The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 87, Issue 3

Scientific Articles | March 01, 2005

Ossification of the Posterior Longitudinal Ligament: Results of Anterior Cervical Decompression and Arthrodesis in Sixty-one North American Patients

Theodore A. Belanger, MD¹; Jeffrey S. Roh, MD²; Stephen E. Hanks, MD³; James D. Kang, MD⁴; Sanford E. Emery, MD, MBA⁵; Henry H. Bohlman, MD²

¹ Miller Orthopaedic Clinic, 1001 Blythe Boulevard, Suite 200, Charlotte, NC 28203. E-mail address: ted.belanger@millerclinic.com
² University Hospitals Spine Institute and the Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106.
³ University of Arizona Health Sciences Center, P.O. Box 245064, Tucson, AZ 85719. E-mail address: sehanks@email.arizona.edu
⁴ University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 1010, Pittsburgh, PA 15213. E-mail address: kangjd@upmc.edu
⁵ Robert C. Byrd Health Sciences Center, Box 9196, Morgantown, WV 26506. E-mail address: semery@hsc.wvu.edu

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Medtronic Sofamor Danek. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at University Hospital Spine Institute, Case Western Reserve University, Cleveland, Ohio

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J Bone Joint Surg Am, 2005 Mar 01;87(3):610-615. doi: 10.2106/JBJS.C.01711

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Abstract

Background: Ossification of the posterior longitudinal ligament is commonly associated with cervical myelopathy. Surgical treatment is a matter of controversy. We report on a series of patients who were managed with anterior cervical decompression and arthrodesis for the treatment of cervical myelopathy associated with ossification of the posterior longitudinal ligament.

Methods: We retrospectively reviewed the records for all sixty-five patients who had been managed with anterior decompression and arthrodesis for the treatment of cervical ossification of the posterior longitudinal ligament and associated neurologic compression from 1982 to 2001. Sixty-one patients (thirty-nine men and twenty-two women) were followed for at least two years (or until the time of death). The average number of vertebrae resected was 2.2. The average duration of follow-up for the sixty surviving patients was four years (range, two years to fifteen years and four months). The preoperative, six-week postoperative, and final follow-up clinical status (including neurological function as assessed with the Nurick grading system) was recorded for each patient.

Results: Fifty-six of the sixty-one patients had neurological improvement, with an average improvement of 1.5 Nurick grades at the time of the final follow-up. Eight patients had absent dura at the time of surgery and, of these, five had development of a cerebrospinal fluid fistula. Eight patients had development of new neurological signs and/or symptoms in the upper extremity postoperatively. Eight patients required reoperation because of a painful pseudarthrosis (one patient), strut-graft dislodgment (three), cerebrospinal fluid leakage (three), or compression of a nerve root caudad to the area of the original procedure (one). One patient died as the result of cardiac arrest on the third postoperative day. Fifty-eight patients had an osseous fusion, one had an asymptomatic nonunion, and one had a symptomatic pseudarthrosis that was treated with revision surgery.

Conclusions: Anterior decompression and arthrodesis is an effective way to achieve pain relief and neurological improvement in North American patients of non-Asian descent who have cervical myelopathy associated with ossification of the posterior longitudinal ligament. The risk of durocutaneous fistula, graft dislodgment, and postoperative neurological symptoms appears to be high in patients with cervical myelopathy associated with this condition.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Ossification of the posterior longitudinal ligament is an uncommon disorder that is often associated with neurological symptoms secondary to compression of the cervical spinal cord or nerve roots. Once thought to be unique to individuals of Asian descent, ossification of the posterior longitudinal ligament has become recognized as an uncommon disorder among North American patients with myelopathy^1,2. Genetic and environmental factors have been implicated in the etiology of ossification of the posterior longitudinal ligament, but the cause remains unknown. An association with diffuse idiopathic skeletal hyperostosis has been suggested^3,4.

