Patients Who Underwent Thoracic Spinal Surgery for Compressive Myelopathy. Neurol Med Chir (Tokyo) 2024; 64:184-191. [PMID: 38403719 PMCID: PMC11153844 DOI: 10.2176/jns-nmc.2023-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 12/22/2023] [Indexed: 02/27/2024] Open
Abstract
Ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) are related diseases associated with the ossification of spinal ligaments that can occasionally lead to thoracic myelopathy. We retrospectively analyzed the clinical data of 34 consecutive patients who underwent thoracic spinal surgeries for OPLL and/or OLF at our hospital between July 2010 and June 2022, and statistically compared data between patients with thoracic OPLL (TOPLL; n = 12) and those with thoracic OLF (TOLF; n = 22). The mean age of the TOPLL group was significantly lower than that of the TOLF group (53.7 vs. 68.4 years). The TOPLL group exhibited a greater female predominance than the TOLF group (58.3% vs. 18.2%). The median body mass index of the TOPLL group was significantly higher than that of the TOLF group (33.0 vs. 26.0 kg/m2). Patients with TOPLL significantly required instrumented fusion and repetitive surgical intervention more than those with TOLF (83.3% vs. 9.1%; 50.0% vs. 0.0%). Although neurological deterioration just after the intervention was more common in patients with TOPLL (41.7% vs. 4.6%), no difference was observed in thoracic Japanese Orthopaedic Association score and recovery rate in the chronic phase between TOPLL and TOLF. The TOPLL group had a younger onset, female dominance, and a greater degree of obesity when compared with the TOLF group. The surgery for TOPLL is challenging, considering that it requires long-range decompression and fusion, subsequent operations, careful management, and long-term follow-up, when compared to TOLF, which necessitates only simple decompression.
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Affiliation(s)
- Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Sho Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Kazuo Saita
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Satoshi Ogihara
- Department of Orthopaedic Surgery, Saitama Medical Center, Saitama Medical University
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Xu ML, Yang YT, Zeng HZ, Cao YT, Zheng LD, Jin C, Zhu SJ, Zhu R. Finite element modeling and analysis of effect of preexisting cervical degenerative disease on the spinal cord during flexion and extension. Med Biol Eng Comput 2024; 62:1089-1104. [PMID: 38148413 DOI: 10.1007/s11517-023-02993-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 12/07/2023] [Indexed: 12/28/2023]
Abstract
Recent studies have emphasized the importance of dynamic activity in the development of myelopathy. However, current knowledge of how degenerative factors affect the spinal cord during motion is still limited. This study aimed to investigate the effect of various types of preexisting herniated cervical disc and the ligamentum flavum ossification on the spinal cord during cervical flexion and extension. A detailed dynamic fluid-structure interaction finite element model of the cervical spine with the spinal cord was developed and validated. The changes of von Mises stress and maximum principal strain within the spinal cord in the period of normal, hyperflexion, and hyperextension were investigated, considering various types and grades of disc herniation and ossification of the ligamentum flavum. The flexion and extension of the cervical spine with spinal canal encroachment induced high stress and strain inside the spinal cord, and this effect was also amplified by increased canal encroachments and cervical hypermobility. The spinal cord might evade lateral encroachment, leading to a reduction in the maximum stress and principal strain within the spinal cord in local-type herniation. Although the impact was limited in the case of diffuse type, the maximum stress tended to appear in the white matter near the encroachment site while compression from both ventral and dorsal was essential to make maximum stress appear in the grey matter. The existence of canal encroachment can reduce the safe range for spinal cord activities, and hypermobility activities may induce spinal cord injury. Besides, the ligamentum flavum plays an important role in the development of central canal syndrome.Significance. This model will enable researchers to have a better understanding of the influence of cervical degenerative diseases on the spinal cord during extension and flexion.
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Affiliation(s)
- Meng-Lei Xu
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration of the Ministry of Education, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Shanghai, 200065, China
| | - Yi-Ting Yang
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
| | - Hui-Zi Zeng
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yu-Ting Cao
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
| | - Liang-Dong Zheng
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
| | - Chen Jin
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration of the Ministry of Education, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Shanghai, 200065, China
| | - Shi-Jie Zhu
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China
| | - Rui Zhu
- Shanghai YangZhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, 200092, China.
- Key Laboratory of Spine and Spinal Cord Injury Repair and Regeneration of the Ministry of Education, Tongji Hospital, School of Medicine, Tongji University, 389 Xincun Road, Shanghai, 200065, China.
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Li J, Deng Z, Wang L, Wang L, Yang H, Yang X, Song Y. The Quality of Life of the Patients with Thoracic Ossification of the Ligamentum Flavum after Surgery Using EQ-5D-5L. Orthop Surg 2024; 16:57-71. [PMID: 38010864 PMCID: PMC10782254 DOI: 10.1111/os.13937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/08/2023] [Accepted: 10/11/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE There is a lack of studies on the quality of life (QoL) after posterior laminectomy in patients with thoracic ossification of the ligamentum flavum (TOLF), and risk factors associated with poor prognosis remain controversial. Therefore, the present study was conducted to illustrate the QoL for TOLF patients after surgery and determine its relationship with their demographic, surgery-related, clinical characteristics and imaging data. METHODS One hundred and eighteen patients diagnosed with thoracic myelopathy because of TOLF were enrolled in this retrospective study. They all underwent posterior decompressive laminectomy from August 2010 to January 2022. The QoL was evaluated based on the EQ-5D-5L. Collecting gender, age, number of operations, compressed segments, Frankel grade, complications, body mass index (BMI), symptoms and duration, modified Japanese Orthopaedic Association (mJOA) score (preoperative), follow-up time and type of ossification, increased signal on Sagittal T2-weighted Images (ISST2I), occupancy rate and analyzing by Mann-Whitney U-test, Kruskal-Wallis test, the χ2 -test, and logistic regression tests. RESULTS Average follow-up 70.8 months (18-149), the mean age was 59.74 ± 9.81 years and the mean score for the QoL based on the EQ-5D-5 L and visual analogue scale (VAS) score were 0.71 ± 0.28 and 78.88 ± 10.21 at the final follow-up. Moderate and severe problems were found in the pain/discomfort in 22.0% of the patients. These mobility and usual activities numbers were slightly higher (24.6% and 30.4%, respectively). The mean scores for QoL and VAS were significantly higher in patients with mild and moderate neurological impairment, normal BMI, <60 years of age, no dural tears, symptom relief at hospital discharge, unilateral and bilateral ossification on axial CT scan, ≤ 50% spinal canal occupancy on CT and MRI, and none or fuzzy on ISST2I. CONCLUSION QoL after posterior laminectomy in TOLF patients is generally satisfactory compared to preoperative levels. Preoperative mJOA score, Age, comorbid diabetes, the major symptom is activity limitation, BMI, ISST2I, Intraoperative dural tears and spinal canal occupancy rate correlate significantly with the corresponding dimensions and are predictive. Age, spinal canal occupancy rate, ISST2I, preoperative mJOA score, BMI are significantly associated with and have predictive value for overall postoperative QoL.
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Affiliation(s)
- Junhu Li
- Department of Orthopaedic SurgeryOrthopaedic Research Institute, West China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
| | - Zhipeng Deng
- Department of Orthopaedic SurgeryOrthopaedic Research Institute, West China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
| | - Linnan Wang
- Department of Orthopaedic SurgeryOrthopaedic Research Institute, West China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
| | - Lei Wang
- Department of Orthopaedic SurgeryOrthopaedic Research Institute, West China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
| | - Hailing Yang
- Program in Cellular and Molecular Physiology, Graduate School of Biomedical Sciences, Tufts UniversityBostonMassachusettsUSA
| | - Xi Yang
- Department of Orthopaedic SurgeryOrthopaedic Research Institute, West China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
| | - Yuemin Song
- Department of Orthopaedic SurgeryOrthopaedic Research Institute, West China Hospital, West China School of Medicine, Sichuan UniversityChengduChina
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Wu PH, Chin BZJ, Kim HS, Sim SI, Jang IT. Uniportal Thoracic Endoscopic Unilateral Laminotomy with Bilateral Decompression of Thoracic Ossification of Ligamentum Flavum: A Systematic Review of Current Literature. World Neurosurg 2023; 178:340-350.e2. [PMID: 37480986 DOI: 10.1016/j.wneu.2023.07.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard treatment for TOLF is open posterior laminectomy, it is often accompanied by high rates of complications and perioperative morbidity. There have been studies looking into feasibility of endoscopic posterior decompression for TOLF, citing potential for lower perioperative morbidity and achieving similar functional outcomes to its open laminectomy counterparts. We provide an up-to-date systematic review of clinical outcomes after endoscopic posterior decompression for TOLF from the latest assemblage of evidence. METHODS A systematic review of the technique was conducted from May 2000 to May 2023. Articles were selected based on PRISMA guidelines. Eligibility of studies was independently by 2 reviewers, with disagreements resolved by a third author. RESULTS Nineteen primary references comprising 337 patients with TOLF who underwent endoscopic posterior decompression were included in the systematic review. Mean follow-up time across all studies ranged from 8.9 to 65.3 months. Mean age ranged from 51.2 to 63 years, with mean intraoperative blood loss ranging from 15 to 62 mL. There is significant improvement in visual analog scale (VAS) score, VAS back, VAS leg, modified Japanese Orthopaedic Association score, and Oswestry Disability Index compared with preoperative recorded values across all studies, with low rates of complications reported. CONCLUSIONS Endoscopic posterior spinal decompression is a safe and effective technique for treatment of TOLF, with a low rate of complications and improvement in pain and function.
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Affiliation(s)
- Pang Hung Wu
- Achieve Spine And Orthopaedic Centre, Mount Elizabeth Hospital, Singapore; National University Health System, Jurong Health Campus, Orthopaedic Surgery, Singapore
| | - Brian Zhao Jie Chin
- National University Health System, Jurong Health Campus, Orthopaedic Surgery, Singapore; National University Health System, Kent Ridge Campus, Orthopaedic Surgery, Singapore
| | - Hyeun Sung Kim
- Nanoori Gangnam Hospital, Spine Surgery, Seoul, Republic of South Korea.
| | - Seth Ian Sim
- National University Health System, Kent Ridge Campus, Orthopaedic Surgery, Singapore
| | - Il-Tae Jang
- Nanoori Gangnam Hospital, Spine Surgery, Seoul, Republic of South Korea
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6
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Chen J, Yu Q, Wang H, An H, Dou C, Lu Z, Ding A, Ma L. Short shaft ratio: A novel predictor for dural ossification in patients with ossification of the ligamentum flavum. Heliyon 2023; 9:e18541. [PMID: 37520950 PMCID: PMC10382634 DOI: 10.1016/j.heliyon.2023.e18541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023] Open
Abstract
Background Dural ossification (DO) is strongly correlated with an increased incidence of complications during the surgery for the patients with thoracic ossification of the ligamentum flavum (OLF). Some methods for predicting DO have emerged, but the accuracy remains to be improved. We aimed to find a more accurate way to predict the appearance of DO. Methods Retrospective study was adopted in this study. According to the intraoperative findings, ninety-one patients with thoracic OLF were ultimately included and divided into two groups based on the presence or absence of DO. Patient characteristics and radiographic data were recorded. The residual area ratio (RAR, residual area/cross-section area of normal spinal canal × 100%) and the short shaft ratio (SSR, the length of short shaft of the ellipse-like shape/the length of the spinal canal × 100%) were measured and calculated by 2 independent observers, followed by statistical analysis. The receiver operating characteristic curve was used to evaluate the accuracy of the SSR and RAR in predicting DO. Results No significant differences were found in sex, age and BMI between the DO group and the non-DO group. The mean RAR (and standard deviation) in the Non-DO group (62.6% ± 10.2%) was significantly higher (p < 0.001) than that in the DO group (46.1% ± 10.5%). The mean SSR (and standard deviation) in the Non-DO group (61.6% ± 6.0%) was significantly higher (p < 0.001) than that in the DO group (43.6% ± 9.2%). The receiver operating characteristic curve indicated that the SSR and RAR can be used as the efficient indicators to identify DO, and the SSR has a higher accuracy in indicating the presence of DO, with a cutoff value of <48.71% (sensitivity of 100% and specificity of 85.0%). Conclusion The SSR can be used as a supplement parameter to traditional methods to predict DO, and it could be a better predictor. And, compared with bilateral and bridged type, unilateral type of OLF was more likely to develop DO with a larger SSR.
