Microsurgical resection of ossification of the posterior longitudinal ligament in the thoracic spine via the transthoracic approach without spinal fusion: case series and technical note

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OBJECTIVE

Surgical management of thoracic ossification of the posterior longitudinal ligament (OPLL) remains challenging because of the anatomical complexity of the thoracic spine and the fragility of the thoracic spinal cord. Several surgical approaches have been described, but it remains unclear which of these is the most effective. The present study describes the microsurgical removal of OPLL in the middle thoracic level via the transthoracic anterolateral approach without spinal fusion, including the surgical outcome and operative tips.

METHODS

Between 2002 and 2017, a total of 8 patients with thoracic myelopathy due to OPLL were surgically treated via the transthoracic anterolateral approach without spinal fusion. The surgical techniques are described in detail. Clinical outcome, surgical complications, and the pre- and postoperative thoracic kyphotic angle were assessed.

RESULTS

The mean patient age at the time of surgery was 55 years (range 47–77 years). There were 5 women and 3 men. The surgically treated levels were within T3–9. The clinical symptoms and Japanese Orthopaedic Association (JOA) score improved postoperatively in 7 cases, but did not change in 1 case. The mean JOA score increased from 6.4 preoperatively to 7.5 postoperatively (recovery rate 26%). Intraoperative CSF leakage occurred in 4 cases, and was successfully treated with fibrin glue sealing and spinal drainage. The mean follow-up period was 82.6 months (range 15.3–169 months). None of the patients had deterioration of the thoracic kyphotic angle.

CONCLUSIONS

Anterior decompression is the logical and ideal procedure to treat thoracic myelopathy caused by OPLL on the concave side of the spinal cord; however, this procedure is technically demanding. Microsurgery via the transthoracic anterolateral approach enables direct visualization of the thoracic ventral ossified lesion. The use of microscopic procedures might negate the need for bone grafting or spinal instrumentation.

ABBREVIATIONS JOA = Japanese Orthopaedic Association; OPLL = ossification of the posterior longitudinal ligament.

Article Information

Correspondence Ryo Kanematsu: Spinal Disorders Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan. ryo.knmt@gmail.com.

INCLUDE WHEN CITING Published online May 24, 2019; DOI: 10.3171/2019.3.SPINE181388.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Illustration showing exposure of the lateral side of the vertebral body after the removal of the rib head. Copyright MIWA-SHOTEN Ltd. Published with permission. Figure is available in color online only.

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    Illustration showing the drilling of the vertebral body. Copyright MIWA-SHOTEN Ltd. Published with permission. Figure is available in color online only.

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    Illustration showing the direct visualization and microsurgical drilling of the ossified ligament. Copyright MIWA-SHOTEN Ltd. Published with permission. Figure is available in color online only.

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    Illustration of the intraoperative view before microsurgical drilling of the ossified ligament, and an axial schematic drawing showing the area of bone resection. Copyright MIWA-SHOTEN Ltd. Published with permission. Figure is available in color online only.

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    Images obtained in a 50-year-old man with OPLL who underwent the removal of T4–7 via the right anterolateral approach. A: Preoperative sagittal CT. B: Postoperative sagittal CT. C: Preoperative sagittal T2-weighted MR image. D: Postoperative sagittal T2-weighted MR image. E: Preoperative axial CT of T4/5. G: Postoperative axial CT of T4/5. F: Preoperative axial CT of T5/6. H: Postoperative axial CT of T5/6.

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    Images obtained in a 54-year-old woman with new bone formation after anterolateral removal of thoracic OPLL. A: Preoperative axial CT. B: Axial CT on postoperative day 1. C: Axial CT at 149.7 months postoperatively.

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