Several surgical treatment strategies have been proposed, including extensive cervical laminectomy with or without posterior arthrodesis, posterior cervical laminoplasty of numerous types, and anterior decompression and arthrodesis^1,2,5-11. Neurological improvement can be achieved with any of these three general approaches. Problems with postlaminectomy instability and deformity have made cervical laminectomy without arthrodesis a generally poor option for the treatment of myelopathy. In 1994, Epstein suggested that anterior decompression and arthrodesis provides better outcomes than laminectomy does². Anterior decompression and arthrodesis has been our preferred treatment method. The purpose of the present study was to describe the long-term results for a series of patients who had been managed with anterior cervical decompression and arthrodesis for the treatment of cervical myelopathy associated with ossification of the posterior longitudinal ligament.

Materials and Methods

Materials and Methods | Results (see Appendix) | Discussion | Appendix | References

From 1982 to 2001, sixty-five patients with ossification of the posterior longitudinal ligament of the cervical spine were managed with anterior decompression and arthrodesis by the senior authors (H.H.B., S.E.E., and J.D.K). Four patients who had not been followed for a minimum of two years (or until death) were excluded. The records of the remaining sixty-one patients were retrospectively reviewed. This group included thirty-nine men and twenty-two women. All patients were of non-Asian descent. One of the sixty-one patients died in the perioperative period; the mean duration of follow-up for the sixty surviving patients was four years (range, two years to fifteen years and four months). The mean age at the time of surgery was fifty-four years (range, thirty-four to seventy-nine years). All diagnoses were confirmed by a pathologist on the basis of a histological evaluation of specimens obtained at the time of surgery.

The medical records and imaging studies (including radiographs, magnetic resonance images, and computerized tomography-myelography scans) were reviewed by orthopaedic surgeons (T.A.B., J.S.R., and S.E.H.) who were not directly involved in the treatment of these patients. The charts were reviewed with regard to the clinical course, pain, and neurological status. The neurological status of each patient was classified according to the Nurick grading system¹² (Table I) preoperatively, at six weeks postoperatively, and at the time of the final follow-up. Surgical details, including the absence of the dura, the levels of decompression and arthrodesis, and any complications, were recorded. Plain radiographs, magnetic resonance images, and computerized tomographymyelography scans were inspected in order to classify the ossification of the posterior longitudinal ligament as continuous, segmental, mixed, or other according to the system of Hirabayashi². The preoperative extent of ossification of the posterior longitudinal ligament and the space available for the cord were measured on preoperative standard lateral radiographs of the cervical spine. The presence or absence of diffuse idiopathic skeletal hyperostosis was noted on cervical radiographs and the preoperative chest radiograph^3,13, and solid fusion or pseudarthrosis was determined on the basis of plain flexion and extension lateral radiographs of the cervical spine. The criteria for radiographic union included the absence of radiolucency at the graft-host bone interface, bridging trabecular bone across the graft-host bone interface, and/or <2 mm of interspinous motion on lateral flexion and extension radiographs of the cervical spine.

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TABLE I Nurick Classification System of Myelopathy

Grade	Description of Neurologic Status
0	No dysfunction of the spinal cord
1	Signs of spinal cord involvement, normal gait
2	Mild gait impairment, able to work and to do activities of daily living
3	Gait impaired, unable to work and do activities of daily living
4	Only able to walk with assistance
5	Wheelchair dependent or bedridden

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TABLE I Nurick Classification System of Myelopathy

Grade	Description of Neurologic Status
0	No dysfunction of the spinal cord
1	Signs of spinal cord involvement, normal gait
2	Mild gait impairment, able to work and to do activities of daily living
3	Gait impaired, unable to work and do activities of daily living
4	Only able to walk with assistance
5	Wheelchair dependent or bedridden

The average number of levels with radiographically evident ossification of the posterior longitudinal ligament causing neurological compression was 2.0 (range, 0.5 to 4.5). The average number of vertebral levels resected was 2.2 (range, 0.5 to 5.0). The average preoperative space available for the spinal cord was 10.8 mm (range, 3 to 17 mm). Among the sixty-one patients, the radiographic pattern of ossification of the posterior longitudinal ligament was continuous in eleven, segmental in nineteen, mixed in twenty-three, and other in eight. The diagnosis of diffuse idiopathic skeletal hyperostosis was established for ten patients on the basis of radiographs of the chest.