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He JL, Du Q, Hu WD, Xin ZJ, Shao XX, Liao WB. CT-based radiographic measurements and effectiveness estimates of full-endoscopic surgery in thoracic myelopathy caused by ossification of ligamentum flavum. BMC Surg 2023; 23:84. [PMID: 37041487 PMCID: PMC10091596 DOI: 10.1186/s12893-023-01989-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/04/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Evaluate the effectiveness of posterior percutaneous full-endoscopic technique for patients with thoracic myelopathy caused by ossification of ligamentum flavum (TOLF). METHODS A prospective study was conducted for 16 patients with TOLF, who were treated with posterior endoscopic technique from 2017 to 2019. The sagittal and cross-sectional CT images are used to measure the area of ossified ligamentum and evaluate the decompression of surgery, respectively. The effectiveness was evaluated with visual analog scale (VAS), modified Japanese Orthopedic Association scale (mJOA), The Oswestry Disability Index (ODI), and Macnab efficacy evaluation. RESULTS The average area of TOLF on sagittal and cross-sectional CT images in the 16 patients was (116.62 ± 32.72) mm2 and (141.59 ± 27.25) mm2 preoperatively, (15.99 ± 12.54) mm2 and (11.72 ± 8.64) mm2 at 3 days after the operation, (16.78 ± 11.49) mm2 and (10.82 ± 7.57) mm2 postoperative 1 year, respectively. The invasive proportion of spinal canal at preoperative sagittal and cross-sectional CT images was (48.10 ± 10.04) % and (57.58 ± 11.37) %, which decreased to (6.83 ± 4.48) % and (4.40 ± 3.01) % at the final follow-up. The average score of mJOA, VAS and ODI improved. The excellent and good rate was 87.50% according to Macnab evaluation. Compared with preoperative, differences in areas of TOLF, proportions of spinal canal, and clinical assessments of postoperative 3 days and 1 year were all statistically significant. Two cases of dural tear were observed. CONCLUSION Endoscopic surgery has a good clinical effect on TOLF, which has the advantage of less trauma to the paraspinal muscles and no impact on the spinal structure. The CT-based radiographic measurements can quantitatively evaluate the degree of spinal canal stenosis in TOLF.
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Affiliation(s)
- Jia-Lin He
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi, 563006, Guizhou, China
| | - Qian Du
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi, 563006, Guizhou, China
| | - Wan-Dong Hu
- Guizhou Aerospace Hospital, Zunyi, Guizhou, 563099, China
| | - Zhi-Jun Xin
- Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Xin-Xin Shao
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi, 563006, Guizhou, China
| | - Wen-Bo Liao
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi, 563006, Guizhou, China.
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Bagga RS, Shetty AP, Viswanathan VK, Reddy GJ, Kanna RM, Rajasekaran S. Thoracic Myelopathy in Ossified Ligamentum Flavum: Surgical Management and Long-Term Outcome Following 2 Different Techniques of Surgical Decompression. Global Spine J 2023; 13:659-667. [PMID: 33840238 DOI: 10.1177/21925682211003061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Thoracic ossified ligamentum flavum (TOLF) has been reported to present with varying degrees of neuro-deficit and multiple factors have been purported to affect its outcome. Purpose of study was to analyze factors affecting outcome and impact of ultrasonic osteotome (UO). METHODS We retrospectively reviewed patients treated for thoracic myelopathy secondary to OLF between 2010 and 2017. 77 patients with complete clinico-radiological records and 2 years follow-up were included. Initial 45 patients, conventional high-speed burr (HSB-group A) was used for decompression. In others, UO was used in combination with HSB (group B). Myelopathy was graded using modified Japanese orthopaedic association grading pre-operatively and each postoperative visit. At final follow-up, recovery rate was calculated. Radiological details including location, morphology, dural ossification, signal change and spinal ossifications were recorded. RESULTS Mean mJOA at presentation and final follow-up were 4.3±1.8 and 7.6±1.9 respectively (p = 0.001). HRR was 49.9±23 at final follow-up. A significant reduction in dural tear (12.5%; 29%) and surgical time (125.8±49.5; 189.4±52.5) were observed in group B (p = 0.00). However, there was no statistically significant difference (p = 0.18) in recovery rates between groups A (44.8±26.1) and B (52.8±24.3). Symptom duration (p = 0.00), severity of myelopathy (p = 0.04) and cord signal changes on MRI (p = 0.02) were important predictors of outcome. CONCLUSION Use of UO significantly reduced operative time and dural tears, although resulted in similar recovery rate as compared with HSB. Pre-operative severity of myelopathy, symptom duration and presence of cord signal change were the most significant predictors of outcome.
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Affiliation(s)
| | - Ajoy P Shetty
- Department of Spine Surgery, Ganga Hospital, Coimbatore, India
| | | | | | | | - S Rajasekaran
- Department of Spine Surgery, Ganga Hospital, Coimbatore, India
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Zhao Y, Xiang Q, Jiang S, Lin J, Wang L, Sun C, Li W. Incidence and risk factors of dural ossification in patients with thoracic ossification of the ligamentum flavum. J Neurosurg Spine 2023; 38:131-138. [PMID: 36057125 DOI: 10.3171/2022.7.spine22645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/20/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Dural ossification (DO) is a common clinical feature in patients with thoracic ossification of the ligamentum flavum (OLF) and associated with the increased risk of perioperative complications. However, few studies have been conducted to determine the incidence and independent risk factors of DO in patients with thoracic OLF. The aim of this retrospective study was to determine the incidence and independent risk factors of DO in patients with thoracic OLF. METHODS A total of 107 patients with thoracic OLF who were admitted to the authors' hospital from December 2020 to December 2021 were included in this study. The independent risk factors of DO in patients with thoracic OLF were determined through univariate analysis followed by multivariate logistic regression analysis with p < 0.05. The diagnostic efficacy of the DO in OLF (DO-OLF) risk classification model was determined on the basis of independent risk factors and evaluated on the basis of sensitivity, specificity, and agreement rate. RESULTS The incidence of DO in patients with thoracic OLF was 35% (37/107 patients). The tuberous type according to the Sato classification (OR 9.75, p < 0.01) and larger (≥ 9°) supine local kyphosis angle (LKA) (OR 8.13, p < 0.01) were two independent risk factors of DO in thoracic OLF. The DO-OLF risk classification, a novel approach for the diagnosis of DO in patients with thoracic OLF, was established on the basis of the combination of the tuberous type according to the Sato classification and larger supine LKA. The sensitivity, specificity, and agreement rate of this approach for distinguishing between patients with thoracic OLF at high and low risk of DO were 87%, 93%, and 91%, respectively. CONCLUSIONS The incidence of DO in patients with thoracic OLF was 35%. The tuberous type according to the Sato classification and larger supine LKA (≥ 9°) were independent risk factors of DO in patients with thoracic OLF. The novel DO-OLF risk classification approach could serve as an efficient method for predicting DO in patients with thoracic OLF.
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Affiliation(s)
- Yongzhao Zhao
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Qian Xiang
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Shuai Jiang
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Jialiang Lin
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Longjie Wang
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Chuiguo Sun
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Weishi Li
- 1Department of Orthopaedics, Peking University Third Hospital, Beijing
- 2Beijing Key Laboratory of Spinal Disease Research, Beijing; and
- 3Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
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Dou X, Mao T, Ma Y, Jia F, Liu Y, Liu X. Fibrotic and inflammatory characteristics of epidural fat adjacent to the ossification area in patients with ossification of the ligament flavum. JOR Spine 2022; 5:e1229. [PMID: 36601380 PMCID: PMC9799088 DOI: 10.1002/jsp2.1229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 09/20/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives To observe histological and inflammatory characteristics of epidural fat (EF) adjacent to the ossification area in patients with ossification of the thoracic ligament flavum (TOLF) and provide a preliminary research basis for investigating the impact of the EF on OLF. Methods Samples of EF and autologous subcutaneous adipose tissue (SCAT) from TOLF patients (n = 26) and non-TOLF patients (n = 23) were harvested during posterior thoracic spine surgery. Adipocyte size and fibrosis were measured by histology. Vascularization and inflammatory cell infiltration were evaluated by immunohistochemical staining. Adipogenesis-related genes were assessed by real-time quantitative PCR. Conditioned media from cultured EF were evaluated via enzyme-linked immunosorbent assay to detect the secretion of inflammatory cytokines, including interleukin-6 (IL-6), tumor necrosis factor (TNF-α), and leptin. The phosphorylated STAT3 protein level in ligament flavum (LF) was examined using Western blot. Results Adipocytes size in EF was similar between in the TOLF and non-TOLF groups, but significantly smaller than that from autologous SCAT. Adipogenesis-related mRNA expression in EF was lower than that in SCAT. More fibrosis and vascularization were found in TOLF than in non-TOLF. EF in the TOLF group exhibited more macrophages and B lymphocytes infiltrated. The levels of cytokines such as IL-6, TNF-α, and leptin secreted by EF were significantly higher in the TOLF group than non-TOLF. The level of phosphorylated STAT3 in LF was significantly upregulated in the TOLF group. Conclusions Morphologically, EF adjacent to the ossification area is smaller and more uniform than autologous SCAT, exhibiting a characteristic similarity to visceral fat. EF in the TOLF group shows a more fibrotic, vascularized, and inflammatory phenotype, which secretes multiple cytokines. The phosphorylated STAT3 protein was significantly upregulated in the TOLF group. Whether these properties of EF directly affect the process of OLF needs to be further explored.
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Affiliation(s)
- Xinyu Dou
- Department of OrthopedicsPeking University Third HospitalBeijingChina,Beijing Key Laboratory of Spinal DiseasesBeijingChina,Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
| | - Tianli Mao
- Department of OrthopedicsPeking University Third HospitalBeijingChina,Beijing Key Laboratory of Spinal DiseasesBeijingChina,Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
| | - Yunlong Ma
- Pain Medicine CenterPeking University Third HospitalBeijingChina
| | - Fei Jia
- Department of OrthopedicsPeking University Third HospitalBeijingChina,Beijing Key Laboratory of Spinal DiseasesBeijingChina,Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
| | - Yu Liu
- Department of OrthopedicsPeking University Third HospitalBeijingChina,Beijing Key Laboratory of Spinal DiseasesBeijingChina,Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
| | - Xiaoguang Liu
- Department of OrthopedicsPeking University Third HospitalBeijingChina,Beijing Key Laboratory of Spinal DiseasesBeijingChina,Engineering Research Center of Bone and Joint Precision MedicineBeijingChina
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Effect of degenerative factors on cervical spinal cord during flexion and extension: a dynamic finite element analysis. Biomech Model Mechanobiol 2022; 21:1743-1759. [PMID: 35931861 DOI: 10.1007/s10237-022-01617-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 07/13/2022] [Indexed: 11/02/2022]
Abstract
Spinal cord injury (SCI) is a global problem that brings a heavy burden to both patients and society. Recent investigations indicated degenerative disease is taking an increasing part in SCI with the growth of the aging population. However, little insight has been gained about the effect of cervical degenerative disease on the spinal cord during dynamic activities. In this work, a dynamic fluid-structure interaction model was developed and validated to investigate the effect of anterior and posterior encroachment caused by degenerative disease on the spinal cord during normal extension and flexion. Maximum von-Mises stress and maximum principal strain were observed at the end of extension and flexion. The abnormal stress distribution caused by degenerative factors was concentrated in the descending tracts of the spinal cord. Our finding indicates that the excessive motion of the cervical spine could potentially exacerbate spinal cord injury and enlarge injury areas. Stress and strain remained low compared to extension during moderate flexion. This suggests that patients with cervical degenerative disease should avoid frequent or excessive flexion and extension which could result in motor function impairment, whereas moderate flexion is safe. Besides, encroachment caused by degenerative factors that are not significant in static imaging could also cause cord compression during normal activities.
