The short-term outcomes of minimally invasive decompression surgery in patients with lumbar ossification or calcification of the ligamentum flavum

View More View Less
  • 1 Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine; and
  • 2 Department of Orthopaedic Surgery, Shimada Hospital, Osaka, Japan
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Although minimally invasive endoscopic surgery techniques are established standard treatment choices for various degenerative conditions of the lumbar spine, the surgical indications of such techniques for specific cases, such as segments with ossification of the ligamentum flavum (OLF) or calcification of the ligamentum flavum (CLF), remain under investigation. Therefore, the authors aimed to demonstrate the short-term outcomes of minimally invasive endoscopic surgery in patients with degenerative lumbar disease with CLF or OLF.

METHODS

This is a retrospective cohort study including consecutive patients who underwent microendoscopic posterior decompression at the authors’ institution, where the presence of OLF and CLF did not influence the surgical indication. Fifty-nine patients with OLF and 39 patients with CLF on preoperative CT were identified from the database. Subsequently, two matched control groups (one each matched to the OLF and CLF groups) were created using propensity scores to adjust for age, sex, preoperative Japanese Orthopaedic Association (JOA) score and Oswestry Disability Index, and diagnosis. The background, surgical outcomes, and changes in clinical scores were compared between the matched groups. If there was a significant difference in the improvement of clinical scores, a multivariate linear regression model was applied.

RESULTS

On performing univariate analysis, patients with OLF were found to have a higher body mass index (Mann-Whitney U-test, p = 0.001), higher incidence of preoperative motor weakness (chi-square test, p = 0.019), longer operative time (Mann-Whitney U-test, p < 0.001), and lower improvement in the JOA score (mixed-effects model, p = 0.023) than the matched controls. On performing multivariate analysis, the presence of OLF was identified as an independent variable associated with a poor recovery rate based on the JOA score (multivariate linear regression, p < 0.001). In contrast, there were no significant differences between patients with CLF and their matched controls in terms of preoperative and surgical data and postoperative improvements in clinical scores.

CONCLUSIONS

Although the perioperative surgical outcomes, including the surgical complications, and the in-hospital period did not significantly differ, the short-term improvement in the JOA score was significantly lower in patients with degenerative lumbar disease accompanied by OLF than in the patients from the matched control group. In contrast, there were no significant differences in the short-term improvement in clinical scores and perioperative outcomes between patients with CLF and their matched control group. Thus, the surgical indications of minimally invasive posterior decompression for patients with CLF can be the same as those for patients without CLF; however, the indications for patients with OLF should be further investigated in future studies, including the other surgical methods.

ABBREVIATIONS BMI = body mass index; CLF = calcification of the ligamentum flavum; JOA = Japanese Orthopaedic Association; ODI = Oswestry Disability Index; OLF = ossification of the ligamentum flavum.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Koji Tamai: Osaka City University Graduate School of Medicine, Osaka, Japan. koji.tamai@msic.med.osaka-cu.ac.jp.

INCLUDE WHEN CITING Published online November 6, 2020; DOI: 10.3171/2020.6.SPINE20946.

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

  • 1

    Mori K, Kasahara T, Mimura T, Prevalence, distribution, and morphology of thoracic ossification of the yellow ligament in Japanese: results of CT-based cross-sectional study. Spine (Phila Pa 1976). 2013;38(19):E1216E1222.

    • Search Google Scholar
    • Export Citation
  • 2

    Shepard NA, Shenoy K, Cho W, D Sharan A. Extensive ossification of the ligamentum flavum treated with triple stage decompression: a case report. Spine J. 2015;15(4):e9e14.

    • Search Google Scholar
    • Export Citation
  • 3

    Guo JJ, Luk KD, Karppinen J, Prevalence, distribution, and morphology of ossification of the ligamentum flavum: a population study of one thousand seven hundred thirty-six magnetic resonance imaging scans. Spine (Phila Pa 1976). 2010;35(1):5156.

    • Search Google Scholar
    • Export Citation
  • 4

    Kurihara A, Tanaka Y, Tsumura N, Iwasaki Y. Hyperostotic lumbar spinal stenosis. A review of 12 surgically treated cases with roentgenographic survey of ossification of the yellow ligament at the lumbar spine. Spine (Phila Pa 1976). 1988;13(11):13081316.

    • Search Google Scholar
    • Export Citation
  • 5

    Gao R, Yuan W, Yang L, Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum. Spine J. 2013;13(9):10321038.

    • Search Google Scholar
    • Export Citation
  • 6

    Ruiz Santiago F, Alcázar Romero PP, López Machado E, García Espona MA. Calcification of lumbar ligamentum flavum and facet joints capsule. Spine (Phila Pa 1976). 1997;22(15):17301735.

    • Search Google Scholar
    • Export Citation
  • 7

    Khan MH, Smith PN, Donaldson WF III. Acute quadriparesis caused by calcification of the entire cervical ligamentum flavum in a white female—report of an unusual case and a brief review of the literature: case report. Spine (Phila Pa 1976). 2005;30(22):E687E691.

    • Search Google Scholar
    • Export Citation
  • 8

    Yayama T, Baba H, Furusawa N, Pathogenesis of calcium crystal deposition in the ligamentum flavum correlates with lumbar spinal canal stenosis. Clin Exp Rheumatol. 2005;23(5):637643.

