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Ifthekar S, Seuk JW, Hwang UD, Lee HC, Lee SH, Bae J. The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series. Asian Spine J 2024; 18:265-273. [PMID: 38650096 PMCID: PMC11065508 DOI: 10.31616/asj.2023.0175] [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] [Received: 09/09/2023] [Revised: 12/27/2023] [Accepted: 12/27/2023] [Indexed: 04/25/2024] Open
Abstract
This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.
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Affiliation(s)
- Syed Ifthekar
- Department of Orthopaedics, All India Institute of Medical Sciences, Bibinagar,
India
| | - Ju-Wan Seuk
- Department of Spine Surgery, Wooridul Spine Hospital, Seoul,
Korea
| | - Ui Dong Hwang
- Department of Cardiothoracic and Vascular Surgery, Wooridul Spine Hospital, Seoul,
Korea
| | - Hyung Chang Lee
- Department of Cardiothoracic and Vascular Surgeon, Wooridul Spine Hospital, Busan,
Korea
| | - Sang-Ho Lee
- Department of Spine Surgery, Wooridul Spine Hospital, Seoul,
Korea
| | - Junseok Bae
- Department of Spine Surgery, Wooridul Spine Hospital, Seoul,
Korea
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Zhao Y, Xiang Q, Jiang S, Wang L, Lin J, Sun C, Li W. Prevalence, diagnosis, and impact on clinical outcomes of dural ossification in the thoracic ossification of the ligamentum flavum: a systematic review. 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 2023; 32:1245-1253. [PMID: 36877368 DOI: 10.1007/s00586-023-07625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 03/07/2023]
Abstract
STUDY DESIGN Systematic review. BACKGROUND CONTEXT Thoracic ossification of the ligamentum flavum (TOLF) has become the principal cause of thoracic spinal stenosis. Dural ossification (DO) was a common clinical feature accompanying with TOLF. However, on account of the rarity, we know little about the DO in TOLF so far. PURPOSE This study was conducted to elucidate the prevalence, diagnostic measures, and impact on the clinical outcomes of DO in TOLF by integrating the existing evidence. METHODS PubMed, Embase, and Cochrane Database were comprehensively searched for studies relevant to the prevalence, diagnostic measures, or impact on the clinical outcomes of DO in TOLF. All retrieved studies meeting the inclusion and criterion were included into this systematic review. RESULTS The prevalence of DO in TOLF treated surgically was 27% (281/1046), ranging from 11 to 67%. Eight diagnostic measures have been put forward to predict the DO in TOLF using the CT or MRI modalities, including "tram track sign", "comma sign", "bridge sign", "banner cloud sign", "T2 ring sign", TOLF-DO grading system, CSAOR grading system, and CCAR grading system. DO did not affect the neurological recovery of TOLF patients treated with the laminectomy. The rate of dural tear or CSF leakage in TOLF patients with DO was approximately 83% (149/180). CONCLUSION The prevalence of DO in TOLF treated surgically was 27%. Eight diagnostic measures have been put forward to predict the DO in TOLF. DO did not affect the neurological recovery of TOLF treated with laminectomy but was associated with high risk of complications.
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Affiliation(s)
- Yongzhao Zhao
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Qian Xiang
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Shuai Jiang
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Longjie Wang
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Jialiang Lin
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Chuiguo Sun
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, No. 49 NorthGarden Road, Haidian District, Beijing, 100191, China. .,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China. .,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China.
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Novel therapeutic strategy in the treatment of ossification of the ligamentum flavum associated with dural ossification. 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 2023; 32:1068-1076. [PMID: 36717400 DOI: 10.1007/s00586-023-07549-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
PURPOSE To investigate the imaging characteristics of thoracic ossification of ligamentum flavum (OLF) combined with dural ossification (DO) and the clinical efficacy of zoning laminectomy. METHOD The clinical data of 48 patients with thoracic OLF combined with DO who underwent zoning laminectomy between June 2016 and May 2020 were retrospectively analyzed. The modified Japanese Orthopedic Association (mJOA) score was used to evaluate neurological function before and after surgery, and the clinical efficacy was evaluated according to the improvement rate. RESULTS The symptoms of all patients significantly improved after the operation, and the average follow-up time was 27.8 (10-47) months. In addition, the average mJOA score had increased from 5.0 (2-8) preoperatively to 8.7 (6-11) postoperatively (t = 18.880, P < 0.05). The average improvement rate was 62.6% (25-100%), with 16 patients graded as excellent, 21 as good, and 11 as fair. Cerebrospinal fluid leakage occurred in 12 cases (25.0%), and all of them healed well after treatment. No postoperative aggravation of neurological dysfunction, wound infection or hematoma occurred. At the last follow-up, there was no recurrence of symptoms and kyphosis. CONCLUSION The Zoning laminectomy described here is both safe and effective.