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12
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Zhai J, Guo S, Li J, Chen B, Zhao Y. Progression of Spinal Ligament Ossification in Patients with Thoracic Myelopathy. Orthop Surg 2022; 14:1958-1963. [PMID: 35837729 PMCID: PMC9483086 DOI: 10.1111/os.13291] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/14/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the rate of increase in thickness and cross‐section area (CSA) of the ossification in thoracic myelopathy with or without cervical and lumbar spinal ligament ossification. Methods A total of 24 patients with 170 segments (47 ligamentum flavum [OLF] and 123 cases of ossification of the posterior longitudinal ligament [OPLL]) of spinal ligament ossification between January 2012 and March 2019 at a single institution were retrospectively reviewed. Demographic data, classification of OPLL, Sato classification of OLF, pre‐ and postoperative neurological function and complications were recorded. The thickness and CSA at the segment of maximum compression were measured with Image J software on the axial CT image. Results Twelve female and 12 male patients with thoracic myelopathy and spinal ligament ossification were enrolled in the study. The mean age of the patients was 54.0 ± 11.9 years with an average follow‐up of 22.2 ± 23.5 months. Overall, the mean rate of progression in thickness and CSA was 1.2 ± 1.6 and 18.4 ± 50.6 mm2/year, respectively. Being female, aging (≥45 years), and lower BMI (<28 kg/m2) predisposed patients to have faster ossification growth in thickness and CSA. The difference between the rate of OPLL and OLF progression in thickness and CSA was not significant. However, the rate of OPLL progression in the thoracic spine was significantly higher than that in the cervical spine regarding thickness (1.4 ± 1.9 vs. 0.6 ± 0.7 mm/year) and CSA (27.7 ± 72.0 vs. 7.3 ± 10.3 mm2/year). Conclusion This is the first study to investigate ligament ossification progression in patients with thoracic myelopathy. The difference between the rate of OPLL and OLF progression in thickness and CSA was not significant. However, the rate of thoracic OPLL progression in thickness and CSA was significantly higher than that in the cervical spine.
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Affiliation(s)
- Jiliang Zhai
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shigong Guo
- Department of Rehabilitation Medicine, Southmead Hospital, Bristol, UK
| | - Jiahao Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingrong Chen
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yu Zhao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Du P, Ma L, Ding W. The influence of ossification morphology on surgery outcomes in patients with thoracic ossification of ligamentum flavum (TOLF). J Orthop Surg Res 2022; 17:229. [PMID: 35413915 PMCID: PMC9004029 DOI: 10.1186/s13018-022-03064-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/09/2022] [Indexed: 11/27/2022] Open
Abstract
Background To determine whether there is a correlation between the type of ossification and radiological parameters, modified thoracic JOA scores, and complications in patients with thoracic ossification of ligamentum flavum treated by posterior thoracic surgery. Methods This retrospective cohort study included 48 patients with thoracic myelopathy caused by single-level thoracic ossification of ligamentum flavum who underwent thoracic posterior approach surgery in our Hospital o between December 2013 to December 2018. Patients were divided into unilateral, bilateral, and bridged groups in axial position, and beak and round groups in sagittal position. The differences were analyzed according to the ossification morphology. Results In axial myelopathy, there was no significant difference in preop and postop JOA scores and RR among the three groups in axial position (P = 0.884). In sagittal view, there was no significant difference in preoperative JOA score between the two groups (P = 0.710), while the postop JOA score and the recovery rate in the beak group were significantly lower than that of the round group (P = 0.010, P = 0.034). Two-way ANOVA showed that sagittal morphology had a significant effect on postop JOA score (P = 0.028), but axial morphology don’t (P = 0.431); there was no interaction between them (P = 0.444). For the recovery rate, sagittal morphology also had a significant effect (P = 0.043), but axial ossification don’t (P = 0.998); there was no interaction between them (P = 0.479). Conclusion Sagittal morphology had a significant adverse effect on postop JOA score and surgical outcome, while axial morphology had no effect on surgical outcome, and there was no interaction between sagittal morphology and axial morphology.
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Affiliation(s)
- Peiyu Du
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Lei Ma
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Wenyuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
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How i do it: biportal endoscopic thoracic decompression for ossification of the ligamentum flavum. Acta Neurochir (Wien) 2022; 164:43-47. [PMID: 34697694 DOI: 10.1007/s00701-021-05031-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 10/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Currently, decompressive laminectomy with or without concomitant fusion is a standard treatment for ossification of the ligamentum flavum (OLF). However, conventional thoracic decompressive laminectomy is not free of the inevitable destruction of the posterior ligamentous complex, and facet injury may lead to various sequelae. METHOD We used the biportal endoscopic technique for posterior thoracic decompression (BE-PTD) and describe the steps with discussion regarding the indications, advantages, possible complications, and ways to overcome complications. CONCLUSION BE-PTD can obtain endoscopic visualizations of all the boundaries of the OLF lesion and achieve direct neural decompression of thoracic OLF.
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Dissatisfaction Risk Factors of Patients after Laminectomy for Thoracic Ossification of Ligamentum Flavum: A Retrospective Cohort Study of Different Follow-Up Periods. Pain Res Manag 2021; 2021:3971396. [PMID: 34966472 PMCID: PMC8712141 DOI: 10.1155/2021/3971396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/01/2021] [Indexed: 11/18/2022]
Abstract
Objectives To explore the influencing factors of satisfaction with postoperative treatment in patients diagnosed with thoracic ossification of the ligamentum flavum during different follow-up periods. Methods This was a retrospective study of 57 patients who were diagnosed with thoracic ossification of ligamentum flavum (TOLF) and treated with laminectomy in the Spine Surgery Department of the Third Hospital of Hebei Medical University from January 2010 to January 2017. The Patient Satisfaction Index (PSI) was collected at discharge and at 6-month, 1-year, and the last follow-up. According to the evaluation results, the patients could be divided into a satisfied group and a dissatisfied group. The patient's Japanese Orthopaedic Association (JOA) score improvement rate was evaluated at the last follow-up. Possible influencing factors of the two groups of patients were compared and the related influencing factors of satisfaction with postoperative treatment in patients during different follow-up periods were summarized. Results At the time of discharge, the dissatisfied and satisfied groups had significant differences in variables of diabetes mellitus, duration of preoperative symptoms, urination disorder, intramedullary signal change on MRI, dural ossification, residual rate of cross-sectional spinal canal area on CT, shape on the sagittal MRI, hospital stay, hospitalization expenses, postoperative pain in LE VAS, delayed wound healing, postoperative depression, and intercostal pain (P < 0.05). There were also significant differences in urination disorder, postoperative pain according to the LE VAS, JOA score, and postoperative depression during the 6-month follow-up (P < 0.05). There were no significant differences in other variables between the two groups (P > 0.05). One year after the operation, there were significant differences between the dissatisfied group and the satisfied group in urination disorder, JOA score, and symptom recurrence (P < 0.05). There were also significant differences in the JOA score and symptom recurrence at the final follow-up (P < 0.05). For further analysis, the duration of preoperative symptoms in the satisfied group was less than 24 months and the duration of preoperative symptoms in the dissatisfied group was more than 24 months. The JOA scores of patients in the satisfied group and the dissatisfied group increased gradually with the improvement of neurological function in different follow-up periods, but, at the last follow-up, the JOA scores of patients in the satisfied group were significantly higher than those in the dissatisfied group. Conclusions In conclusion, for thoracic ossification of ligamentum flavum patients who received laminectomy, dissatisfaction with the early and medium-term postoperative results may be related to diabetes, the duration of preoperative symptoms, hospitalization expenses, delayed wound healing, intercostal pain, and urination disorder, and dissatisfaction with the long-term postoperative results might be related to the low JOA score improvement rate and symptom recurrence.
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Wang ZW, Wang Z, Zhou YH, Sun JY, Ding WY, Yang DL. Clinical effect analysis of laminectomy alone and laminectomy with instrumentation in the treatment of TOLF. BMC Musculoskelet Disord 2021; 22:667. [PMID: 34372819 PMCID: PMC8351435 DOI: 10.1186/s12891-021-04564-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background To explore the clinical effect of laminectomy alone and laminectomy with instrumentation in the treatment of TOLF. Methods A retrospective study was conducted on the clinical data of 142 patients with TOLF and laminectomy who underwent spine surgery at XXX Medical University from January 2003 to January 2018. According to whether the laminectomy was combined with instrumentation, the patients were divided into two groups: group A (laminectomy alone (LA), n = 77) and group B (laminectomy with instrumentation (LI), n = 65). Comparisons of possible influencing factors of demographic variables and operation-related variables were carried out between the two groups. In this study, the clinical effects of LA and LI in the treatment of TOLF were discussed. Thus, we explored the clinical effect of LA and LI in the treatment of TOLF. Results In terms of demographics, there was a statistically significant difference in BMI between group A and group B (P < 0.05). The differences in age, sex, smoking, drinking, heart disease, hypertension and diabetes were not statistically significant (P > 0.05). In terms of preoperative symptoms, there was a significant difference in gait disturbance, pain in the LE, and urination disorder between group A and group B (P < 0.05), but there was no significant difference in other variables between the two groups (P > 0.05). In terms of operation-related variables, there was a significant difference in the preoperative duration of symptoms, intramedullary signal change on MRI, dural ossification, residual rate of cross-sectional spinal canal area on CT, shape on the sagittal MRI, operation time, pre-mJOA, post-mJOA at 1 year, and leakage of cerebrospinal fluid between group A and group B (P < 0.05), but there was no significant difference in other variables between the two groups (P > 0.05). The preoperative average JOA score of group A was 6.37 and that of group B was 5.19. In group A, the average JOA score at 6 months, 1 year and 2 years after surgery was 7.87, 8.23 and 8.26, respectively, and the average JOA score improvement rate was 32.79 %, 38.32 and 38.53 %, respectively. In group B, the average JOA score at 6 months, 1 year and 2 years after surgery was 7.74, 8.15 and 8.29, respectively, and the average JOA score improvement rate was 39.15 %, 46.86 and 47.12 %, respectively. Conclusions Currently, there is no consensus on whether instrumentation is needed after laminectomy for TOLF. We found that for patients with a long duration of gait disturbance, urination disorder, preoperative duration of symptoms, intramedullary signal change on MRI, dural ossification, residual rate of cross-sectional spinal canal area on CT less than 60 %, and shape on the sagittal MRI being beak and low, pre-mJOA had better clinical effects after LI as compared to those after LA, and the incidence of perioperative complications was lower.
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Affiliation(s)
- Zhi-Wei Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139Ziqiang Road, 050051, Shijiazhuang, PR China
| | - Zheng Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139Ziqiang Road, 050051, Shijiazhuang, PR China
| | - Yan-Hong Zhou
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139Ziqiang Road, 050051, Shijiazhuang, PR China
| | - Jia-Yuan Sun
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139Ziqiang Road, 050051, Shijiazhuang, PR China
| | - Wen-Yuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139Ziqiang Road, 050051, Shijiazhuang, PR China.,Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, 139Ziqiang Road, 050051, Shijiazhuang, PR China
| | - Da-Long Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, 139Ziqiang Road, 050051, Shijiazhuang, PR China.
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Krishnan A, Samal P, Mayi S, Degulmadi S, Rai RR, Dave B. Thoracic Spine Stenosis: Does Ultrasonic Osteotome Improve Outcome in Comparison to Conventional Technique? Malays Orthop J 2021; 15:62-69. [PMID: 34429824 PMCID: PMC8381659 DOI: 10.5704/moj.2107.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/25/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION To investigate the efficacy of Ultrasonic Bone Scalpel (UBS) in thoracic spinal stenosis (TSS) in comparison to traditional technique. MATERIAL AND METHODS A total of 55 patients who had undergone conventional surgery (Group A) are compared with 45 patients of UBS (Group B) in TSS. The primary outcome measure of Modified Japanese Orthopaedic Association score (m JOA) with neurological complications and dural injury were assessed. Secondary outcome measures of total blood loss (TBL), time duration of surgery (ORT) and length of hospital stay (LHS) were analysed. RESULTS The pre-operative mJOA score 5.00(4.00-6.00) in the group A and 5.00(4.00-6.00) in the group B improved to 7.00(7.00-8.00) in the group A and 9.00(9.00-10.00) in the group B, respectively (P<0.001) at final average follow-up of 117.55 months for group A and 75.69 months in group B. More significant grade of myelopathy improvement and mJOA recovery rate (RR) were noted in group B. The TBL, ORT and LHS were more favourable in group B as compared to group A (p<0.0001). The group A had 9 (16.36%) neurological deficits compared to 2 (4.44%) in group B (p<0.001). Dural tears occurred in both groups (A=11, B=9). It was more frequent and not repairable in group A but without significant statistical difference. CONCLUSION UBS can reduce neurological deficits and improve outcomes in TSS. Secondarily, reduced blood loss, lesser surgical time and reduced LHS are significant added advantages of this new technology.