All patients were managed with anterior decompression and arthrodesis¹². All procedures were performed through a standard left-sided Robinson-Smith anterior cervical approach. Decompression consisted of anterior cervical discectomy with foraminotomy, hemicorpectomy, or subtotal corpectomy at one to five levels as determined by the extent of neurological impingement. An effort was made to remove all ossified tissue compressing the spinal cord or nerve roots in each patient. The management of patients who have eroded dura secondary to ossification of the posterior longitudinal ligament has been described previously¹⁴. Autograft was used for arthrodesis in all sixty-one patients. A tricortical iliac crest bone graft was used at each level for discectomies and for corpectomies involving fewer than two levels. Autogenous bone from the fibula was used as a strut graft for corpectomies involving two levels or more. End plates were prepared by burring through subchondral bone to bleeding cancellous bone. Thirty-nine patients were managed without instrumentation. Thirty-five of these thirty-nine patients were immobilized in a two-poster brace for six weeks, followed by a soft collar for one to six weeks for comfort. The other four patients in that group were placed in a halo vest for six weeks, followed by a hard collar for four to six weeks, followed by a soft collar for one to six weeks. Twenty-two patients had internal fixation with an anterior cervical plate and were immobilized postoperatively with a hard collar for six weeks, followed by a soft collar for one to four weeks.

Most patients were extubated before transport out of the operating room. Some patients were kept intubated overnight after multiple-level procedures that had exceeded four hours. They were extubated on the first postoperative day or thereafter once they had passed a "leak test," which involves establishing whether or not an intubated patient can successfully breathe around a deflated endotracheal cuff. This has generally been a satisfactory strategy to prevent postoperative airway management problems after extensive cervical spine procedures¹⁵. Unless the patient had a cerebrospinal fluid leak intraoperatively, he or she was mobilized from bed after extubation. Patients with absent dura at the time of surgery were confined to bed rest for one to five days, depending on the judgment of the surgeon. They were monitored closely for a persistent cerebrospinal fluid leak, which may present as increasing neck swelling, difficulty swallowing, respiratory compromise, and/or the development of a durocutaneous fistula¹⁴.

Results (see Appendix)

Materials and Methods | Results (see Appendix) | Discussion | Appendix | References

Of the sixty-one patients who had been followed for a minimum of two years (or until death), sixteen had been managed surgically by other physicians prior to the diagnosis of ossification of the posterior longitudinal ligament. Eleven of these patients reported rapid worsening of symptoms within two years after the initial operation. The remaining five patients reported incomplete relief of major symptoms such as gait disturbance or quadriparesis. Of these sixteen patients, eight had been managed with anterior discectomy and arthrodesis and eight had been managed with laminectomy or laminoplasty.

One patient died in the perioperative period. This patient, a seventy-four-year-old man who had been quadriparetic preoperatively, died as a result of cardiac arrest on the third postoperative day. During the interim postoperative period, the neurological status improved with regard to both upper and lower extremity motor strength.

Fifty-eight of the sixty surviving patients went on to have osseous fusion (Figs. 1-A, 1-B, 1-C, 1-D). One of the remaining two patients had an asymptomatic nonunion. The other patient had a symptomatic pseudarthrosis that was repaired with posterior wiring and an iliac crest bone graft, which resulted in solid fusion. Three patients who had had a multiple-level decompression had extrusion of the fibular strut graft and required early revision surgery to replace it, and four other patients who had had a multiple-level decompression had partial extrusion of a fibular strut graft but went on to have solid fusion without additional operative intervention. There were no other complications in the patients with graft extrusion.