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Sun K, Sun X, Zhu J, Huang F, Huan L, Xu X, Zhang P, Sun J, Shi J. Comparison of Surgical Results of the Bridge Crane Technique Versus Laminectomy for the Treatment of Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum. Global Spine J 2023; 13:384-392. [PMID: 33685278 PMCID: PMC9972286 DOI: 10.1177/2192568221996689] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN A retrospective study. OBJECTIVES This study aimed to evaluate the safety and effectiveness of the bridge crane technique versus laminectomy for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum (OLF). METHODS Totally 41 patients who underwent surgical decompression due to thoracic OLF from May 2017 to June 2018 in our institution were enrolled in this study and were divided into group BG (bridge crane technique, n = 19) and group L (laminoectomy, n = 22). Demographic data was collected from medical records and the modified Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the neurological outcomes during the follow-up. Surgery-related complications were analyzed. RESULTS The mean duration of follow-up was comparable between group BG (19.4 ± 1.5 months) and group L (19.6 ± 1.4 months). No statistical differences were observed between two groups in terms of gender, age, duration of symptoms, preoperative occupying rate, involved levels, operation time, intraoperative blood loss, and complications. The JOA score significantly increased at the final follow-up in both groups. However, patients in group BG had higher JOA score and recovery rate (P < 0.05). Four patients in group L experienced complications, including 3 cerebrospinal fluid (CSF) leakage and one postoperative hematoma. Only one patient in group BG had CSF leakage. CONCLUSION The results of this study suggested that bridge crane technique may be relatively safe and effective for patients with symptomatic thoracic OLF with more satisfactory clinical improvement. However, high-quality studies are still required to validate the results of this study.
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Affiliation(s)
- Kaiqiang Sun
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China
| | - Xiaofei Sun
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China
| | - Jian Zhu
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China
| | - Fei Huang
- The First Department of Orthopedics, The
910th Hospital, Quanzhou City, Fujian Province, People’s Republic of China
| | - Le Huan
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China
| | - Ximing Xu
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China
| | - Peng Zhang
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China
| | - Jingchuan Sun
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China,Jiangang Shi and Jingchuan Sun, Department
of Spine Surgery, Changzheng Hospital, Naval Medical University, No. 415
Fengyang Road, Shanghai 200003, People’s Republic of China. Emails:
;
| | - Jiangang Shi
- Department of Spine Surgery, Changzheng
Hospital, Naval Medical University, Shanghai, People’s Republic of China,Jiangang Shi and Jingchuan Sun, Department
of Spine Surgery, Changzheng Hospital, Naval Medical University, No. 415
Fengyang Road, Shanghai 200003, People’s Republic of China. Emails:
;
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Pan Q, Zhang Z, Zhu Y, Jiang W, Su K, Liu P, Kang Y, Shao Z, Mei W, Wang Q. Zoning laminectomy for the treatment of ossification of the thoracic ligamentum flavum. Asian J Surg 2023; 46:723-729. [PMID: 35803890 DOI: 10.1016/j.asjsur.2022.06.118] [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: 03/22/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Spinal cord injury is a common occurrence during spinal surgery. In this study, we proposed a zoning laminectomy, which could reduce the incidence of nerve injury. We also discussed the safety and clinical efficacy of the zoning laminectomy for thoracic ossification of the ligamentum flavum (TOLF). METHODS Forty-five patients with TOLF who underwent zoning laminectomy from October 2016 to February 2020 were included in the retrospective analysis. The Japan Orthopedic Association (JOA) score was used to evaluate clinical outcomes. Meanwhile, the occurrence of complications was recorded. RESULTS All 45 patients underwent the operation successfully, and the mean follow-up period was 25.3 months, the mean operation time was 160.2 min, the average blood loss was 474.2 ml, and the average hospital time was 8.0 days. At the final evaluation, the JOA score was significantly higher than the preoperative JOA score (P < 0.001) and the overall recovery rate of the JOA score averaged 69.6%. Seventeen patients were graded as excellent, twenty-six as good, and two as fair. The complications included dural tears in nine patients (20.0%), cerebrospinal fluid leakage in seven patients (15.6%), deep infection in one patient (2.2%), and epidural hematoma in one patient (2.2%). All patients recovered well after treatment. Besides, there was no neurological deterioration and thoracic kyphosis occurred. CONCLUSIONS Zoning laminectomy adopts a phased resection from "safe zone" to "danger zone" and defines the safe removal range of the lamina, which reduces the risks of spinal cord injury caused by instrument manipulation. Therefore, it is a safe and effective surgical option.
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Affiliation(s)
| | - Zhenhui Zhang
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Yanyu Zhu
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Wentao Jiang
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Kai Su
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Peilin Liu
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Yongsheng Kang
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Zhe Shao
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Wei Mei
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China
| | - Qingde Wang
- Department of Spinal Surgery, Zheng Zhou Orthopaedics Hospital, Zhengzhou, China.
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Alsoof D, Anderson G, DiSilvestro KJ, McDonald CL, Kuris EO, Daniels AH. Diffuse Spinal Hyperostosis Causing Severe Spinal Stenosis and Thoracic Myelopathy. Orthop Rev (Pavia) 2022; 14:37832. [DOI: 10.52965/001c.37832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction Spinal stenosis has a wide range of causes including disc herniation, facet hypertrophy, degenerative spondylosis, facet cyst, ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL). We present three cases of diffuse spinal hyperostosis causing severe spinal stenosis and myelopathy, which demonstrate a unique association between obesity and a novel syndrome of hyperostosis. Case Presentation This report describes 3 morbidly obese patients with diffuse spinal hyperostosis causing critical thoracic stenosis. Their presenting complaints focus on lower extremity weakness and the CT/MRI imaging is striking for diffuse hyper-ossification at thoracic levels. Two patients were subsequently managed with spinal decompression, and one patient was managed non-operatively. Discussion Metabolic changes associated with obesity may result in diffuse hyperostosis with ligament ossification and spinal stenosis. Pre-operative imaging is essential to identify the degree of ossification and potential dural involvement as this may complicate management.
