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European Spine Journal

, Volume 20, Issue 2, pp 205–215 | Cite as

Thoracic myelopathy due to ossification of ligamentum flavum: a retrospective analysis of predictors of surgical outcome and factors affecting preoperative neurological status

  • Amish V. Sanghvi
  • Harvinder Singh Chhabra
  • Amrithlal A. Mascarenhas
  • Vivek K. Mittal
  • Gururaj M. Sangondimath
Original Article

Abstract

Despite good posterior decompression of thoracic myelopathy due to ossification of ligamentum flavum (OLF), recovery varies widely from 25 to 100%. Neurological status on presentation also varies widely in different patients. We, therefore retrospectively studied relation of various clinical and magnetic resonance imaging (MRI) parameters with preoperative neurological status and postoperative recovery in 25 patients who underwent decompressive laminectomy for thoracic myelopathy due to OLF. Patients were assessed using leg-trunk-bladder scores of JOA scale and recovery rate (RR) was calculated as RR = postoperative score − preoperative score/11 − preoperative score × 100. With Pearson’s correlation, postoperative recovery rate (RR) significantly correlated with preoperative duration of symptoms, JOA score, sensory JOA score, canal grade, dural canal-body ratio (DCBR), intramedullary signal size (ISS), and intramedullary signal type (IST) on MRI. On MRI, two types of signal changes were identified: normal in T1/hyperintense in T2 representing cord edema and hypointense in T1/hyperintense in T2 representing cystic changes indicating lesser and higher grades, respectively. Presence or absence of signal changes did not correlate with postoperative recovery; but whenever present, ISS greater than 15 mm significantly compromised recovery. Multiple regression analysis (MRA) identified preoperative duration of symptoms and preoperative ISS as significant predictors of postoperative outcome. Based on MRA, we formulated a multiple regression equation to predict RR as Predicted RR = 83.4 + (0.1 × age in years) − (0.7 × preoperative duration of symptoms in months) + (1.5 × preoperative JOA score) + (0.2 × preoperative canal grade in percentage) − (2.5 × ISS in mm) − (1.5 × IST in grade). Though age, preoperative anal sensations, spasticity, canal grade, DCBR, ISS, and IST significantly correlated with preoperative neurological status, MRA identified ISS as most important factor determining preoperative neurological status. Preoperative duration of symptoms and developmentally narrow canal had no influence on preoperative neurological status. Patients with developmentally narrow canal showed significant correlation with younger age at onset of myelopathy. To conclude, only independent factor determining preoperative neurological status is ISS. Predictors of postoperative recovery are preoperative duration of symptoms and ISS. Postoperative recovery can be predicted by formulated equation.

Keywords

Ossification of ligamentum flavum Thoracic spine Thoracic myelopathy Predictors of outcome Thoracic stenosis 

Notes

Acknowledgments

The statistical analysis of this study was carried out by Dr. B S Nagi, Former director of research, Council for social development, New Delhi, India. The authors of this article are very grateful to him for providing scientific inputs related to the rationale and application of statistical tests.