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Affiliation(s)
- A Krishnan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - P Samal
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - S Mayi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - S Degulmadi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - R R Rai
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - B Dave
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
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Sagittal Alignment in Patients with Thoracic Myelopathy Caused by the Ossification of the Ligamentum Flavum: A Retrospective Matched Case-Control Study. Spine (Phila Pa 1976) 2021; 46:300-306. [PMID: 33534440 DOI: 10.1097/brs.0000000000003791] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case-control study. OBJECTIVE The aim of this study was to describe and compare the sagittal spinal alignment between patients with and without the ossification of the ligamentum flavum in the thoracic spine (TOLF). SUMMARY OF BACKGROUND DATA Although mechanical factors play an important role in the development of TOLF, limited evidence exists on the association of sagittal spinal alignment and TOLF in the literature. METHODS The present study assessed the preoperative sagittal alignment parameters in consecutive patients who underwent posterior decompression for TOLF in a single institution between January 2014 and December 2019. The sagittal parameters of the patients with TOLF were compared to those of the age- and sex-matched control group with lumbar spondylosis. RESULTS The TOLF group (n = 43 [23 men, 20 women]), with a mean age of 69.5 (range: 41-86) years, and the control group (n = 86) were compared. The TOLF group had a significantly smaller sacral slope (27.60 ± 7.49 vs. 30.61 ± 8.15, P = 0.045) and lumbar lordosis (36.84 ± 13.63 vs. 45.08 ± 9.90, P < 0.001) and a larger pelvic incidence minus lumbar lordosis (PI-LL, 8.06 ± 15.05 vs.1.00 ± 11.34, P = 0.004) than the control group. Moreover, the thoracic kyphosis was smaller in the TOLF group, although the difference was not statistically significant (25.73 ± 11.29 vs. 28.22 ± 9.34, P = 0.187). The TOLF group had a significantly smaller slope angle at the inflection point (11.97 ± 5.85 vs. 15.78 ± 5.62, P < 0.001) and a higher tendency to have a Roussouly type 2 morphology (46.5% vs. 36.0%, P = 0.252) than the control group. CONCLUSION This is the first study to describe the sagittal alignment in patients with TOLF. The TOLF group showed a hypolordotic spine with a larger PI-LL mismatch compared to the age- and sex-matched control group with lumbar spondylosis.Level of Evidence: 4.
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Yamada T, Shindo S, Yoshii T, Ushio S, Kusano K, Miyake N, Arai Y, Otani K, Okawa A, Nakai O. Surgical outcomes of the thoracic ossification of ligamentum flavum: a retrospective analysis of 61 cases. BMC Musculoskelet Disord 2021; 22:7. [PMID: 33397347 PMCID: PMC7784257 DOI: 10.1186/s12891-020-03905-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/22/2020] [Indexed: 12/05/2022] Open
Abstract
Background Thoracic ossification of ligamentum flavum (T-OLF), as one of the causes of thoracic myelopathy, is often combined with other spinal disorders. Concurrent lumbar spinal canal stenosis (LCS) is often obscured by symptoms due to T-OLF, leading to difficulty in identifying the origin of these neurological findings. It is common to be misdiagnosed or delayed diagnosis due to the complicated nature. We evaluated the prevalence, distribution, and clinical characteristics of OLF, especially in patients with LCS. Methods The authors performed a retrospective analysis of the outcomes of 61 patients who underwent thoracic surgeries performed for symptomatic T-OLF. In all the patients, whole spine lesions were evaluated preoperatively. We examined the factors related to poor outcomes (the recovery rate of the Japanese Orthopedic Association score for thoracic myelopathy is less than 40%) following OLF surgeries. We compared the clinical outcomes according to whether there was concurrent LCS, and determined the optimal surgical approach. Results The occurrence of T-OLF increased with age. Forty-six cases (75.4%) were considered to be tandem T-OLF and LCS (LCS group). An advanced age, and concurrent LCS were associated with a poor outcome after the surgery. The LCS group significantly included a greater number of elderly, and more light-weighted patients with Modic change in thoracic spine and a greater sagittal vertical axis, resulting in the lower neurological recovery. Additional lumbar surgery (13cases) effectively improved both the T-JOA and L-JOA scores (from 6.5 ± 2.0 points to 8.0 ± 1.8 points, p = 0.0406, and from 14.5 ± 4.7 points to 20.7 ± 2.6 points, p = 0.001, respectively) in OLF patients with LCS. Conclusions T-OLF was highly associated with other spinal disorders. Poor outcomes in T-OLF surgery could be associated with age and concurrent LCS, and an additional surgery for another lumbar lesion significantly improved neurological findings in T-OLF patients.
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Affiliation(s)
- Tsuyoshi Yamada
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan. .,Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan.
| | - Shigeo Shindo
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
| | - Shuta Ushio
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Kazuo Kusano
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Norihiko Miyake
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Yoshiyasu Arai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, 5-11-5 Nishikawaguchi, 332-8558, Kawaguchi-city, Saitama, Japan
| | - Kazuyuki Otani
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
| | - Osamu Nakai
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan.,Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
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Zhang H, Wang C, Wang D, Zhou C, Zhu K, Tu Q, Kong M, Zhao C, Ma X. Predictive Risk Factors of Poor Preliminary Postoperative Outcome for Thoracic Ossification of the Ligamentum Flavum. Orthop Surg 2020; 13:408-416. [PMID: 33314773 PMCID: PMC7957384 DOI: 10.1111/os.12884] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/08/2020] [Accepted: 10/26/2020] [Indexed: 12/15/2022] Open
Abstract
Objective The aim of the present study was to ascertain the independent risk factors of poor preliminary outcome and to reveal the value of these factors in predicting the postoperative prognosis. Methods A total of 165 patients diagnosed with thoracic myelopathy because of thoracic ossification of the ligamentum flavum (TOLF) were enrolled in this retrospective study. All of them underwent posterior decompressive laminectomy surgery in our hospital from May 2016 to June 2019. The postoperative improvement of symptoms was evaluated using the modified Japanese Orthopaedic Association (mJOA) scoring system. Clinical data, such as age, sex, body mass index (BMI), duration of symptoms, history of hypertension and diabetes, tobacco use, history of drinking, symptoms of incontinence, number of compressed segments, and preoperative mJOA score, were respectively recorded. Radiologic features data included sagittal maximum spinal cord compression (MSCC), axial spinal canal occupation ratio (SCOR), grades and extension of increased signal on sagittal T2‐weighted images (ISST2I), types of increased signal on axial T2‐weighted images (ISAT2I), and the classification of ossification on axial CT scan and sagittal MRI. The t‐test, the χ2‐test, Fisher's exact test, binary logistic regression analyses, receiver operating characteristic (ROC) curves, and subgroup analyses were used to evaluate the effects of individual risk predictors on surgical outcomes. Results A total of 76 men and 89 women were enrolled in this study. The mean age of all patients was 58.53 years. After comparison between two groups, we found some risk factors that may be associated with postoperative outcomes, such as age, preoperative mJOA score, BMI, history of hypertension, MSCC, SCOR, grade and extension of ISST2I, type of ISAT2I, axial type of ossification, and sagittal type of ossification (P < 0.05, respectively). Binary logistic regression analysis revealed that older age (odds ratio [OR] = 1.062, 95% confidence interval [CI] = 1.006–1.121, P = 0.030), number of compressed segments (OR = 1.916, 95% CI = 1.250–2.937, P = 0.003), bilateral and bridged types of ossification (OR = 4 314, 95% CI = 1.454–8.657, P = 0.019; OR = 6.630, 95% CI = 2.580–17.530, P = 0.004), and grade 1 and 2 ISST2I (OR = 8.986, 95% CI =3.056–20.294, P < 0.001; OR = 7.552, 95% CI = 3.529–16.004, P < 0.001) were independent risk factors for a poor preliminary postoperative outcome. ROC curve analysis showed that the grade of ISST2I had an excellent discriminative power (area under the curve [AUC] = 0.817). In addition, risk factors have different values for predicting the clinical outcome in each subgroup. Conclusion Age, duration of symptoms, number of compressed segments, SCOR, grade, and extension of ISST2I and classification of ossification were associated with the preliminary prognosis, and the intramedullary increased signal on sagittal T2‐weighted MRI was highly predictive of poor postoperative outcome.
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Affiliation(s)
- Hao Zhang
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chao Wang
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dexun Wang
- Department of Orthopaedics, The West Coast of Qingdao New District People's Hospital, Qingdao, China
| | - Chuanli Zhou
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kai Zhu
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qihao Tu
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Kong
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chong Zhao
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuexiao Ma
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Baba S, Shiboi R, Yokosuka J, Oshima Y, Takano Y, Iwai H, Inanami H, Koga H. Microendoscopic Posterior Decompression for Treating Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum: Case Series. ACTA ACUST UNITED AC 2020; 56:medicina56120684. [PMID: 33321989 PMCID: PMC7763969 DOI: 10.3390/medicina56120684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/24/2020] [Accepted: 12/07/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Ossification of the ligamentum flavum (OLF) is a relatively common cause of thoracic myelopathy. Surgical treatment is recommended for patients with myelopathy. Generally, open posterior decompression, with or without fusion, is selected to treat OLF. We performed minimally invasive posterior decompression using a microendoscope and investigated the efficacy of this approach in treating limited type of thoracic OLF. Materials and Methods: Microendoscopic posterior decompression was performed for 19 patients (15 men and four women) with thoracic OLF with myelopathy aged between 35 to 81 years (mean age, 61.9 years). Neurological examination and preoperative magnetic resonance imaging (MRI) and computed tomography (CT) were used to identify the location and morphology of OLF. The surgery was performed using a midline approach or a unilateral paramedian approach depending on whether the surgeon used a combination of a tubular retractor and endoscope. The numerical rating scale (NRS) and modified Japanese Orthopedic Association (mJOA) scores were compared pre- and postoperatively. Perioperative complications and the presence of other spine surgeries before and after thoracic OLF surgery were also investigated. Results: Four midline and 15 unilateral paramedian approaches were performed. The average operative time per level was 99 min, with minor blood loss. Nine patients had a history of cervical or lumbar spine surgery before or after thoracic spine surgery. The mean pre- and postoperative NRS scores were 6.6 and 5.3, respectively. The mean recovery rate as per the mJOA score was 33.1% (mean follow-up period, 17.8 months), the recovery rates were significantly different between patients who underwent thoracic spine surgery alone (50.5%) and patients who underwent additional spine surgeries (13.7%). Regarding adverse events, one patient experienced dural tear, another experienced postoperative hematoma, and one other underwent reoperation for adjacent thoracic stenosis. Conclusion: Microendoscopic posterior decompression was applicable in limited type of thoracic OLF surgery including beak-shaped type and multi vertebral levels. However, whole spine evaluation is important to avoid missing other combined stenoses that may affect outcomes.
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Affiliation(s)
- Satoshi Baba
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
- Department of Orthopaedic Surgery, The University of Tokyo, 57-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
- Department of Spinal Surgery, Japan Community Health Care Organization, Tokyo Shinjuku Medical Center, 5-1 Tsukudo-chou, Shinjuku-ku, Tokyo 162-8643, Japan
- Correspondence: ; Tel.: +81-3-3269-8111; Fax: +81-3-3260-7840
| | - Ryutaro Shiboi
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
- Department of Orthopaedic Surgery, Ohno Chuo Hospital, 3-20-3 Shimokaizuka, Ichikawa-shi, Chiba 272-0821, Japan
| | - Jyunichi Yokosuka
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
| | - Yasushi Oshima
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
- Department of Orthopaedic Surgery, The University of Tokyo, 57-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Yuichi Takano
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
| | - Hiroki Iwai
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
| | - Hirohiko Inanami
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
| | - Hisashi Koga
- Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, 8-17-2 Minamikoiwa, Edogawa-ku, Tokyo 133-0056, Japan; (R.S.); (J.Y.); (Y.O.); (Y.T.); (H.I.); (H.I.); (H.K.)