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Hwang SH, Chung CK, Kim CH, Yang SH, Choi Y, Yoon J. Value of Additional Instrumented Fusion in the Treatment of Thoracic Ossification of the Ligamentum Flavum. J Korean Neurosurg Soc 2022; 65:719-729. [PMID: 35988925 PMCID: PMC9452387 DOI: 10.3340/jkns.2021.0167] [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: 07/07/2021] [Accepted: 12/29/2021] [Indexed: 12/03/2022] Open
Abstract
Objective The ossification of the ligamentum flavum (OLF) is one of the major causes of thoracic myelopathy. Surgical decompression with or without instrumented fusion is the mainstay of treatment. However, few studies have reported on the added effect of instrumented fusion. The objective of this study was to compare clinical and radiological outcomes between surgical decompression without instrumented fusion (D-group) and that with instrumented fusion (F-group).
Methods A retrospective review was performed on 28 patients (D-group, n=17; F-group, n=11) with thoracic myelopathy due to OLF. The clinical parameters compared included scores of the Japanese Orthopedic Association (JOA), the Visual analogue scale of the back and leg (VAS-B and VAS-L), and the Korean version of the Oswestry disability index (K-ODI). Radiological parameters included the sagittal vertical axis (SVA), the pelvic tilt (PT), the sacral slope (SS), the thoracic kyphosis angle (TKA), the segmental kyphosis angle (SKA) at the operated level, and the lumbar lordosis angle (LLA; a negative value implying lordosis). These parameters were measured preoperatively, 1 year postoperatively, and 2 years postoperatively, and were compared with a linear mixed model.
Results After surgery, all clinical parameters were significantly improved in both groups, while VAS-L was more improved in the F-group than in the D-group (-3.4±2.5 vs. -1.3±2.2, p=0.008). Radiological outcomes were significantly different in terms of changes in TKA, SKA, and LLA. Changes in TKA, SKA, and LLA were 2.3°±4.7°, -0.1°±1.4°, and -1.3°±5.6° in the F-group, which were significantly lower than 6.8°±6.1°, 3.0°±2.8°, and 2.2°±5.3° in the D-group, respectively (p=0.013, p<0.0001, and p=0.037). Symptomatic recurrence of OLF occurred in one patient of the D-group at postoperative 24 months.
Conclusion Clinical improvement was achieved after decompression surgery for OLF regardless of whether instrumented fusion was added. However, adding instrumented fusion resulted in better outcomes in terms of lessening the progression of local and regional kyphosis and improving leg pain. Decompression with instrumented fusion may be a better surgical option for thoracic OLF.
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Deng Y, Yang M, Xia C, Chen Y, Xie Z. Unilateral biportal endoscopic decompression for symptomatic thoracic ossification of the ligamentum flavum: a case control study. INTERNATIONAL ORTHOPAEDICS 2022; 46:2071-2080. [PMID: 35725953 DOI: 10.1007/s00264-022-05484-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/11/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Thoracic ossification of the ligamentum flavum (OLF) is an uncommon disease that mostly occurs in East Asians. Laminectomy is often considered when patients develop neuro-related symptoms but may associate with treatment-related complications. This study aimed to evaluate the efficacy and safety of unilateral biportal endoscopic (UBE) decompression treatment in patients with symptomatic OLF. METHODS From January 2020 to January 2021, patients with spinal cord compression symptoms and imaging-defined single-level thoracic OLF were enrolled in this study and received UBE decompression treatment. Their pre- and postoperative neurological statuses were evaluated by the modified Japanese Orthopaedic Association (mJOA) score, Visual Analog Scale (VAS) for leg pain, and Frankel grade. RESULTS Fourteen patients with an average age of 59.4 years were enrolled in the study. The mean operation time was 66.1 ± 15.4 minutes. Patients were followed up for at least one year after receiving the treatment. Our data suggested that their mJOA score (preop 6.2 ± 1.2, 1 year 8.5 ± 0.9; P < 0.001) and VAS score (preop 4.5 ± 2.0, 1 year 0.5 ± 0.9; P < 0.001) were significantly improved compared with that before operation. Cerebrospinal fluid leakage occurred in one patient, head and neck pain occurred in two patients, and hyperalgesia of lower limbs occurred in two patients. All these complications did not cause serious consequences. CONCLUSION This primary study indicated that the UBE decompression treatment can achieve satisfactory clinical results in patients with thoracic OLF at single level and provide an alternative treatment option.