References

  1. 1.
    Iguchi K, Kurokawa T, Nakamura K, Saita K, Miyoshi K, Takeshita K (1995) Surgical outcomes of ossification of ligamentum flavum of the thoracic spine, in Investigation Committee on ossification of spinal ligament. Japanese Ministry of Public Health and Welfare, Tokyo, pp 238–241 (in Japanese)Google Scholar
  2. 2.
    Ikeda K (2003) Treatment of thoracic myelopathy caused by ossification of the spinal ligaments. Yamaguchi Igaku 52:275–283 (in Japanese)Google Scholar
  3. 3.
    Kawaguchi Y, Kanamori M, Ishihara Y, Nobukiyo M, Abe Y, Seki S (2004) Factors related to long-term outcome after surgery for ossification of the ligamentum flavum of the thoracic spine, in Investigation Committee on ossification of spinal ligament. Japanese Ministry of Public Health and Welfare, Tokyo, pp 118–123 (in Japanese)Google Scholar
  4. 4.
    Kawakami M, Tamaki T, Terao K, Hamazaki H, Ando M, Iwahashi T (1992) Analysis of neurological symptoms and clinical results in patients surgically treated for ossification of the ligamentum flavum. Sekitsui Sekizui 5:71–77 (in Japanese)Google Scholar
  5. 5.
    Kinjo Y, Sato S, Kise H, Takara H, Ibaraki K (1996) Surgical result of thoracic myelopathy with ossification of the yellow ligament, in Investigation Committee on Ossification of Spinal Ligament. Japanese Ministry of Public Health and Welfare, 1996, Tokyo, pp 286–289 (in Japanese)Google Scholar
  6. 6.
    Kohno Y, Hirofuji E, Nishimatsu H, Kondo K, Yoshida K (2001) The clinical results of Kirita’s laminectomy for ossification of the ligamentum flavum in the thoracic spine. Chubu Rosaishi 44:1059–1060 (in Japanese)Google Scholar
  7. 7.
    Takei H, Hayashi M, Ito Y, Hashimoto J, Sagae M, Goto F et al (1997) Clinical evaluations of the surgical treatment for ossification of the ligamentum flavum. Rinsho Seikeigeka 32:1359–1365 (in Japanese)Google Scholar
  8. 8.
    Takei Y (1996) Posterior decompression surgery of thoracic myelopathy due to ossification of intraspinal canal ligaments. J Tokyo Med Coll 54:253–263Google Scholar
  9. 9.
    Ueyama K, Harata S, Nitobe T, Iwata D, Okada A (1998) Long-term results and operative methods of ossification of the ligamentum flavum. Sekitsui Sekizui 11:511–516 (in Japanese)Google Scholar
  10. 10.
    Miyakoshi N, Shimada Y, Suzuki T, Hongo M, Kasukawa Y, Okada K et al (2003) Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg 99(3 Suppl):251–256PubMedGoogle Scholar
  11. 11.
    Shiokawa K, Hanakita J, Suwa H, Saiki M, Oda M, Kajiwara M (2001) Clinical analysis and prognostic study of ossified ligamentum flavum of the thoracic spine. J Neurosurg 94(2 Suppl):221–226PubMedGoogle Scholar
  12. 12.
    Chang UK, Choe WJ, Chung CK, Kim HJ (2001) Surgical treatment for thoracic spinal stenosis. Spinal Cord 39:362–369CrossRefPubMedGoogle Scholar
  13. 13.
    Cho YH, Moon SM, Roh SW, Joen SR, Rhim SC (2002) Surgical outcome and prognostic factors of ossified ligamentum flavum of the thoracic spine. J Korean Neurosurg Soc 32:424–430Google Scholar
  14. 14.
    Kuh SU, Kim YS, Cho YE, Jin BH, Kim KS, Yoon YS et al (2006) Contributing factors affecting the prognosis surgical outcome for thoracic OLF. Eur Spine J 15:485–491CrossRefPubMedGoogle Scholar
  15. 15.
    Hur H, Lee JK, Lee JH, Kim JH, Kim SH (2009) Thoracic myelopathy caused by ossification of ligamentum flavum. J Korean Neurosurg Soc 46:189–194CrossRefPubMedGoogle Scholar
  16. 16.
    He S, Hussain N, Li S, Hou T (2005) Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population. J Neurosurg Spine 3:348–354CrossRefPubMedGoogle Scholar
  17. 17.
    Liao CC, Chen TY, Jung SM, Chen LR (2005) Surgical experience with symptomatic thoracic ossification of the ligamentum flavum. J Neurosurg Spine 2:34–39CrossRefPubMedGoogle Scholar
  18. 18.
    Jayakumar PN, Devi BI, Bhat DI, Das BS (2002) Thoracic cord compression due to ossified hypertrophied ligamentum flavum. Neurol India 50:286–289PubMedGoogle Scholar
  19. 19.
    Trivedi P, Behari S, Paul L, Banerji D, Jain VK, Chhabra DK (2001) Thoracic myelopathy secondary to ossified ligamentum flavum. Acta Neurochir Wien 143:775–782CrossRefPubMedGoogle Scholar
  20. 20.
    Al-Orainy IA, Kolawole T (1998) Ossification of the ligament flavum. Eur J Radiol 29:76–82CrossRefPubMedGoogle Scholar
  21. 21.
    Ben Hamouda K, Jemel H, Haouet S, Khaldi M (2003) Thoracic myelopathy caused by ossification of the ligamentum flavum: a report of 18 cases. J Neurosurg 99(2 Suppl):157–161PubMedGoogle Scholar