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Figs. 1-A through 1-D: A fifty-year-old woman presented with neck pain, arm pain, and hyperactive reflexes in all four extremities. She had minimal gait disturbance. Fig. 1-A Lateral cervical radiograph showing disc-space narrowing and spondylosis at the C5-C6 disc level. The arrowhead indicates ossification of the posterior longitudinal ligament behind the sixth cervical vertebral body. Fig. 1-B Anteroposterior myelographic radiograph demonstrating rarefaction of contrast medium (arrowheads) at the fifth and sixth cervical levels.

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Fig. 1-C: Axial computerized tomography-myelography scan showing the central ossification of the posterior longitudinal ligament. The patient was managed with anterior cervical decompression and arthrodesis with use of iliac crest strut autograft. Hemicorpectomies were performed at the levels of the fifth and sixth cervical vertebrae, and the intervening disc was excised. No dural absence was encountered.

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Fig. 1-D: Postoperative lateral cervical radiograph showing the site of decompression and strut-grafting. No residual ossification of the posterior longitudinal ligament can be seen. The patient was neurologically normal at the six-week follow-up as well as at the time of the final follow-up, four years postoperatively.

Preoperatively, all sixty-one patients had axial neck pain. Thirty-two patients reported mild pain, twenty-two reported moderate pain, and seven reported severe pain. Postoperatively, twenty-nine of the sixty surviving patients reported no postoperative pain, twenty-seven reported mild pain, four reported moderate pain, and none reported severe pain.

Eight of the sixty-one patients had absent dura in proximity to adherent ossification of the posterior longitudinal ligament that was encountered at the time of surgery. Three of these patients were described previously¹⁴. Five of these eight patients had leakage of cerebrospinal fluid postoperatively. One was managed with observation and had complete resolution; one was successfully managed with primary placement of a lumbar subarachnoid drain; one was managed with a fascial patch, gel foam, and fibrin glue in order to achieve a watertight seal at the time of repeat surgery, followed by bed rest for five days; and one was managed with both dural repair and a lumbar drain, followed by bed rest for seven days. The final patient had development of a persistent leak and a cerebrospinal fluid fistula that required urgent reintubation, operative repair, placement of a lumbar subarachnoid drain, bed rest, and prolonged intubation followed by tracheostomy. This patient ultimately recovered.

Eight of the sixty-one patients had development of new neurological signs and/or symptoms postoperatively. Three of these patients, two of whom had absent dura at the time of surgery, had severe deltoid weakness immediately postoperatively. One of these three patients also had development of new radicular arm pain and was managed with a posterior foraminotomy at the C7-T1 level on the fifth postoperative day for the treatment of compression of the eighth cervical nerve root. No obvious compression of the fifth cervical nerve root was demonstrable. The radicular symptoms resolved immediately, and the deltoid strength gradually returned completely. Both of the other two patients with absent dura who had development of deltoid weakness ultimately recovered full strength. Five other patients had development of dysesthesias in the upper extremities postoperatively. One had persistent neuropathic arm pain, three had persistent numbness in one or more fingers, and one had complete recovery.

The mean preoperative, six-week postoperative, and final follow-up Nurick grades for the sixty surviving patients were 2.3, 1.1, and 0.8, respectively, with fifty-two patients showing improvement by at least one grade in the initial six-week period after surgery. Only one patient had neurological worsening according to the Nurick grade in the initial six-week follow-up period; this worsening resulted in profound deltoid weakness, which ultimately resolved. At the time of the final follow-up, fifty-six patients demonstrated improvement by at least one Nurick grade whereas four patients showed no improvement compared with the preoperative status. The average improvement at the time of the final follow-up was 1.5 grades (range, 0 to 3 grades). No patient was neurologically worse at the time of the final follow-up.