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Affiliation(s)
- Yue Deng
- Department of Spine Surgery, Hengyang Medical School, Shigu District, The First Affiliated HospitalUniversity of South ChinaHunan Province, No. 69, Chuanshan Road, Hengyang City, 421001, China
| | - Mingzhi Yang
- Department of Spine Surgery, Hengyang Medical School, Shigu District, The First Affiliated HospitalUniversity of South ChinaHunan Province, No. 69, Chuanshan Road, Hengyang City, 421001, China
| | - Chao Xia
- Department of Spine Surgery, Hengyang Medical School, Shigu District, The First Affiliated HospitalUniversity of South ChinaHunan Province, No. 69, Chuanshan Road, Hengyang City, 421001, China
| | - Yong Chen
- Department of Spine Surgery, Hengyang Medical School, Shigu District, The First Affiliated HospitalUniversity of South ChinaHunan Province, No. 69, Chuanshan Road, Hengyang City, 421001, China
| | - Zhong Xie
- Department of Spine Surgery, Hengyang Medical School, Shigu District, The First Affiliated HospitalUniversity of South ChinaHunan Province, No. 69, Chuanshan Road, Hengyang City, 421001, China.
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Bal J, Bruneau M, Berhouma M, Cornelius JF, Cavallo LM, Daniel RT, Froelich S, Jouanneau E, Meling TR, Messerer M, Roche PH, Schroeder HWS, Tatagiba M, Zazpe I, Paraskevopoulos D. Management of non-vestibular schwannomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section Part II: Trigeminal and facial nerve schwannomas (CN V, VII). Acta Neurochir (Wien) 2022; 164:299-319. [PMID: 35079891 DOI: 10.1007/s00701-021-05092-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-vestibular schwannomas are relatively rare, with trigeminal and jugular foramen schwannomas being the most common. This is a heterogenous group which requires detailed investigation and careful consideration to management strategy. The optimal management for these tumours remains unclear and there are several controversies. The aim of this paper is to provide insight into the main principles defining management and surgical strategy, in order to formulate a series of recommendations. METHODS A task force was created by the EANS skull base section committee along with its members and other renowned experts in the field to generate recommendations for the surgical management of these tumours on a European perspective. To achieve this, the task force performed an extensive systematic review in this field and had discussions within the group. This article is the second of a three-part series describing non-vestibular schwannomas (V, VII). RESULTS A summary of literature evidence was proposed after discussion within the EANS skull base section. The constituted task force dealt with the practice patterns that exist with respect to pre-operative radiological investigations, ophthalmological assessments, optimal surgical and radiotherapy strategies, and follow-up management. CONCLUSION This article represents the consensually derived opinion of the task force with respect to the treatment of trigeminal and facial schwannoma. The aim of treatment is maximal safe resection with preservation of function. Careful thought is required to select the appropriate surgical approach. Most middle fossa trigeminal schwannoma tumours can be safely accessed by a subtemporal extradural middle fossa approach. The treatment of facial nerve schwannoma remains controversial.
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Affiliation(s)
- Jarnail Bal
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK
| | - Michael Bruneau
- Department of Neurosurgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Moncef Berhouma
- Neuro-Oncologic and Vascular Department, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Luigi M Cavallo
- Department of Neurosurgery, University Hospital of Naples Federico II, Napoli, Italy
| | - Roy T Daniel
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, 42 rue du Bugnon, 1011, Lausanne, Switzerland
| | | | - Emmanuel Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Torstein R Meling
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, Lausanne University Hospital and University of Lausanne, 42 rue du Bugnon, 1011, Lausanne, Switzerland
| | | | - Henry W S Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Greifswald, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Idoya Zazpe
- Department of Neurosurgery, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK.
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Shah KS, Uchiyama CM. Thoracic ossification of the ligamentum flavum causing acute myelopathy in a patient with cervical ossification of the posterior longitudinal ligament: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE2178. [PMID: 35855184 PMCID: PMC9265228 DOI: 10.3171/case2178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 08/04/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND Ossification of the ligamentum flavum (OLF) has been well characterized as a distinct entity but also in tandem with ossification of the posterior longitudinal ligament (OPLL) in noncontiguous spinal regions. The majority of OLF cases are reported from East Asian countries where prevalent, but such cases are rarely reported in the North American population. OBSERVATIONS The authors present a case of a Thai-Cambodian American who presented with symptomatic thoracic OLF in tandem with asymptomatic cervical OPLL. A “floating” thoracic laminectomy, resection of OLF, and partial dural ossification (DO) resection with circumferential release of ossified dura were performed. Radiographic dural reexpansion and spinal cord decompression occurred despite the immediate intraoperative appearance of persistent thecal sac compression from retained DO. LESSONS Entire spinal axis imaging should be considered for patients with spinal ligamentous ossification disease, particularly in those of East Asian backgrounds. A floating laminectomy is one of several surgical approaches for OLF, but no consensus approach has been clearly established. High surgical complication rates are associated with thoracic OLF, most commonly dural tears/cerebrospinal fluid (CSF) leaks. DO commonly coexists with OLF, is recognizable on computed tomographic scans, and increases the risk of CSF leaks.
