Cervical spine stenosis secondary to ossification of the posterior longitudinal ligament

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✓ Ossification of the posterior longitudinal ligament (OPLL) is a well-documented cause of cervical spine stenosis and myelopathy among Japanese patients. Reports of OPLL in North Americans are rare. Choices of diagnostic method and treatment for this entity remain controversial. The authors report the results of management of 20 patients in the United States with symptomatic OPLL of the cervical spine. These represented 10% to 20% of patients operated on over the last 3 years for myelopathy secondary to structural spinal compression. Most of these OPLL patients were Caucasian (60%), male (male:female 4:1), and middle-aged (median age 47.5 years). Six had previously undergone laminectomy or discectomy. Cervical roentgenograms and standard myelography occasionally suggested the diagnosis. Axial computerized tomography (CT) metrizamide myelography with small interslice intervals proved invaluable for diagnosis and operative planning. Magnetic resonance imaging was not necessary for diagnosis. Retrovertebral calcification extended over one to five bodies (mean 2.75). The mass ranged in size from 5 to 16 mm in anteroposterior diameter and reduced the residual canal diameter to a mean (± standard deviation) caliber of 9.42 ± 2.41 mm (mean narrowing ratio 0.44 ± 0.12).

Anterior cervical decompression by medial corpectomy and discectomy with fusion uniformly reduced preoperative myelopathy. Complications were limited to transient neurological deterioration in two patients, recurrent laryngeal nerve palsy in one, and halo device pin site infections in two. At a mean postoperative interval of 15 months, improvement was seen in each category of deficit: extremity weakness, hypesthesia, hypertonia, and urinary dysfunction. All fusions produced solid unions.

It is concluded that OPLL of the cervical spine is an unexpectedly prevalent cause of myelopathy among patients treated in the United States. Thin-section axial CT metrizamide myelography with small interslice intervals is essential for the investigation of patients who may have OPLL. Anterior decompression and stabilization by medial corpectomy, discectomy, removal of the calcified mass, and fusion is a safe and effective method of treatment.

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Figures

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    Preoperative axial computerized tomography scans without metrizamide. These scans from two different patients demonstrate the variability in shape of the ossified mass. Left: The calcified ligament extends from the medial aspect of the vertebral body and the mass appears pedunculated. Right: The calcified mass is seen as an irregularly-shaped osteoma protruding from the entire posterior surface of the vertebral body.

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    Preoperative axial computerized tomography scans with metrizamide from two different patients. Metrizamide highlights the cord compression caused by triangular (left) and semicircular (right) ossified masses.

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    Sagittal reconstruction of a computerized tomography scan. A computer-generated reconstruction identifies the C-4 level as the site of maximum canal compromise. In addition to the calcification of the posterior longitudinal ligament from C-1 to C-6, partial calcification is seen of the anterior longitudinal ligaments of C-4, C-5, and C-6 and the ligamenta flava of C-2 and C-3.

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    Postoperative computerized tomography scans. Axial scans (left and center) of the two patients whose preoperative scans are shown in Fig. 2 demonstrate removal of the compressing mass and midline placement of a fibula strut graft. A sagittal reconstruction (right) confirms complete removal of anteriorly compressive elements.

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    Follow-up lateral cervical radiograph 10 months after the operation showing a solid fusion from C-3 to C-7.

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