    • Search Google Scholar
    • Export Citation
  • 9

    Telfeian AE, Veeravagu A, Oyelese AA, Gokaslan ZL. A brief history of endoscopic spine surgery. Neurosurg Focus. 2016;40(2):E2.

  • 10

    Minamide A, Yoshida M, Yamada H, Endoscope-assisted spinal decompression surgery for lumbar spinal stenosis. J Neurosurg Spine. 2013;19(6):664671.

    • Search Google Scholar
    • Export Citation
  • 11

    Pao JL, Chen WC, Chen PQ. Clinical outcomes of microendoscopic decompressive laminotomy for degenerative lumbar spinal stenosis. Eur Spine J. 2009;18(5):672678.

    • Search Google Scholar
    • Export Citation
  • 12

    Fujii K, Abe T, Funayama T, Lateral lumbar interbody fusion for ossification of the yellow ligament in the lumbar spine: first reported case. Case Rep Orthop. 2017;2017:3404319.

    • Search Google Scholar
    • Export Citation
  • 13

    Katz JN, Stucki G, Lipson SJ, Predictors of surgical outcome in degenerative lumbar spinal stenosis. Spine (Phila Pa 1976). 1999;24(21):22292233.

    • Search Google Scholar
    • Export Citation
  • 14

    Yamashita K, Ohzono K, Hiroshima K. Five-year outcomes of surgical treatment for degenerative lumbar spinal stenosis: a prospective observational study of symptom severity at standard intervals after surgery. Spine (Phila Pa 1976). 2006;31(13):14841490.

    • Search Google Scholar
    • Export Citation
  • 15

    Rubin DB. Propensity score methods. Am J Ophthalmol. 2010;149(1):79.

  • 16

    Rubin DB. The design versus the analysis of observational studies for causal effects: parallels with the design of randomized trials. Stat Med. 2007;26(1):2036.

    • Search Google Scholar
    • Export Citation
  • 17

    Minamide A, Yoshida M, Simpson AK, Minimally invasive spinal decompression for degenerative lumbar spondylolisthesis and stenosis maintains stability and may avoid the need for fusion. Bone Joint J. 2018;100-B(4):499506.

    • Search Google Scholar
    • Export Citation
  • 18

    al-Orainy IA, Kolawole T. Ossification of the ligament flavum. Eur J Radiol. 1998;29(1):7682.

  • 19

    Sato R, Takahashi M, Yamashita Y, Calcium crystal deposition in cervical ligamentum flavum: CT and MR findings. J Comput Assist Tomogr. 1992;16(3):352355.

    • Search Google Scholar
    • Export Citation
  • 20

    Fujiwara A, Kobayashi N, Saiki K, Association of the Japanese Orthopaedic Association score with the Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Short-Form 36. Spine (Phila Pa 1976). 2003;28(14):16011607.

    • Search Google Scholar
    • Export Citation
  • 21

    Fairbank JC, Couper J, Davies JB, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66(8):271273.

    • Search Google Scholar
    • Export Citation
  • 22

    Hirabayashi K, Watanabe K, Wakano K, Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine (Phila Pa 1976). 1983;8(7):693699.

    • Search Google Scholar
    • Export Citation
  • 23

    Haberman SJ. The analysis of residuals in cross-classified tables. Biometrics. 1973;29(1):205220.

  • 24

    Okuda T, Baba I, Fujimoto Y, The pathology of ligamentum flavum in degenerative lumbar disease. Spine (Phila Pa 1976). 2004;29(15):16891697.

    • Search Google Scholar
    • Export Citation
  • 25

    Takenaka S, Aono H. Prediction of postoperative clinical recovery of drop foot attributable to lumbar degenerative diseases, via a Bayesian network. Clin Orthop Relat Res. 2017;475(3):872880.

    • Search Google Scholar
    • Export Citation
  • 26

    Iizuka Y, Iizuka H, Tsutsumi S, Foot drop due to lumbar degenerative conditions: mechanism and prognostic factors in herniated nucleus pulposus and lumbar spinal stenosis. J Neurosurg Spine. 2009;10(3):260264.

    • Search Google Scholar
    • Export Citation
  • 27

    Li B, Guo S, Qiu G, A potential mechanism of dural ossification in ossification of ligamentum flavum. Med Hypotheses. 2016;92:12.

  • 28

    Muthukumar N. Dural ossification in ossification of the ligamentum flavum: a preliminary report. Spine (Phila Pa 1976). 2009;34(24):26542661.

    • Search Google Scholar
    • Export Citation
  • 29

    Yu L, Li B, Yu Y, The relationship between dural ossification and spinal stenosis in thoracic ossification of the ligamentum flavum. J Bone Joint Surg Am. 2019;101(7):606612.

    • Search Google Scholar
    • Export Citation
  • 30

    Youn MS, Shin JK, Goh TS, Lee JS. Predictors of clinical outcome after endoscopic partial facetectomy for degenerative lumbar foraminal stenosis. World Neurosurg. 2019;126:e1482e1488.

    • Search Google Scholar
    • Export Citation
  • 31

    Ikuta K, Arima J, Tanaka T, Short-term results of microendoscopic posterior decompression for lumbar spinal stenosis. Technical note. J Neurosurg Spine. 2005;2(5):624633.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 103 103 103
Full Text Views 8 8 8
PDF Downloads 7 7 7
EPUB Downloads 0 0 0