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Affiliation(s)
- Kishan S. Shah
- Department of Molecular, Cellular, and Developmental Biology, University of California, Los Angeles, Los Angeles, California; and
- Department of Neurosurgery, Scripps Clinic Medical Group, La Jolla, California
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Zhai J, Guo S, Zhao Y, Li C, Niu T. The role of cerebrospinal fluid cross-section area ratio in the prediction of dural ossification and clinical outcomes in patients with thoracic ossification of ligamentum flavum. BMC Musculoskelet Disord 2021; 22:701. [PMID: 34404364 PMCID: PMC8369786 DOI: 10.1186/s12891-021-04574-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/22/2021] [Indexed: 11/12/2022] Open
Abstract
Background It is imperative to preoperatively distinguish dural ossification (DO) and thus anticipate the risks and outcome of the surgery for patients with ossification of ligamentum flavum (OLF). However, studies have disagreed as to the efficacy of the radiographic signs or factors to predict DO and surgical outcome. In additon, the association between the cerebrospinal fluid cross-section area ratio (CCAR) and DO or clinical outcome had not been reported. The purpose of this study was to analyse CCAR and its role in prediction of DO and neurological function recovery rate in patients with OLF. Methods Fifty-two consecutive patients with OLF, who underwent posterior thoracic decompression and fusion between September 2012 and March 2019 at a single institution, were retrospectively reviewed. Demographic data, radiographic signs of DO, CCAR, pre- and postoperative modified Japanese Orthopedic Association (mJOA) score were recorded. Results There were 27 patients in the DO group and 25 patients in the non-DO group, with a mean age at surgery of 57.4 years and 53.9 years, respectively. No significant differences were found in sex, age, segment of maximum compression and preoperative mJOA score between the two groups. The receiver operating characteristic curve showed that the value of CCAR had a relatively high value for diagnosis of DO and prediction of neurological function recovery rate (P = .000). According to the value of CCAR, three zones were defined as DO zone (≤14.3%), non-DO zone (≥44.5%), and gray zone (14.3 to 44.5%). When the value of CCAR≤14.3%, the recovery rate was poor or fair, while it had good or excellent recovery when CCAR≥45.2%. Conclusion The value of CCAR had a high diagnostic value for prediction of DO and neurological function recovery rate in patients with OLF.
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Affiliation(s)
- Jiliang Zhai
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, shuaifuyuan 1#, Dongcheng district, Beijing, China
| | - Shigong Guo
- Department of Rehabilitation Medicine, Southmead Hospital, Bristol, UK
| | - Yu Zhao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, shuaifuyuan 1#, Dongcheng district, Beijing, China.
| | - Chunxu Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, shuaifuyuan 1#, Dongcheng district, Beijing, China
| | - Tong Niu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, shuaifuyuan 1#, Dongcheng district, Beijing, China
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Li J, Yu L, Guo S, Zhao Y. Identification of the molecular mechanism and diagnostic biomarkers in the thoracic ossification of the ligamentum flavum using metabolomics and transcriptomics. BMC Mol Cell Biol 2020; 21:37. [PMID: 32404047 PMCID: PMC7218621 DOI: 10.1186/s12860-020-00280-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background To establish a metabolite fingerprint of ossification of the thoracic ligamentum flavum (OTLF) patients using liquid chromatography-mass spectrometry (LC-MS) in combination with transcriptomic data and explore the potential molecular mechanism of pathogenesis. Results The study cohort was composed of 25 patients with OTLF and 23 healthy volunteers as a control group. Thirty-seven metabolites were identified out by UPLC-MS including uric acid and hypoxanthine. Nine metabolites, including uric acid and hypoxanthine, were found with a Variable Importance in Projection (VIP) score over 1 (p < 0.05). Pathway enrichment indicated that purine metabolism pathways and the other four metabolism pathways were enriched. Transcriptomic data revealed that purine metabolism have a substantial change in gene expression of OTLF and that xanthine dehydrogenase (XDH) is the key regulatory factor. Receiver operating characteristic (ROC) analysis indicated that 17 metabolites, including uric acid, were found with an AUC value of over 0.7. Conclusion Uric acid might be the potential biomarker for OTLF and play an important role within the detailed pathway. XDH could affect purine metabolism by suppressing the expression of hypoxanthine and xanthine leading to low serum levels of uric acid in OTLF, which could be a focal point in developing new therapeutic methods for OTLF.
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Affiliation(s)
- Jiahao Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, No. 1 Shuaifuyuan Dongdan, Dongcheng District, 100730, Beijing, P.R. China
| | - Lingjia Yu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, No. 1 Shuaifuyuan Dongdan, Dongcheng District, 100730, Beijing, P.R. China
| | - Shigong Guo
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
| | - Yu Zhao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, No. 1 Shuaifuyuan Dongdan, Dongcheng District, 100730, Beijing, P.R. China.