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22
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Iwai H, Inanami H, Koga H. Full-Endoscopic Spine Surgery for the Treatment of Lumbar Ossification of the Ligamentum Flavum: Technical Report. World Neurosurg 2020; 142:487-494.e1. [PMID: 32599183 DOI: 10.1016/j.wneu.2020.06.132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/13/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ossification of the ligamentum flavum (OLF) is a relatively common disease in East Asia. Although surgical decompression using a posterior approach is commonly used to treat OLF, there are several different treatment strategies. The purpose of this study is to clarify the technically important points for the treatment of OLF using full-endoscopic spine surgery (FESS). METHODS FESS was performed on 7 patients with lumbar OLF. Patients had a mean age of 62.3 years and single-level involvement. Computed tomography and magnetic resonance imaging were used to classify the OLF. Two different types of spinal endoscope were used for posterior decompression. Interlaminal and translaminal approaches were performed in 6 and 1 patient, respectively. Preoperative and postoperative pain was evaluated using the numeric rating scale score. RESULTS The mean operation time was 84.1 minutes. Unilateral round-type OLF was treated using a 4.1-mm working channel endoscope. The bilateral type was treated using a 6.4-mm working channel endoscope. A dural tear occurred in 1 patient with beak-type OLF, but no symptoms resulting from the tear were observed. The mean preoperative and postoperative numeric rating scale scores were 7.7 and 1.6, respectively. CONCLUSIONS Posterior decompression using FESS can be used to treat patients with lumbar OLF. Unilateral round-type OLF with ipsilateral radiculopathy can be treated using a 4.1-mm working channel endoscope. Bilateral-type OLF with cauda equina symptoms should be treated using a 6.4-mm working channel endoscope.
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Affiliation(s)
- Hiroki Iwai
- Department of Neurosurgery, Iwai FESS Clinic, Tokyo, Japan; Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, Tokyo, Japan; Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Hirohiko Inanami
- Department of Neurosurgery, Iwai FESS Clinic, Tokyo, Japan; Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, Tokyo, Japan; Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Hisashi Koga
- Department of Neurosurgery, Iwai FESS Clinic, Tokyo, Japan; Department of Orthopaedics, Iwai Orthopaedic Medical Hospital, Tokyo, Japan; Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan.
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Cheng XK, Chen B. Percutaneous Endoscopic Thoracic Decompression for Thoracic Spinal Stenosis Under Local Anesthesia. World Neurosurg 2020; 139:488-494. [PMID: 32376381 DOI: 10.1016/j.wneu.2020.04.199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Thoracic spinal stenosis (TSS), a common vertebral degenerative disease, is generally treated via surgical decompression. Percutaneous endoscopic thoracic decompression (PETD) under local anesthesia is considered a relatively safe, minimally invasive procedure. Few reports detail the success of endoscopic decompression for treatment of TSS caused by ossification of ligamentum flavum, the most common cause of TSS. This study investigated application of PETD for treatment of TSS caused by ossification of ligamentum flavum, ossification of posterior longitudinal ligament, or thoracic disc herniation. METHODS From January 2017 to January 2019, 12 consecutive patients (6 men and 6 women) underwent PETD. TSS was caused by ossification of ligamentum flavum in 5 patients, thoracic disc herniation in 5 patients, and ossification of posterior longitudinal ligament in 2 patients. All cases were followed up for 1 year postoperatively. Preoperative and postoperative neurologic status was evaluated using the modified Japanese Orthopaedic Association score, and complications were documented. RESULTS Average modified Japanese Orthopaedic Association score improved significantly from 6.25 ± 1.60 preoperatively to 9.75 ± 1.21 at final follow-up. Dural tear was observed in 1 case during the intervention, and 1 case had transient worsening of preoperative paralysis. Recovery at final follow-up was classified as excellent in 5 cases, good in 6 cases, and poor in 1 case. CONCLUSIONS This retrospective analysis showed that PETD under local anesthesia may be a feasible alternative to treat TSS in elderly patients with other underlying complications for whom general anesthesia or major surgical trauma would be harmful.
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Affiliation(s)
- Xiao-Kang Cheng
- Orthopaedic Department, Chengde Medical University Affiliated Hospital, Chengde, China
| | - Bin Chen
- Orthopaedic Department, Chengde Medical University Affiliated Hospital, Chengde, China.
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24
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Surgical results and prognostic factors following percutaneous full endoscopic posterior decompression for thoracic myelopathy caused by ossification of the ligamentum flavum. Sci Rep 2020; 10:1305. [PMID: 31992790 PMCID: PMC6987090 DOI: 10.1038/s41598-020-58198-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/13/2020] [Indexed: 12/13/2022] Open
Abstract
Minimally invasive surgery (MIS) has shown satisfactory surgical results for the treatment of thoracic myelopathy (TM) caused by ossification of the ligamentum flavum (OLF). This study investigated the prognostic factors following MIS and was based on the retrospective analysis of OLF patients who underwent percutaneous full endoscopic posterior decompression (PEPD). Thirty single-segment OLF patients with an average age of 60.4 years were treated with PEPD under local anaesthesia. Clinical data were collected from the medical and operative records. The surgical results were assessed by the recovery rate (RR) calculated from the modified Japanese Orthopaedic Association (mJOA) score. Correlations between the RR and various factors were analysed. Patients’ neurological status improved from a preoperative mJOA score of 6.0 ± 1.3 to a postoperative mJOA score of 8.5 ± 2.0 (P < 0.001) at an average follow-up of 21.3 months. The average RR was 53.8%. Dural tears in two patients (6.7%, 2/30) were the only observed complications. Multiple linear regression analysis showed that a longer duration of preoperative symptoms and the presence of a high intramedullary signal on T2-weighted MRI (T2HIS) were significantly associated with poor surgical results. PEPD is feasible for the treatment of TM patients with a particular type of OLF. Patients without T2HIS could achieve a good recovery if they received PEPD early.
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25
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Prasad GL. Thoracic spine ossified ligamentum flavum: single-surgeon experience of fifteen cases and a new MRI finding for preoperative diagnosis of dural ossification. Br J Neurosurg 2019; 34:638-646. [DOI: 10.1080/02688697.2019.1670333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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26
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Posterior Percutaneous Endoscopic Technique Through Bilateral Translaminar Osseous Channels for Thoracic Spinal Stenosis Caused by Ossification of the Ligamentum Flavum Combined with Disk Herniation at the T10-11 Level: A Technical Note. World Neurosurg 2019; 133:135-141. [PMID: 31505277 DOI: 10.1016/j.wneu.2019.08.215] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The occurrence rate of thoracic spinal stenosis caused by ossification of the ligamentum flavum combined with disk herniation is lower than that of ossified ligamentum flavum in the thoracic spine, and the treatment method has rarely been reported. In this paper, we applied an endoscopic technique to a patient with thoracic spinal stenosis caused by ossification of the ligamentum flavum combined with disk herniation at the T10-11 level. METHODS We performed surgical decompression of the thoracic spinal cord for a patient diagnosed with thoracic spinal stenosis at the T10-11 level caused by ossification of the ligamentum flavum combined with disk herniation using percutaneous endoscopic surgery via the bilateral translaminar osseous channel approach. Pre- and postoperative computed tomography (CT) scan and magnetic resonance imaging (MRI) examinations were performed, and pre- and postoperative neurologic status was evaluated using the Modified Japanese Orthopaedic Association and visual analog scale scores. RESULTS The ossified ligamentum flavum and herniated disk material were removed through this osseous channel. Postoperative CT and MRI scanning revealed adequate decompression of the spinal cord at the T10-11 level. The patient was discharged home on postoperative day 3. At 6-month postoperative follow-up, the patient experienced complete resolution of T12 dermatomal numbness. The strength in her bilateral lower extremities improved slightly to grade 5. CONCLUSIONS We have applied percutaneous endoscopic surgery via bilateral translaminar osseous channels for the treatment of thoracic spinal stenosis caused by ossification of the ligamentum flavum combined with disk herniation. This surgery could provide sufficient decompression for thoracic spinal cord with minimum trauma.
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Contiguous Multilevel Thoracic Ossification of Ligamentum Flavum in a Young Adult Spine. Case Rep Orthop 2019; 2019:1640485. [PMID: 31360567 PMCID: PMC6652055 DOI: 10.1155/2019/1640485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/29/2019] [Indexed: 11/19/2022] Open
Abstract
The ossification of the ligamentum flavum (OLF) was characterized by the replacement of the ligamentum flavum by ectopic new bone formation. Although OLF is well known as one of the causes of thoracic myelopathy through the compression of the spinal cord from the posterolateral side, contiguous multilevel OLF is quite a rare cause of myelopathy. Severe ossifications were reported that only present in individuals aged over 25 years. External triggers of OLF might likely be increased as a consequence of biomechanical stress to the effect of posttraumatic ossification. The authors described one rare case of an enormous contiguous multilevel OLF in a 20-year-old female's thoracic spine after mild back trauma, to the extent that it was misdiagnosed as an old epidural hematoma initially. This female with obesity presented with a 6-month history of progressively worsening dorsal cord disorders. Resection or floating of the enormous OLF could be successfully achieved using O-arm-based navigation, and sensory loss, numbness, and gait disturbance were improved after operation.
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Oh JYL, Wang VTJ, Teo TWW, Kaliya-Perumal AK, Hee HT. Ossification of the yellow ligament in the cervical spine - an unusual location. Biomedicine (Taipei) 2019; 9:14. [PMID: 31124460 PMCID: PMC6533938 DOI: 10.1051/bmdcn/2019090214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/21/2019] [Indexed: 11/14/2022] Open
Abstract
Ossification of the yellow ligament (OYL) or ligamentum flavum, usually occurs in the thoracic spine. Focal OYL occurring in the cervical spine is considered rare and is sparsely reported in the literature. We came across a 30-year-old male patient with progressive left upper limb and bilateral lower limb weakness over a period of 3 months, associated with an unsteady gait. Clinical examination revealed bilateral generalized hyper-reflexia in both upper and lower limbs, inverted supinator jerk, Hoffman’s sign and clonus. Myelopathy due to cord compression was suspected and further investigations were done. MRI and CT scans revealed a bony mass in relation to the C6 spinous process projecting anterosuperiorly and narrowing the cervical spinal canal causing cord signal changes from C4 to C6 levels. In view of the deteriorating neurological status, immediate surgery in the form of decompression and posterior stabilization from C4-C6 was performed. Patient gradually recovered after surgery and attained full functional status. We report this case considering the unusual location of OYL and its successful management.
