J Korean Neurosurg Soc.  2017 Sep;60(5):597-603. 10.3340/jkns.2017.0404.017.

Minimally Invasive Anterior Decompression Technique without Instrumented Fusion for Huge Ossification of the Posterior Longitudinal Ligament in the Thoracic Spine: Technical Note And Literature Review

• Yu JW
• Yun SO
• Hsieh CS
• Lee SH

• KMID: 2457968
• DOI: http://doi.org/10.3340/jkns.2017.0404.017

Abstract

OBJECTIVE
Several surgical methods have been reported for treatment of ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine. Despite rapid innovation of instruments and techniques for spinal surgery, the postoperative outcomes are not always favorable. This article reports a minimally invasive anterior decompression technique without instrumented fusion, which was modified from the conventional procedure. The authors present 2 cases of huge beak-type OPLL. Patients underwent minimally invasive anterior decompression without fusion. This method created a space on the ventral side of the OPLL without violating global thoracic spinal stability. Via this space, the OPLL and anterior lateral side of the dural sac can be seen and manipulated directly. Then, total removal of the OPLL was accomplished. No orthosis was needed. In this article, we share our key technique and concepts for treatment of huge thoracic OPLL.
METHODS
Case 1. 51-year-old female was referred to our hospital with right lower limb radiating pain and paresis. Thoracic OPLL at T6-7 had been identified at our hospital, and conservative treatment had been tried without success. Case 2. This 54-year-old female with a 6-month history of progressive gait disturbance and bilateral lower extremity radiating pain (right>left) was admitted to our institute. She also had hypoesthesia in both lower legs. Her symptoms had been gradually progressing. Computed tomography scans showed massive OPLL at the T9-10 level. Magnetic resonance imaging of the thoracolumbar spine demonstrated ventral bony masses with severe anterior compression of the spinal cord at the same level.
RESULTS
We used this surgical method in 2 patients with a huge beaked-type OPLL in the thoracic level. Complete removal of the OPLL via anterior decompression without instrumented fusion was accomplished. The 1st case had no intraoperative or postoperative complications, and the 2nd case had 1 intraoperative complication (dural tear) and no postoperative complications. There were no residual symptoms of the lower extremities.
CONCLUSION
This surgical technique allows the surgeon to safely and effectively perform minimally invasive anterior decompression without instrumented fusion via a transthoracic approach for thoracic OPLL. It can be applied at the mid and lower level of the thoracic spine and could become a standard procedure for treatment of huge beak-type thoracic OPLL.

Keyword

Thoracic vertebrae; Minimal invasive surgical procedure; Ossification of the posterior longitudinal ligament; Anterior decompression; Anterior approach

MeSH Terms

Decompression*
Female
Gait
Humans
Hypesthesia
Intraoperative Complications
Leg
Longitudinal Ligaments*
Lower Extremity
Magnetic Resonance Imaging
Methods
Middle Aged
Orthotic Devices
Paresis
Postoperative Complications
Spinal Cord
Spine*
Thoracic Vertebrae

Figure

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  Fig. 1 Preoperative sagittal and axial magnetic resonance (A and B) and computed tomography (C and D) images showing a huge beak-type ossification of the posterior longitudinal ligament at the T6–7 level with severe compression of the spinal cord.

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  Fig. 2 Postoperative sagittal (A) and axial (B) magnetic resonance and sagittal (C) and axial (D) computed tomography images reveal complete removal of the ossified posterior longitudinal ligament and total decompression of the spinal cord at the T6–7 level.

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  Fig. 3 Preoperative thoracolumbar magnetic resonance (A and B) and computed tomography (C and D) images show the beak-type ossification of the posterior longitudinal ligament at T9–10, which had compressed the spinal cord.

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  Fig. 4 Postoperative sagittal (A) and axial (B) magnetic resonance and sagittal (C) and axial (D) computed tomography images show complete removal of the ossified posterior longitudinal ligament and total decompression of the spinal cord at the T9–10 level.

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  Fig. 5 A: The endothoracic fascia opening can be followed posteriorly to the proximal rib head, which was excised. B: The rostral portion of the pedicle directly caudal to the disc space can also be drilled down to improve exposure of the dural sac and ossification of the posterior longitudinal ligament.

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  Fig. 6 A: After releasing the adhesion between the ossification of the posterior longitudinal ligament (OPLL) and the dural sac by dissection, the OPLL was removed. B: Bleeding was controlled using Avitene and cottonoids.

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  Fig. 7 During operation, the segmental artery (black arrow) was preserved.

Reference

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