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Kachonkittisak K, Kunakornsawat S, Pluemvitayaporn T, Piyaskulkaew C, Pruttikul P, Kittithamvongs P. Congenital Spinal Canal Stenosis with Ossification of the Ligamentum Flavum in an Achondroplastic Patient: A Case Report and Literature Review. Asian J Neurosurg 2019; 14:1231-1235. [PMID: 31903369 PMCID: PMC6896628 DOI: 10.4103/ajns.ajns_170_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Achondroplasia has an effect on intracartilaginous ossification during the development of the spine resulting in a narrow spinal canal. This abnormal anatomy could make an achondroplastic patient tend to have spinal canal stenosis. We reported a case of congenital spinal canal stenosis with achondroplasia combined with ossified ligamentum flavum (OLF) at the thoracolumbar and lumbar spine, which was treated by decompressive surgery. We reported a 52-year-old Thai male with achondroplasia presented with progressive myelopathy and neurogenic claudication due to spinal canal stenosis. Spinal canal stenosis was observed at T10/11 and L1-L5 and OLF at T10/11 through L5 varying in size. Laminectomy and removal of the OLF were performed at T11 and L1-L5. The patient's neurological symptom improved after the surgery. He could walk with a walker at the time of 6-month follow-up postoperatively. In this report, we describe a rare case of achondroplasia with OLF presenting with progressive myelopathy and claudication symptoms from multiple levels of spinal canal stenosis. Laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and function.
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Affiliation(s)
- Kritsadakorn Kachonkittisak
- Department of Orthopaedic Surgery, Spine Unit, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand
| | - Sombat Kunakornsawat
- Department of Orthopaedic Surgery, Spine Unit, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand
| | - Tinnakorn Pluemvitayaporn
- Department of Orthopaedic Surgery, Spine Unit, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand
| | - Chaiwat Piyaskulkaew
- Department of Orthopaedic Surgery, Spine Unit, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand
| | - Pritsanai Pruttikul
- Department of Orthopaedic Surgery, Spine Unit, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand
| | - Piyabuth Kittithamvongs
- Department of Orthopaedic Surgery, Spine Unit, Institute of Orthopaedics, Lerdsin Hospital, Bangkok, Thailand
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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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15
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Yu L, Li B, Yu Y, Li W, Qiu G, Zhao Y. The Relationship Between Dural Ossification and Spinal Stenosis in Thoracic Ossification of the Ligamentum Flavum. J Bone Joint Surg Am 2019; 101:606-612. [PMID: 30946194 DOI: 10.2106/jbjs.17.01484] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dural ossification represents a difficult problem in the surgical management of thoracic ossification of the ligamentum flavum. Few studies have focused on this condition because of the relatively low prevalence. We speculated that dural ossification occurs only when spinal stenosis of patients with thoracic ossification of the ligamentum flavum progresses. Herein, we aimed to determine the relationship between dural ossification and spinal stenosis in thoracic ossification of the ligamentum flavum. METHODS In this study, 123 consecutive patients with ossification of the ligamentum flavum were retrospectively analyzed. Sixty-seven patients were ultimately included and were divided into a group that had dural ossification and a group that did not have dural ossification. Patient characteristics and radiographic data were recorded. The cross-sectional area occupying ratio ([1 - cross-sectional area of the narrowest level/normal cross-sectional area] × 100%) was measured and was calculated by 3 independent observers, followed by statistical analysis. RESULTS The 2 groups were comparable with respect to sex, age, body mass index, and distribution of the segment with maximum compression. The mean cross-sectional area occupying ratio (and standard deviation) in the T9-T12 subgroup in the group with dural ossification (63.4% ± 8.6%) was significantly higher (p < 0.001) than that in the group without dural ossification (30.7% ± 10.4%). The overall interobserver reliability for measurements of the cross-sectional area occupying ratio (interclass correlation coefficient, 0.976) was excellent. Thus, the cross-sectional area occupying ratio could be used as an indicator to distinguish between patients with ossification of the ligamentum flavum who did and did not have dural ossification, with a high diagnostic value, in the T9-T12 subgroup. A cross-sectional area occupying ratio of >55% (sensitivity of 81.5% and specificity of 100%), the "ossification zone," was indicative of dural ossification in patients with ossification of the ligamentum flavum, whereas a value of <45% (sensitivity of 100% and specificity of 89.7%) was considered safe. Moreover, ratios between 45% and 55% were considered to be in the "gray zone." CONCLUSIONS The results of this study indicate that the severity of spinal stenosis was significantly associated with dural ossification in ossification of the ligamentum flavum and the cross-sectional area occupying ratio may be used as an indicator of dural ossification in the lower thoracic spine. CLINICAL RELEVANCE The diagnosis of dural ossification was based on the intraoperative evidence, and the results could help spine surgeons to prepare for the surgical procedure.