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Affiliation(s)
- Jacob Yoong-Leong Oh
- Department of Orthopaedic Surgery, Spine Division, Tan Tock Seng Hospital, Singapore
| | | | | | - Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Spine Division, Tan Tock Seng Hospital, Singapore - Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical sciences and Research, Affiliated to the Tamil Nadu Dr MGR Medical University, Tamil Nadu, India
| | - Hwan Tak Hee
- Pinnacle Spine and Scoliosis Centre, Mount Elizabeth Medical Centre, Singapore
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An B, Li XC, Zhou CP, Wang BS, Gao HR, Ma HJ, He Y, Zhou HG, Yang HJ, Qian JX. Percutaneous full endoscopic posterior decompression of thoracic myelopathy caused by ossification of the ligamentum flavum. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:492-501. [PMID: 30656471 DOI: 10.1007/s00586-018-05866-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/06/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Ossification of ligamentum flavum (OLF) is the leading cause of progressive thoracic myelopathy (TM) in East Asian countries. Surgical decompression is the general treatment for TM. This study investigated the application of percutaneous full endoscopic posterior decompression (PEPD) for the treatment of thoracic OLF. METHODS Eighteen patients with TM were treated by PEPD under local anaesthesia. Patients had an average age of 59.1 years and single-level lesions mostly at the lower thoracic vertebrae. Computed tomography and magnetic resonance imaging were used to classify the OLF. The pre- and postoperative neurological statuses were evaluated using the American Spinal Injury Association (ASIA) sensory and motor score, modified Japanese Orthopaedic Association (mJOA) score and Frankel grade. RESULTS OLF for all patients was classed as lateral, extended, and enlarged types without comma and tram track signs. Decompression was completed, and a dome-shaped laminotomy was performed through limited laminectomy and flavectomy. Dural tears in 2 patients were the only observed complication. The average score of ASIA sensory and motor, mJOA, as well as the Frankel grade improved significantly after surgery at an average follow-up time of 17.4 months. The average recovery rate (RR) was 47.5% as calculated from the mJOA scores. According to RR, 10 cases were classified as good, 4 cases fair, and 4 cases unchanged. CONCLUSIONS For patients with thoracic OLF at a single level and lateral, extended, and enlarged types without comma and tram track signs, it is safe and reliable to perform PEPD, which has satisfactory clinical results. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Bo An
- Department of Orthopedics, Tangdu Hospital Affiliated to Air Force Medical University, No.1 Xinsi Road, Baqiao District, Xi'an, 710000, Shanxi Province, China
| | - Xing-Chen Li
- Department of Spinal Surgery, Third Hospital of Henan Province, No.198, Funiu Road, Zhongyuan District, Zhengzhou, 450000, Henan Province, China
| | - Cheng-Pei Zhou
- Department of Orthopedics, Tangdu Hospital Affiliated to Air Force Medical University, No.1 Xinsi Road, Baqiao District, Xi'an, 710000, Shanxi Province, China
| | - Bi-Sheng Wang
- Department of Spinal Surgery, Third Hospital of Henan Province, No.198, Funiu Road, Zhongyuan District, Zhengzhou, 450000, Henan Province, China
| | - Hao-Ran Gao
- Department of Orthopedics, Tangdu Hospital Affiliated to Air Force Medical University, No.1 Xinsi Road, Baqiao District, Xi'an, 710000, Shanxi Province, China
| | - Hai-Jun Ma
- Department of Spinal Surgery, Third Hospital of Henan Province, No.198, Funiu Road, Zhongyuan District, Zhengzhou, 450000, Henan Province, China
| | - Yi He
- Department of Spinal Surgery, Third Hospital of Henan Province, No.198, Funiu Road, Zhongyuan District, Zhengzhou, 450000, Henan Province, China
| | - Hong-Gang Zhou
- Department of Spinal Surgery, Third Hospital of Henan Province, No.198, Funiu Road, Zhongyuan District, Zhengzhou, 450000, Henan Province, China
| | - He-Jun Yang
- Department of Spinal Surgery, Third Hospital of Henan Province, No.198, Funiu Road, Zhongyuan District, Zhengzhou, 450000, Henan Province, China.
| | - Ji-Xian Qian
- Department of Orthopedics, Tangdu Hospital Affiliated to Air Force Medical University, No.1 Xinsi Road, Baqiao District, Xi'an, 710000, Shanxi Province, China.
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Barath AS, Wu OC, Patel M, Kasliwal MK. Repeated recurrence of thoracic spine stenosis following decompression alone for ossification of the ligamentum flavum: case report. J Neurosurg Spine 2018; 30:332-336. [PMID: 30544345 DOI: 10.3171/2018.8.spine18517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 08/24/2018] [Indexed: 11/06/2022]
Abstract
Ossification of the ligamentum flavum (OLF) is a well-recognized but rare cause of thoracic myelopathy. Its subtle and variable clinical presentation often makes the diagnosis challenging. The treatment of symptomatic OLF requires surgical intervention, with the most common surgical procedure being a posterior decompression with or without instrumentation. Recurrence of ossification and stenosis after surgery is rare and usually occurs at the same intervertebral level. Multiple recurrences of ossification and stenosis are exceptionally rare. The authors report the case of OLF in a 60-year-old man who experienced recurrence of ossification and stenosis twice after posterior decompression surgeries alone. The patient was ultimately treated with revision decompression and instrumented fusion. The authors also present a pertinent review of the literature.
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Kim JK, Ryu HS, Moon BJ, Lee JK. Clinical Outcomes and Prognostic Factors in Patients With Myelopathy Caused by Thoracic Ossification of the Ligamentum Flavum. Neurospine 2018; 15:269-276. [PMID: 30185766 PMCID: PMC6226126 DOI: 10.14245/ns.1836128.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 08/15/2018] [Indexed: 11/23/2022] Open
Abstract
Objective The objective of this study was to investigate the surgical outcomes and prognostic factors for thoracic ossification of the ligamentum flavum (OLF) after decompressive laminectomy, focusing on the quantitative signal intensity ratio (SIR) of preoperative magnetic resonance imaging (MRI) and its prognostic significance.
Methods We retrospectively reviewed 24 patients who previously underwent total laminectomy to remove OLF from 2010 to 2015. MRI and computed tomography were performed to detect OLF. The SIR between the regions of interest of high signal intensity lesions and the normal cord at the T1–2 disc levels was calculated. We divided patients into 2 groups based on the extent of the modified Japanese Orthopaedic Association (JOA) recovery rate (RR): good (RR ≥ 50%) and poor (RR < 50%).
Results The mean preoperative and postoperative modified JOA scores for thoracic myelopathy were 6.67 ± 1.73 and 8.63 ± 1.81, respectively (p < 0.001). The preoperative JOA score (7.5 vs. 5.83, p = 0.028), postoperative JOA score (9.83 vs. 7.42, p = 0.000), and SIR (1.16 vs. 1.41, p = 0.009) were significantly different between the good and poor RR groups. A higher preoperative JOA score and lower SIR were associated with a good RR according to the JOA criteria.
Conclusion The clinical outcomes for thoracic OLF after decompressive laminectomy were favorable. A higher RR was correlated with a lower SIR and higher preoperative modified JOA score. Therefore, a relatively low SIR on MRI and a relatively high preoperative JOA score could be positive prognostic indicators for the JOA RR in patients with thoracic OLF.
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Affiliation(s)
- Jae-Kwang Kim
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Seung Ryu
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Bong Ju Moon
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Ruetten S, Hahn P, Oezdemir S, Baraliakos X, Merk H, Godolias G, Komp M. Full-endoscopic uniportal decompression in disc herniations and stenosis of the thoracic spine using the interlaminar, extraforaminal, or transthoracic retropleural approach. J Neurosurg Spine 2018; 29:157-168. [PMID: 29856303 DOI: 10.3171/2017.12.spine171096] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery for thoracic disc herniation and spinal canal stenosis is comparatively rare and often challenging. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique and approach are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon's experience. The objective of the study was to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the interlaminar, extraforaminal, or transthoracic retropleural approach in patients with symptomatic disc herniation and stenosis of the thoracic spine, taking specific advantages and disadvantages and literature into consideration. METHODS Between 2009 and 2015, decompression was performed in 55 patients with thoracic disc herniation or stenosis using a full-endoscopic uniportal technique via an interlaminar, extraforaminal, or transthoracic retropleural approach. Imaging and clinical data were collected during follow-up examinations for 18 months. RESULTS Sufficient decompression was achieved in the full-endoscopic uniportal technique. One patient required revision due to secondary bleeding, and another exhibited persistent deterioration on myelopathy. No other serious complications were observed. All but one patient experienced regression or improvement of their symptoms. CONCLUSIONS The full-endoscopic uniportal technique with an interlaminar, extraforaminal, or transthoracic retropleural approach was found to be a sufficient and minimally invasive method. To cover the entire range of thoracic disc herniations and stenosis within the criteria named, all full-endoscopic approaches are required.
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Affiliation(s)
- Sebastian Ruetten
- 1Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group-Catholic Hospital Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital of the Ruhr University of Bochum/Marien Hospital Witten, Herne
| | - Patrick Hahn
- 1Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group-Catholic Hospital Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital of the Ruhr University of Bochum/Marien Hospital Witten, Herne
| | - Semih Oezdemir
- 1Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group-Catholic Hospital Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital of the Ruhr University of Bochum/Marien Hospital Witten, Herne
| | - Xenophon Baraliakos
- 2Center for Rheumatology, Rheumazentrum Ruhrgebiet, Ruhr University of Bochum, Herne
| | - Harry Merk
- 3Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald
| | - Georgios Godolias
- 4Center for Orthopedics and Traumatology of the St. Elisabeth Group-Catholic Hospital Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital of the Ruhr University Bochum/Marien Hospital Witten, Herne; and
| | - Martin Komp
- 5Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group-Catholic Hospital Rhein-Ruhr, St. Anna Hospital Herne, University of Witten/Herdecke, Herne, Germany
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Overexpression of miR-182 inhibits ossification of ligamentum flavum cells by targeting NAMPT. Exp Cell Res 2018; 367:119-131. [DOI: 10.1016/j.yexcr.2018.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 12/31/2022]
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Ju JH, Kim SJ, Kim KH, Ryu DS, Park JY, Chin DK, Kim KS, Cho YE, Kuh SU. Clinical relation among dural adhesion, dural ossification, and dural laceration in the removal of ossification of the ligamentum flavum. Spine J 2018; 18:747-754. [PMID: 28939168 DOI: 10.1016/j.spinee.2017.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 08/28/2017] [Accepted: 09/11/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Dural laceration frequently occurs during surgery in patients with ossification of the ligamentum flavum (OLF), mainly because of dural adhesion (DA) and dural ossification (DO) between the ligamentum flavum and the dura mater. However, the radiological predictive factors of DA in OLF have rarely been reported. PURPOSE The objective of this study was to determine the preoperative radiological signs for predicting intraoperative DA in OLF by using preoperative magnetic resonance imaging (MRI) and computed tomography (CT). STUDY DESIGN This is a retrospective study. PATIENT SAMPLE This study included 182 patients who underwent decompressive laminectomy and OLF removal from 2005 to 2014. OUTCOME MEASURE Demographic data, preoperative neurologic status, surgical procedure and results, and intraoperative and postoperative complications were analyzed. Clinical outcome was assessed with the Japanese Orthopaedic Association score. MATERIALS AND METHODS Depending on the morphologic appearance of OLF in preoperative radiographs, we aimed to investigate the prevalence of intraoperative DA and DO. We used the following factors of representative classifications: (1) surface appearance, (2) "double-layer" or "tram-track" sign, (3) cross-sectional area of the stenosed level, (4) Sato classification as axial classification, (5) Kuh classification as sagittal classification, and (6) high-signal-intensity change on T2-weighted MRI. RESULTS Intraoperative evidence of DA was observed in 52 patients (29%), and DO was observed in 23 patients (13%). Twenty-seven patients (15%) had dural laceration during surgery. Statistically, DA was closely associated with the non-uniform type of surface appearance (odds ratio 5.396, p=.001) and with the presence of either a double-layer sign or a tram-track sign (odds ratio 11.525, p<.001). In the preoperative CT and MRI, 21 out of 23 patients with DO showed a "double-layer sign" or a "tram-track sign." CONCLUSIONS This study identified two predictive factors of DA in OLF, which were the non-uniform surface appearance and the presence of a double-layer sign or a tram-track sign. The presence of DO in OLF was closely associated with a double-layer sign or a tram-track sign in the preoperative radiological images.
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Affiliation(s)
- Jeong-Hyuk Ju
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sung-Jun Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Kyung-Hyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Dal-Sung Ryu
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Dong-Kyu Chin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Keun-Su Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Yong-Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Sung-Uk Kuh
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211, Eonjuro Gangnam-gu, Seoul, 06273, Republic of Korea.
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Zhou SY, Yuan B, Chen XS, Li XB, Zhu W, Jia LS. Imaging grading system for the diagnosis of dural ossification based on 102 segments of TOLF CT bone-window data. Sci Rep 2017; 7:2983. [PMID: 28592849 PMCID: PMC5462817 DOI: 10.1038/s41598-017-03178-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 04/26/2017] [Indexed: 11/12/2022] Open
Abstract
Thoracic ossification of the ligamentum flavum (TOLF) complicated with dural ossification (DO) is a severe clinical disease. The diagnosis of DO preoperatively remains challenging. The current study retrospectively analyzed imaging features of 102 segments with TOLF from 39 patients and proposed a grading system for evaluating DO risk. Logistic regression results showed that unilateral spinal canal occupational rate (UCOR), tram track signs, and C-signs were all risk factors for DO (odds ratios of 5.393, 19.734 and 72.594, respectively). In validation analyses for the TOLF-DO grading system, sensitivity was 76.0% (19/25), specificity was 91.0% (70/77), and Youden’s index was 0.66. Thus, implementation of the TOLF-DO grading system has the potential to improve the diagnosis of DO.