Discussion

Materials and Methods | Results (see Appendix) | Discussion | Appendix | References

Ossification of the posterior longitudinal ligament in the cervical spine often complicates the surgical management of patients who have myelopathy. Kojima et al.⁵, Abe et al.⁶, McAfee et al.¹, Harsh et al.⁷, and Epstein² reported on the use of anterior cervical decompression and arthrodesis for the treatment of ossification of the posterior longitudinal ligament in twelve, twelve, six, nineteen, and thirty-three patients, respectively. In the report by Epstein, the average duration of follow-up was 1.7 years². In the report by Onari et al., the average duration of follow-up was 14.7 years but all thirty patients were managed with anterior arthrodesis without decompression⁸. To our knowledge, the current study represents the largest reported series of North American patients of non-Asian descent who were managed with anterior decompression and arthrodesis for the treatment of cervical radiculomyelopathy associated with ossification of the posterior longitudinal ligament. Also, to our knowledge, the duration of follow-up in the current series is the longest that has been reported to date.

In the present study of patients with ossification of the posterior longitudinal ligament, the male-to-female ratio was 1.8:1. This ratio is similar to those in other series, which have ranged from 1.0:1 to 2.0:1. The average age of fifty-four years at the time of surgery in the present series is also similar to those in previous series, which have ranged from forty-nine to sixty-one years^16-18. The prevalence of diffuse idiopathic skeletal hyperostosis in this population of patients (16%) is not different from that in the general population and is associated with a similar age distribution (15% in women and 25% in men over the age of fifty years)^3,4. Thus, an increased prevalence of diffuse idiopathic skeletal hyperostosis in patients with ossification of the posterior longitudinal ligament was not observed in the present study.

Epstein reported on forty-three North American patients who had ossification of the posterior longitudinal ligament². Thirty-three patients were managed with use of an anterior surgical approach and demonstrated an average improvement of approximately 1.6 Ranawat grades. The other ten patients were managed with use of a posterior approach and demonstrated an average improvement of 0.9 Ranawat grade. The author concluded that anterior decompression and arthrodesis yielded superior results as compared with extensive laminectomy. Onari et al. reported on thirty Japanese patients who had been followed for ten to twenty-three years after anterior surgery (the authors' preferred method of treatment)⁸. At the time of the most recent follow-up, the overall improvement was 1.0 Ranawat grade. The current study demonstrated a mean improvement of 1.5 Nurick grades, which we believe is comparable to the clinical results outlined in those other two studies.

Eight of the sixty-one patients in the present study had absent dura, and five of these eight patients had a cerebrospinal fluid leak. Epstein reported no dural defects among thirty-three patients who had been managed with anterior decompression and arthrodesis². She advocated leaving small patches of ossified posterior longitudinal ligament associated with suspected incompetent or absent dura in place at the time of surgery and allowing them to "float" freely rather than resecting every bit of ossified posterior longitudinal ligament. Areas of hypertrophied posterior longitudinal ligament as well as areas of dural erosion often can be suspected preoperatively on radiographic studies^19-21. For example, the presence of a radiographic "C" sign, single-layer sign, or double-layer sign on computerized tomography can be suggestive of possible dural penetration secondary to ossification of the posterior longitudinal ligament²⁰.

Epstein suggested that the rate of C5 nerve root deficits is as high as 17% after multiple-level anterior cervical corpectomy for the treatment of myelopathy². The specific etiology of this complication remains uncertain. In the present study, three patients had evidence of a C5 nerve root palsy after surgery, and all three recovered over a prolonged period of time. Five other patients had upper extremity dysesthesias that resolved partially (four patients) or completely (one).

Two of the senior authors (S.E.E. and H.H.B.) previously reported the long-term results for patients who had been managed with anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy¹². The major difference between the two patient populations appears to be the greater risk of graft complications, cerebrospinal fluid fistula formation, and postoperative nerve root palsies in patients with ossification of the posterior longitudinal ligament. We conclude that anterior decompression and arthrodesis is an effective way to achieve pain relief and neurological improvement in North American patients of non-Asian descent who have cervical myelopathy associated with ossification of the posterior longitudinal ligament.