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Affiliation(s)
- Lingjia Yu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bo Li
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.,Department of Orthopaedic Surgery, Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Yifeng Yu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wenjing Li
- Department of Orthopaedic Surgery, Fourth Clinical Medical College of Peking University, Beijing Jishuitan Hospital, Beijing, People's Republic of China
| | - Guixing Qiu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yu Zhao
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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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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Hou X, Chen Z, Sun C, Zhang G, Wu S, Liu Z. A systematic review of complications in thoracic spine surgery for ossification of ligamentum flavum. Spinal Cord 2017; 56:301-307. [PMID: 29284792 DOI: 10.1038/s41393-017-0040-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 01/13/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The aim of this systematic review is to summarize the incidence of complications, to relate complication incidence to procedures performed, to assess the impact of the year of study publication and follow-up duration on complication incidence. METHODS The authors conducted the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE searches for relevant literatures. The incidence of complications was summarized. Correlation of the incidence with year of study publications, follow-up duration, and the surgical outcome was statistically evaluated. RESULTS A total of 16 studies met our inclusion criteria, including 475 patients. All of these studies were retrospective case series. The mean age of patients ranged from 55 to 64 years. Average follow-up duration ranged from 26 to 65 months. Partial patients in four studies underwent surgeries and reserved posterior structure of the spinal canal. The others underwent operations removing posterior structure of spinal canal. The mean recovery rate from each individual study varied between 31 and 68% and the pooled neurologic function recovery rate was 53% (95% CI: 43-62%). The mean complication rate was 24%. Cerebrospinal fluid leakage was the most reported postoperative complication (19%), then neurologic deterioration (5%). Other complications included local infections, wound dehiscence, increased kyphotic deformity, an hematoma. CONCLUSIONS Operations removing posterior structure of spinal canal are the main technique to decompress spinal cord. Cerebrospinal fluid leakage and postoperative neurologic deterioration were the most reported complications.
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Affiliation(s)
- Xiaofei Hou
- Department of Orthopaedics, Peking University Shougang Hospital, Beijing, China
| | - Zhongqiang Chen
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.
| | - Chuiguo Sun
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Guangwu Zhang
- Department of Orthopaedics, Peking University Shougang Hospital, Beijing, China
| | - Sijun Wu
- Department of Orthopaedics, Peking University Shougang Hospital, Beijing, China
| | - Zheng Liu
- Department of Orthopaedics, Peking University Shougang Hospital, Beijing, China
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Wang H, Wei F, Long H, Han G, Sribastav SS, Li Z, Huang Y, Zhu R, Liang C. Surgical outcome of thoracic myelopathy caused by ossification of ligamentum flavum. J Clin Neurosci 2017; 45:83-88. [PMID: 28760654 DOI: 10.1016/j.jocn.2017.07.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 05/01/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
Ossification of the ligamentum flavum (OLF) may result in thoracic myelopathy (TM) because of the spinal canal narrowing. The aim of this study was to investigate clinical outcomes of symptomatic thoracic OLF treated using posterior decompressive laminectomy. We made a retrospective review of patients who underwent posterior decompressive laminectomy from 2007 through 2016 for symptomatic TM caused by OLF. Thirty-three patients who had surgery for TM caused by OLF that was diagnosed based on clinical, radiologic, and pathologic evaluations. All patients had undergone decompressive laminectomy and excision of the OLF. The clinical course was evaluated according to modified JOA scores. Magnetic resonance imaging was used to determine the number of vertebral segments demonstrating OLF, the level of thoracic cord involvement, and spine lesions coexisting with OLF. Results showed the neurological status improved at follow up (70.82±32.22months) from a preoperative mean Japanese Orthopaedic Association score of 7.03±1.29 points to 9.52±0.83 points at the last follow up (p<0.01). Recovery outcomes were excellent in 8 patients, good in 22 patients, fair in 2 patients and poor in 1 patient. Surgical complications, which resolved after appropriate and prompt treatment, including cerebrospinal fluid leakage in 4 patient, immediate postoperative neurologic deterioration in 2 patient, and wound infection in 4 patient. Our findings suggest that posterior decompressive laminectomy with or without instrumented fusion is an effective treatment for symptomatic thoracic OLF, which provides satisfactory clinical improvement.
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Affiliation(s)
- Hua Wang
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Fuxin Wei
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Houqing Long
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Guowei Han
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Shilabant Sen Sribastav
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Zemin Li
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Yangliang Huang
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China
| | - Ronglan Zhu
- Department of Neurology, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
| | - Chunxiang Liang
- Department of Orthopaedics, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Second Road, Guangzhou, PR China.
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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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Li B, Qiu G, Guo S, Li W, Li Y, Peng H, Wang C, Zhao Y. Dural ossification associated with ossification of ligamentum flavum in the thoracic spine: a retrospective analysis. BMJ Open 2016; 6:e013887. [PMID: 27998902 PMCID: PMC5223670 DOI: 10.1136/bmjopen-2016-013887] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To investigate the incidence, distribution and radiological characteristics of dural ossification (DO) associated with ossification of ligamentum flavum (OLF) in the thoracic spine. DESIGN A retrospective radiographical analysis. SETTING This study was conducted at a single institution in China. PARTICIPANTS 53 patients with OLF who underwent posterior decompression surgery between January 2011 and July 2015 in a single institution were enrolled in this study. The decompression segments were grouped according to imaging evaluation and intraoperative evidences. OUTCOME MEASURES The demographic distribution, radiological data and detailed surgical records were collected. First, preoperative CT images of decompressed segments were evaluated to identify imaging signs of DO. The 'tram tack sign' (TTS), 'comma sign' and 'bridge sign' were considered as characteristic imaging findings of DO in OLF. 4 kinds of confusing signs (false TTS) were identified and excluded. Then detailed surgical records were reviewed to finally identify segments with DO. RESULTS The incidence of DO in patients with OLF was 43.4%. The incidence of DO in OLF segments was 21.5%. OLF was more common in the lower thoracic spine, and more than half (53.8%) of the DO was located in T9-T12. TTS was the most common sign, but it might be misdiagnosed. After excluding 4 kinds of false TTS, the sensitivity and specificity of imaging diagnosis were 94.23% and 94.21%, respectively. CONCLUSIONS DO was relatively common in thoracic OLF, especially in T9-T12. TTS might be misdiagnosed. After excluding 4 kinds of false TTS, the accuracy of imaging diagnosis was relatively high.