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Affiliation(s)
- Sheng-Yuan Zhou
- Department of Orthopaedics, Shanghai Changzheng Hospital, Fengyang Road No. 415, Shanghai, 200003, China
| | - Bo Yuan
- Department of Orthopaedics, Shanghai Changzheng Hospital, Fengyang Road No. 415, Shanghai, 200003, China
| | - Xiong-Sheng Chen
- Department of Orthopaedics, Shanghai Changzheng Hospital, Fengyang Road No. 415, Shanghai, 200003, China.
| | - Xue-Bin Li
- Department of Orthopaedics, Shanghai Changzheng Hospital, Fengyang Road No. 415, Shanghai, 200003, China
| | - Wei Zhu
- Department of Orthopaedics, Shanghai Changzheng Hospital, Fengyang Road No. 415, Shanghai, 200003, China
| | - Lian-Shun Jia
- Department of Orthopaedics, Shanghai Changzheng Hospital, Fengyang Road No. 415, Shanghai, 200003, China
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Surgical Outcomes of Thoracic Myelopathy Secondary to Ossification of Ligamentum Flavum in a Regional Hospital: A Primitive Report and Literature Review. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2016. [DOI: 10.1016/j.jotr.2015.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Symptomatic thoracic stenosis is an uncommon disease in contrast to cervical and lumbar stenosis. It has been reported that ossification of ligamentum flavum (OLF) is the most common cause of thoracic myelopathy in our locality. Materials and Methods All patients with symptomatic thoracic spinal stenosis secondary to OLF who underwent operative treatment in our institution between January 1999 and December 2013 were retrospectively reviewed for demographic data, causes, complications and surgical outcomes. Results Twenty-six patients who underwent surgical treatment for symptomatic OLF were followed up for an average period of 71.3 months. All patients received decompression with concomitant instrumented fusion in 2 patients (7.7%). In our series, we had 2 cases (7.7%) of early post-operative neurological deterioration secondary to haematoma formation. Four cases (15.4%) were complicated with cerebrospinal fluid leakage. Operative outcome was reported in Frankel classification and modified Japanese Orthopedic Association (JOA) scale for thoracic myelopathy. After operation, 8 patients (30.8%) showed improvement in their Frankel grade, while 16 patients (61.5%) had no change and 2 patients (7.7%) reported deterioration. Mean JOA score showed significant improvement from 5.1 (range 2–8) to 6.9 post-operatively (range 2–11). Discussion and Conclusion OLF is the most common cause of thoracic myelopathy in our locality. Early accurate diagnosis and adequate surgical decompression are important for favourable outcomes despite operative difficulties and possible complications.
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Chen ZQ, Sun CG. Clinical Guideline for Treatment of Symptomatic Thoracic Spinal Stenosis. Orthop Surg 2016; 7:208-12. [PMID: 26311094 DOI: 10.1111/os.12190] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 06/30/2015] [Indexed: 11/28/2022] Open
Abstract
Thoracic spinal stenosis is a relatively common disorder causing paraplegia in the population of China. Until nowadays, the clinical management of thoracic spinal stenosis is still demanding and challenging with lots of questions remaining to be answered. A clinical guideline for the treatment of symptomatic thoracic spinal stenosis has been created by reaching the consensus of Chinese specialists using the best available evidence as a tool to aid practitioners involved with the care of this disease. In this guideline, many fundamental questions about thoracic spinal stenosis which were controversial have been explained clearly, including the definition of thoracic spinal stenosis, the standard procedure for diagnosing symptomatic thoracic spinal stenosis, indications for surgery, and so on. According to the consensus on the definition of thoracic spinal stenosis, the soft herniation of thoracic discs has been excluded from the pathological factors causing thoracic spinal stenosis. The procedure for diagnosing thoracic spinal stenosis has been quite mature, while the principles for selecting operative procedures remain to be improved. This guideline will be updated on a timely schedule and adhering to its recommendations should not be mandatory because it does not have the force of law.
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Affiliation(s)
- Zhong-qiang Chen
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Chui-guo Sun
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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Predictors of surgical outcome in thoracic ossification of the ligamentum flavum: focusing on the quantitative signal intensity. Sci Rep 2016; 6:23019. [PMID: 26960572 PMCID: PMC4785339 DOI: 10.1038/srep23019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 02/25/2016] [Indexed: 12/01/2022] Open
Abstract
The association between intramedullary increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI) and surgical outcome in thoracic ossification of the ligamentum flavum (OLF) remains controversial. We aimed to determine the impact of signal change ratio (SCR) on thoracic OLF surgical outcomes. We retrospectively reviewed 96 cases of thoracic OLF surgery and investigated myelopathy severity, symptom duration, MRI and computed tomographic findings, surgical technique and postoperative recoveries. Surgical outcomes were evaluated according to the modified Japanese Orthopaedic Association (JOA) score and recovery rate. JOA recovery rate <50% was defined as a poor surgical outcome. By multivariate logistic regression analysis, we identified risk factors associated with surgical outcomes. Forty patients (41.7%) had a recovery rate of <50%. In receiver operating characteristic (ROC) curves, the optimal preoperative SCR cutoff value as a predictor of poor surgical outcome was 1.54. Multivariate logistic regression analysis revealed that a preoperative SCR ≥1.54 and symptom duration >12 months were significant risk factors for a poor surgical outcome. These findings suggest that preoperative SCR and duration of symptoms were significant risk factors of surgical outcome for patients with thoracic OLF. Patients with preoperative SCR ≥1.54 can experience poor postoperative recovery.
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Feng FB, Sun CG, Chen ZQ. Progress on clinical characteristics and identification of location of thoracic ossification of the ligamentum flavum. Orthop Surg 2016; 7:87-96. [PMID: 26033987 DOI: 10.1111/os.12165] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/12/2015] [Indexed: 01/26/2023] Open
Abstract
Thoracic ossification of the ligamentum flavum (TOLF) is the most common cause for thoracic spinal stenosis. TOLF is usually complicated by thoracic disc herniation, ossification of the posterior longitudinal ligament and degenerative spinal diseases such as cervical spondylosis and lumbar spinal stenosis, and the ossification also usually has a discontinuous or continuous multi-segment distribution. The resultant superposition of several symptoms makes the clinical manifestations complex. Currently, the diagnosis of TOLF depends mainly on the patient's symptoms, physical examination and thoracic CT and MRI examinations. Identification of the location of TOLF depends more on the doctor's subjective judgement. Diagnostic problems are related to the specific region and level of surgical decompression: if the extent of decompression is insufficient, the treatment is inadequate, resulting in residual symptoms. Obversely, unnecessary trauma and a various complications will occur if the decompression is too extensive. Hence, the clinical features and process of diagnosis, especially the means of identifying the location, still require further improvement. It is necessary to establish a simple and accurate means of identifying the segment of TOLF that is responsible for the neurologic deficit: a number of spinal surgeons have been working hard on this. This article will provided an overview of the clinical features of TOLF and the related problems of clinical identification of the location of the segment causing the neurological deficit. The relationship between the imaging manifestations and clinical characteristics still need to be explored with the aim of establishing a simple and precise method for determining precisely whether TOLF is related to spinal cord injury or not, thus reducing surgical trauma and achieving an optimal prognosis.
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Affiliation(s)
- Fa-bo Feng
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Department of Orthopaedics, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Chui-guo Sun
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Zhong-qiang Chen
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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Moon BJ, Kuh SU, Kim S, Kim KS, Cho YE, Chin DK. Prevalence, Distribution, and Significance of Incidental Thoracic Ossification of the Ligamentum Flavum in Korean Patients with Back or Leg Pain : MR-Based Cross Sectional Study. J Korean Neurosurg Soc 2015; 58:112-8. [PMID: 26361526 PMCID: PMC4564742 DOI: 10.3340/jkns.2015.58.2.112] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/07/2015] [Accepted: 06/11/2015] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Thoracic ossification of the ligamentum flavum (OLF) is a relatively rare disease. Because of ambiguous clinical symptom, it is difficult for early diagnosis of OLF and subsequent treatment can be delayed or missed. Therefore, the purpose of this study is to comprehensively assess the prevalence and distribution of thoracic OLF by magnetic resonance imaging (MRI) and coexisting spinal disease in Korean patients with back pain or leg pain. METHODS The sample included 2134 Korean patients who underwent MRI evaluation for back pain. The prevalence and distribution of thoracic OLF were assessed using lumbar MRI with whole spine sagittal images. Additionally, we examined the presence of coexisting lumbar and cervical diseases. The presence of thoracic OLF as well as clinical parameters such as age, sex, and surgery were retrospectively reviewed. RESULTS The prevalence of thoracic OLF in total patients was 16.9% (360/2134). The prevalence tended to increase with aging and was higher in women than in men. The lower thoracic segment of T10-11 was the most frequently affected segment. Of the 360 patients with OLF, 31.9% had coexisting herniated thoracic discs at the same level. Approximately 74% of the patients with OLF had coexisting lumbar and cervical disease. Nine (2.5%) of 360 OLF patients underwent surgery for thoracic lesion. CONCLUSION The prevalenceof thoracic OLF was relatively higher than those of previous reports. And coexisting lumbar and cervical disease were very frequent. Therefore, we should check coexisting spinal diseases and the exact diagnostic localization of ossification besides lumbar disease.
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Affiliation(s)
- Bong Ju Moon
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Sung Uk Kuh
- Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sungjun Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Su Kim
- Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Kyu Chin
- Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
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Clinical characteristics and surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective analysis of 85 cases. Spinal Cord 2015; 54:188-96. [PMID: 26238315 DOI: 10.1038/sc.2015.139] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 06/24/2015] [Accepted: 07/03/2015] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN A retrospective comparative study. OBJECTIVES To describe the clinical features and radiological findings, to assess the safety and effectiveness of posterior decompressive laminectomy and resection of the ossification of the ligamentum flavum (OLF), and to determine which presurgical and surgical variables were most closely related to postsurgical prognosis of thoracic myelopathy (TM) caused by OLF in China. METHODS Eighty-five patients with the diagnosis of TM caused by OLF received surgical treatment from July 1998 to May 2012. Clinical data were collected from medical and operative records. Correlations between the surgical outcome and various factors were also analyzed. RESULTS All cases were followed up for a mean of 49.2 months (range, 24-190 months) postoperatively. The mean Japanese Orthopaedic Association score was 3.8 points preoperatively and 8.2 points at the final follow-up, yielding a mean recovery rate of 63.0%. Postoperative complications included transient neurological deficits (9 cases), persistent neurological deficits (4 cases), dural tears (17 cases), cerebrospinal fluid leakage (9 cases), wound dehiscence (2 cases) and wound infection (3 cases). The OLF level (middle thoracic), preoperative duration of symptoms, intramedullary signal change on T2WI and preoperative severity of myelopathy were important predictors of surgical outcome. CONCLUSIONS Biomechanical and anatomical factors may have a key role in thoracic OLF progression. Posterior decompressive laminectomy and resection of the OLF can be considered an effective, reliable and safe alternative procedure. The OLF level, preoperative duration of symptoms, intramedullary signal change on T2WI and preoperative severity of myelopathy were confirmed and significantly correlated with the surgical outcome.