Appendix

Materials and Methods | Results (see Appendix) | Discussion | Appendix | References

A table presenting individual clinical and radiographic data on all patients is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results (see Appendix) | Discussion | Appendix | References

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Kojima T, Waga S, Kubo Y, Kanamaru K, Shimosaka S, Shimizu T. Anterior cervical vertebrectomy and interbody fusion for multi-level spondylosis and ossification of the posterior longitudinal ligament. Neurosurgery.1989;24: 864-72.24864 1989 [PubMed][CrossRef]

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Harsh GR 4th, Sypert GW, Weinstein PR, Ross DA, Wilson CB. Cervical spine stenosis secondary to ossification of the posterior longitudinal ligament. J Neurosurg.1987;67: 349-57.67349 1987 [PubMed][CrossRef]

Onari K, Akiyama N, Kondo S, Toguchi A, Mihara H, Tsuchiya T. Long-term follow-up results of anterior interbody fusion applied for cervical myelopathy due to ossification of the posterior longitudinal ligament. Spine.2001;26: 488-93.26488 2001 [PubMed][CrossRef]

Tomita K, Kawahara N, Toribatake Y, Heller JG. Expansive midline T-saw laminoplasty (modified spinous process-splitting) for the management of cervical myelopathy. Spine.1998;23: 32-7.2332 1998 [PubMed][CrossRef]

Matsuoka T, Yamaura I, Kurosa Y, Nakai O, Shindo S, Shinomiya K. Long-term results of the anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament. Spine.2001;26: 241-8.26241 2001 [PubMed][CrossRef]

Seichi A, Takeshita K, Ohishi I, Kawaguchi H, Akune T, Anamizu Y, Kitagawa T, Nakamura K. Long-term results of double-door laminoplasty for cervical stenotic myelopathy. Spine.2001;26: 479-87.26479 2001 [PubMed][CrossRef]

Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up. J Bone Joint Surg Am.1998;80: 941-51.80941 1998 [CrossRef]

Mata S, Hill RO, Joseph L, Kaplan P, Dussault R, Watts CS, Fitzcharles MA, Shiroky JB, Fortin PR, Esdaile JM. Chest radiographs as a screening test for diffuse idiopathic skeletal hyperostosis. J Rheumatol.1993;20: 1905-10.201905 1993 [PubMed]

Smith MD, Bolesta MJ, Leventhal M, Bohlman HH. Postoperative cerebrospinalfluid fistula associated with erosion of the dura. Findings after anterior resection of ossification of the posterior longitudinal ligament in the cervical spine. J Bone Joint Surg Am.1992;74: 270-7.74270 1992

Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am.1991;73: 544-51.73544 1991 [PubMed]

Tomimura K, Sakou T, Taketomi E. Natural history and the postoperative course of ossification of the posterior longitudinal ligament. Seikeigeka Mook.1987;50: 173-83.50173 1987

Matsunaga S, Sakou T, Taketomi E, Yamaguchi M, Okano T. The natural course of myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Clin Orthop.1994;305: 168-77.305168 1994

Matsunaga S, Sakou T, Arishima Y, Koga H, Hayashi K, Komiya S. Quality of life in elderly patients with ossification of the posterior longitudinal ligament. Spine.2001;26: 494-8.26494 2001 [PubMed][CrossRef]

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Topics

ossification of posterior longitudinal ligament ; decompressive incision ; arthrodesis ; cervical decompression

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Theodore A. Belanger, Jeffrey S. Roh, Stephen E. Hanks, James D. Kang, Sanford E. Emery, Henry H. Bohlman; Ossification of the Posterior Longitudinal LigamentResults of Anterior Cervical Decompression and Arthrodesis in Sixty-one North American Patients. The Journal of Bone & Joint Surgery. 2005 Mar;87(3):610-615.

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