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Affiliation(s)
- Bo Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guixing Qiu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shigong Guo
- Department of Trauma & Orthopaedic Surgery, Hillingdon Hospital, London, UK
| | - Wenjing Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huiming Peng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chu Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Zhao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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21
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Li B, Qiu G, Zhao Y. A potential method for identifying dural ossification by measuring the degree of spinal stenosis in thoracic ossification of ligamentum flavum. Med Hypotheses 2016; 96:9-10. [DOI: 10.1016/j.mehy.2016.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/31/2016] [Accepted: 09/20/2016] [Indexed: 11/24/2022]
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Li B, Guo S, Qiu G, Li W, Liu Y, Zhao Y. A potential mechanism of dural ossification in ossification of ligamentum flavum. Med Hypotheses 2016; 92:1-2. [PMID: 27241243 DOI: 10.1016/j.mehy.2016.03.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/25/2016] [Indexed: 11/25/2022]
Abstract
Ossification of the ligamentum flavum (OLF) mostly occurs in the thoracic spine, leading to thoracic spinal stenosis. Surgical treatment is considered as the best option for OLF patients. When the dura mater ossifies, the difficulty of surgery and the risk of complications significantly increase. The cause of dural ossification (DO) is still unknown. Based on the existing research and clinical studies, we propose a potential mechanism of DO in OLF. Firstly, with the progression of OLF, it will compress the dura mater and even the spinal cord. Then, with flexion and extension of spine, relative movement (friction) between the ossified ligamentum flavum and compressed dura mater will lead to local inflammation, subsequently causing dural adhesion. Finally, the adhesion tissue can serve as a pathway for the transportation of osteogenic cytokines (BMP for example) from the ossified ligamentum flavum to the compressed dura mater. Dura will ossify under exposure of these osteogenic cytokines. If this hypothesis is confirmed, it will contribute to the prevention and management of DO. For progressive OLF patients, early surgical treatment before DO should be recommended.
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Affiliation(s)
- Bo Li
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Shigong Guo
- Department of Trauma & Orthopaedic Surgery, Hillingdon Hospital, London, United Kingdom
| | - Guixing Qiu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Wenjing Li
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yongsheng Liu
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yu Zhao
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
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Zhong ZM, Wu Q, Meng TT, Zhu YJ, Qu DB, Wang JX, Jiang JM, Lu KW, Zheng S, Zhu SY, Chen JT. Clinical outcomes after decompressive laminectomy for symptomatic ossification of ligamentum flavum at the thoracic spine. J Clin Neurosci 2016; 28:77-81. [PMID: 26898582 DOI: 10.1016/j.jocn.2015.09.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 08/26/2015] [Accepted: 09/19/2015] [Indexed: 11/16/2022]
Abstract
Ossification of the ligamentum flavum (OLF) is a rare disease that causes acquired thoracic spinal canal stenosis and thoracic myelopathy. The aim of this study was to investigate clinical outcomes of symptomatic thoracic OLF treated using posterior decompressive laminectomy. We retrospectively analyzed the medical records of 22 patients who underwent posterior decompressive laminectomy for symptomatic thoracic OLF. The surgical results were evaluated using the modified Japanese Orthopaedic Association (JOA) scoring system and Hirabayashi recovery rate. The intensity of pain was evaluated using a visual analog scale (VAS). The mean duration of follow-up was 35.6months. The mean JOA score was significantly improved at final follow-up (9.18±standard deviation of 1.53 points [range, 6-11 points]) compared with before surgery (5.64±2.04 points [range, 3-9 points]) (P<0.001). The mean Hirabayashi recovery rate was 65.49% (range, 20-100%). Recovery outcomes were excellent in nine patients, good in eight patients, fair in four patients and unchanged in one patient. No patient was classified as deteriorated. The VAS scores were 2.82±3.08 before surgery and 0.59±1.05 at final follow-up (P=0.001). Surgical complications, which resolved after appropriate and prompt treatment, included dural tear in five patients, cerebrospinal fluid leakage in one patient, immediate postoperative neurologic deterioration in one patient, epidural hematoma in one patient, and wound infection in one patient. Our findings suggest that posterior decompressive laminectomy is an effective treatment for symptomatic thoracic OLF and provides satisfactory clinical improvement, but surgery for thoracic OLF is associated with a relatively high incidence of complications.
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Affiliation(s)
- Zhao-Ming Zhong
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China.
| | - Qian Wu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Ting-Ting Meng
- Department of Anaesthesia, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yong-Jian Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Dong-Bin Qu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Ji-Xing Wang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Jian-Ming Jiang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Kai-Wu Lu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Shuai Zheng
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Si-Yuan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | - Jian-Ting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
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