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Microendoscopic posterior decompression for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum: a technical report. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015. [PMID: 26223744 DOI: 10.1007/s00586-015-4158-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Ossification of the ligamentum flavum (OLF) is a common cause of progressive thoracic myelopathy in East Asia. Good surgical results are expected for patients who already show myelopathy. Surgical decompression using a posterior approach is commonly used to treat OLF. This study investigated the use of microendoscopic posterior decompression for the treatment of thoracic OLF. METHODS Microendoscopic posterior decompression was performed on 9 patients with myelopathy. Patients had a mean age of 59.8 years and single-level involvement, mostly at the T10-11 and T11-12 vertebrae. Computed tomography and magnetic resonance imaging were used to classify the OLF. A tubular retractor and endoscopic system were used for microendoscopic posterior decompression. Midline and unilateral paramedian approaches were performed in 2 and 7 patients, respectively. Intraoperative motor evoked potentials (MEPs) of 7 patients were monitored. Pre- and postoperative neurological status was evaluated using the modified Japanese Orthopaedic Association (mJOA) score. RESULTS Thoracic OLF for all patients were classed as bilateral type with a round morphology. Improvement of MEPs at least one muscle area was recorded in all patients following posterior decompression. A dural tear in one patient was the only observed complication. The mean recovery rate was 44.9 %, as calculated from mJOA scores at a mean follow-up period of 20 months. CONCLUSIONS Microendoscopic posterior decompression combined with MEP monitoring can be used to treat patients with thoracic OLF. The optimal surgical indication is OLF at a single vertebral level and of a unilateral or bilateral nature, without comma and tram track signs, and a round morphology.
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A diagnostic study of thoracic myelopathy due to ossification of ligamentum flavum. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:947-54. [DOI: 10.1007/s00586-015-3818-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 02/14/2015] [Accepted: 02/14/2015] [Indexed: 01/23/2023]
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Zhao Y, Xue Y, Shi N, Zong Y, Yang Z, He D, Wang Y, Ding H, Li Z, Tang Y. The CT and intraoperative observation of pedicel-ossification tunnel in 151 cases of thoracic spinal stenosis from ossification of ligamentum flavum. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1325-31. [PMID: 24610171 DOI: 10.1007/s00586-014-3261-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The aim of this study is to precisely illustrate the pedicle-ossification tunnel (POT)-a spinal cord-free pathway in upper facet joint en bloc resection, which was reported as a comparatively neurological safer decompression surgery for thoracic ossification of ligamentum flavum (OLF). METHODS From 1998 to 2009, 151 patients with thoracic spinal stenosis from OLF were diagnosed by CT, MRI, neurological examinations and confirmed by postoperative pathological examination. The existence and configuration of the POT were observed by interactive CT virtual endoscopic (CTVE) image with multiplanar reconstructions and confirmed by intraoperative observation. Posterior decompression by upper facet joint en bloc resection via POT was conducted in all patients and the advantage of surgery was evaluated by modified Japanese Orthopedic Association scores pre- and post-operatively. RESULTS Through CTVE and intraoperative observation, no spinal cord was found present in POTs. OLF bloc divided the foramen into three parts: upper POT, OLF bloc and lower POT. The POT was the epidural space between the lateral border of OLF and its neighboring pedicles inner cortex. The recovery rate of upper facet joint en bloc resection via POT was 75.24 ± 18.01 %. CONCLUSIONS POT is a spinal cord-free pathway between OLF bloc and its neighboring pedicles in thoracic spinal stenosis which can be applied in neuron preserved decompression surgery.
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Affiliation(s)
- Ying Zhao
- Department of Operative Surgery, Tianjin Medical University, No. 22 Qixiangtai Road, Heping District, Tianjin, China
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Thoracic myelopathy secondary to ossification of ligamentum flavum – Short case series and review of literature. APOLLO MEDICINE 2013. [DOI: 10.1016/j.apme.2013.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Gao R, Yuan W, Yang L, Shi G, Jia L. Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum. Spine J 2013; 13:1032-8. [PMID: 23541451 DOI: 10.1016/j.spinee.2013.02.034] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 09/04/2012] [Accepted: 02/20/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Thoracic myelopathy caused by multilevel (three or more levels) ossification of the ligamentum flavum (OLF) is rare. Little is known about its clinical features, and the surgical outcomes along with its related factors are also unclear. PURPOSE To describe the clinical features, assess the safety and effectiveness of surgical decompression, and determine the prognostic factors relevant for patients with thoracic myelopathy caused by multilevel OLF. STUDY DESIGN/SETTING A retrospective clinical study. PATIENT SAMPLE Seventy-five consecutive multilevel OLF patients who underwent surgical decompression were analyzed. OUTCOME MEASURES Modified Japanese Orthopedic Association (JOA) scale and the recovery rate. METHODS Patients who underwent surgical decompression for symptomatic multilevel OLF during January 1996 to June 2010 were all included. Clinical data were collected from medical and operative records; patients were evaluated by using the JOA scale preoperatively and during the follow-up. Correlations between the surgical outcome and various factors were also analyzed. RESULTS Forty-three men and 32 women with a mean age of 54.7 years (range 36-78 years) were included. The mean number of involved levels is 4.6 and contiguous OLF presented in 73.3% of these patients. The most common involved levels were T10/T11 (15.4%), T9/T10 (13.3%), and T11/T12 (12.5%). Coexisting spinal disorders were found in 41 patients (54.7%). Preoperative evaluation showed the mean JOA score was 5.8±1.7; 37.3% of these patients had mild myelopathy, 53.3% had moderate myelopathy, and 9.3% had severe myelopathy. All patients received posterior laminectomy. The JOA score (mean 8.2±2.1) significantly increased postoperatively (p<.05), and multiple regression analysis showed that preoperative duration of symptoms and preoperative JOA score were important predictors of surgical outcome. CONCLUSIONS Laminectomy with partially internal fixation is safe and effective in treatment of patients with symptomatic multilevel OLF. The results of our study show that preoperative JOA score and preoperative duration of symptoms were important predictors for the clinical outcome.
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Affiliation(s)
- Rui Gao
- Department of Spine Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Rd, Shanghai 200003, China
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Kim YH, Khuyagbaatar B, Kim K. Biomechanical effects of spinal cord compression due to ossification of posterior longitudinal ligament and ligamentum flavum: A finite element analysis. Med Eng Phys 2013; 35:1266-71. [DOI: 10.1016/j.medengphy.2013.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 12/06/2012] [Accepted: 01/15/2013] [Indexed: 11/30/2022]
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Kawaguchi Y, Yasuda T, Seki S, Nakano M, Kanamori M, Sumi S, Kimura T. Variables affecting postsurgical prognosis of thoracic myelopathy caused by ossification of the ligamentum flavum. Spine J 2013; 13:1095-107. [PMID: 23602378 DOI: 10.1016/j.spinee.2013.03.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 11/19/2012] [Accepted: 03/07/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Ossification of the ligamentum flavum (OLF) may result in thoracic myelopathy (TM) because of narrowing of the spinal canal. Because symptoms vary and are subjective, diagnosis of TM caused by OLF is sometimes difficult when based on symptoms and physical examination. Posterior decompression is indicated in patients with TM caused by OLF because it is believed that surgery is the most effective treatment. However, surgical outcomes vary. We are unaware of reports of objective presurgical diagnostic parameters, such as neurologic and radiologic findings, relating to the postsurgical prognosis in patients with TM caused by OLF. PURPOSE To determine which presurgical and surgical variables were most closely related to postsurgical prognosis of TM caused by OLF. STUDY DESIGN Retrospective review of the records of the cohort of patients who had undergone surgery from 1988 through 2008 at the University of Toyama Hospital for TM caused by OLF. PATIENT SAMPLE Forty-one patients who had surgery for TM caused by OLF that was progressive, severe, or both and for which the diagnosis was based on clinical, radiologic, and pathologic evaluations. OUTCOME MEASURES Relationship between the highest follow-up Japanese Orthopaedic Association (JOA) score for neurologic evaluation and of Hirabayashi's formula to indicate the extent of normalization after surgery with respect to the following 10 variables: age at surgery; sex; duration of presurgical symptoms; complications of diabetes mellitus; complications of hypertension; presence of presurgical hyperreflexia in either or both of the patellar tendon reflex and the Achilles tendon reflex; presurgical impairment of joint position sense in the big toes; number of levels affected by OLF; concurrent spinal lesions including ossification of the posterior longitudinal ligament; and intramedullary change of the spinal cord seen on magnetic resonance imaging (MRI). METHODS Multiple linear analyses were used to evaluate the variables related to postsurgical recovery. RESULTS Presurgical impairment of joint position sense in the big toe was the most important predictor of the highest postsurgical JOA score and of the highest percentage recovery rate. The number of affected OLF levels also predicted the postsurgical highest JOA score, but not statistically significantly so. Age at surgery, sex, and duration of symptoms presurgically did not affect postsurgical recovery. Complications of diabetes mellitus or of hypertension did not affect percentage recovery rate. The difference between recovery rate in patients with or without concurrent spinal lesions was not significant. Presurgical hyperreflexia was not correlated with recovery. Postsurgical JOA scores and percentage recovery rates of scores in patients whose presurgical MRIs had shown intramedullary signal change were not statistically significantly different from those whose MRIs had not shown signal change. CONCLUSIONS An excellent postoperative prognosis is not always possible in patients with TM caused by OLF. It may be important to check for impairment of joint position sense in the big toe, the number of levels affected by OLF, and presurgical intramedullary signal change on MRI before continuing to surgery.
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Affiliation(s)
- Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan.
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Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentum flavum: posterior surgery by laminectomy. Acta Neurochir (Wien) 2013; 155:1169-77. [PMID: 23584336 DOI: 10.1007/s00701-013-1694-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Thoracic ossification of ligamentum flavum (TOLF) of the spine is characterized by a heterotopic bone formation in the thoracic ligamentum flavum, which causes slowly progressing spinal cord injury. Surgical decompression is the most common treatment of choice for patients with compressive myelopathy due to TOLF. However, the surgical outcome is not always satisfactory. METHODS To identify the predictors of surgical outcome, we retrospectively studied the associations between various clinical and radiological parameters and postoperative recovery in 78 patients who underwent decompressive laminectomy for thoracic myelopathy due to TOLF between October 1998 and June 2011. Surgical outcomes were assessed using modified Japanese Orthopedic Association (mJOA) recovery rate (RR)/outcome scores. RESULTS At a minimum of 1 year after surgery for TOLF treatment, the postoperative clinical scores showed statistically significant changes with improvement in the JOA scores. The results indicated that a longer duration of preoperative symptoms, fused-type TOLF, and the degree of compression of the anteroposterior diameter and ossified region (middle thoracic OLF) was related to poor prognosis. CONCLUSION Early diagnosis and sufficient surgical decompression improved the functional outcomes of TOLF patients. The surgical risk is relatively higher due to the tenuous blood supply of the spinal cord and the limited spinal canal volume of the middle thoracic spine extending from T4 to T9.
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Nie ZH, Liu FJ, Shen Y, Ding WY, Wang LF. Lamina osteotomy and replantation with miniplate fixation for thoracic myelopathy due to ossification of the ligamentum flavum. Orthopedics 2013; 36:e353-9. [PMID: 23464957 DOI: 10.3928/01477447-20130222-26] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Lamina osteotomy and replantation with miniplate fixation is often used to treat benign intradural tumors, effectively preventing nerve entrapment and postoperative spinal deformities. However, no studies report using this technique to treat thoracic myelopathy due to ossification of the ligamentum flavum (OLF). This article reports the clinical outcome of a series of 18 cases of contiguous multilevel OLF treated by lamina osteotomy and replantation with miniplate fixation.Eighteen consecutive patients at the authors' institution were treated between 2008 and 2010 for contiguous multilevel OLF. Clinical efficacy, operative time, blood loss, sagittal alignment, and complications were investigated. Japanese Orthopaedic Association scale scores improved from 4.7±1.4 preoperatively to 7.9±1.3 three months postoperatively and 8.8±1.3 at final follow-up (P<.01), with a mean recovery rate of 67.8%±13.1%. No significant kyphotic deformity occurred postoperatively, and local kyphosis in the treated area increased by a mean of only 1.9°±1.0° at final follow-up. No patient required additional surgery due to spinal canal reobstruction and progressive spinal deformity. Cerebrospinal fluid leakage occurred in 4 patients and resolved after repair. Pulmonary infection and deep venous thrombosis occurred in 1 patient who was discharged with no complications after routine treatment.Lamina osteotomy and replantation with miniplate fixation is an effective therapeutic option for thoracic myelopathy due to contiguous multilevel OLF compression. The technique provides adequate decompression and stabilized sagittal alignment and avoids invasion of the spinal canal by scar tissue.
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Affiliation(s)
- Zhi-Hong Nie
- Department of Spine Surgery, the Third Hospital of HeBei Medical University, Shijiazhuang, China
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