  22. 22.
    Pascal-Moussellard H, Cabre P, Smadja D, Catonne Y (2005) Symptomatic ossification of the ligamentum flavum: a clinical series from the French Antilles. Spine 30:E400–E405CrossRefPubMedGoogle Scholar
  23. 23.
    Shiraishi T, Crock HV, Lewis P (1995) Thoracic myelopathy due to isolated ossification of the liamentum flavum. J Bone Joint Surg Br 77:131–133PubMedGoogle Scholar
  24. 24.
    Vera CL, Cure JK, Naso WB et al (1997) Paraplegia due to ossification of ligamenta flava in X-linked hypophosphatemia. A case report. Spine 22:710–715CrossRefPubMedGoogle Scholar
  25. 25.
    Inamasu J, Guiot BH (2006) A review of factors predictive of surgical outcome for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg Spine 5(2):133–139CrossRefPubMedGoogle Scholar
  26. 26.
    Okada K, Oka S, Tohge K, Ono K, Yonenobu K, Hosoya T (1991) Thoracic myelopathy caused by ossification of the ligamentum flavum Clinicopathologic study and surgical treatment. Spine 16:280–287CrossRefPubMedGoogle Scholar
  27. 27.
    Ashworth B (1964) Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 192:540–542PubMedGoogle Scholar
  28. 28.
    Mehalic TF, Pezzuti RT, Applebaum BI (1990) Magnetic resonance imaging and cervical spondylotic myelopathy. Neurosurgery 26(2):217–226CrossRefPubMedGoogle Scholar
  29. 29.
    Al-Mefty O, Harkey LH, Middleton TH, Smith RR, Fox JL (1988) Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. J Neurosurg 68(2):217–222CrossRefPubMedGoogle Scholar
  30. 30.
    Kojima T, Oonishi I, Kurokawa T (1992) Ossification of the ligamentum flavum in the thoracolumbar spine of young adults: report of two cases. Int Orthop 16:75–79CrossRefPubMedGoogle Scholar
  31. 31.
    Al-Habib AF, Attabib N, Ball JR, Bajammal S, Casha S, Hurlbert RJ (2009) Clinical Predictors Of Recovery following Blunt Spinal Cord Trauma: Systematic Review. J Neurotrauma doi: 10.1089/neu.2009.1157
  32. 32.
    Park BC, Min WK, Oh CW, Jeon IH, Kim SY, Kyung HS et al (2007) Surgical outcome of thoracic myelopathy secondary to ossification of ligamentum flavum. Joint Bone Spine 74:600–605CrossRefPubMedGoogle Scholar
  33. 33.
    Li KK, Chung OM, Chang YP, So YC (2002) Myelopathy caused by ossification of ligamentum flavum. Spine 27:308–312CrossRefGoogle Scholar
  34. 34.
    Li H, Jiang LS, Dai LY (2008) A review of prognostic factors for surgical outcome of ossification of the posterior longitudinal ligament of cervical spine. Eur Spine J 17(10):1277–1288CrossRefPubMedGoogle Scholar
  35. 35.
    Seichi A, Takeshita K, Nakamura K (2006) Choice of surgical procedures for thoracic ossification of the posterior longitudinal ligament. In: Yonenobu K, Nakamura K, Toyama Y (eds) Ossification of the posterior longitudinal ligament, 2nd edn. Springer, Japan, pp 225–230Google Scholar
  36. 36.
    Valls PL, Naul LG, Kanter SL (1990) Paraplegia after routine lumbar laminectomy: report of a rare complication and successful management. Neurosurgery 27:638–640CrossRefPubMedGoogle Scholar
  37. 37.
    Palumbo MA, Hilibrand AS, Hart RA, Bohlman HH (2001) Surgical treatment of thoracic spinal stenosis: a 2- to 9-year follow-up. Spine 26:558–566CrossRefPubMedGoogle Scholar
  38. 38.
    Min JH, Jang JS, Lee SH (2008) Clinical results of ossification of the posterior longitudinal ligament of the thoracic spine treated by anterior decompression. J Spinal Disord Tech 21(2):116–119CrossRefPubMedGoogle Scholar
  39. 39.
    Shigematsu H, Ueda Y, Koizumi M, Takeshima T, Tanaka Y, Satoh N, Matsumori H, Oshima T, Matsuyama E, Kugai A, Takakura Y (2008) Does developmental canal stenosis influence surgical results of bilateral open-door laminoplasty for cervical spondylotic myelopathy? J Neurosurg Spine 9(4):358–362PubMedGoogle Scholar
  40. 40.
    Matsuyama Y, Kawakami N, Yanase M, Yoshihara H, Ishiguro N, Kameyama T et al (2004) Cervical myelopathy due to OPLL: clinical evaluation by MRI and intraoperative spinal sonography. J Spinal Disord Tech 17:401–404CrossRefPubMedGoogle Scholar
  41. 41.
    Suri A, Chabbra RP, Mehta VS, Gaikwad S, Pandey RM (2003) Effect of intramedullary signal changes on the surgical outcome of patients with cervical spondylotic myelopathy. Spine J. 3:33–45CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Amish V. Sanghvi
    • 1
    • 2
  • Harvinder Singh Chhabra
    • 1
  • Amrithlal A. Mascarenhas
    • 1
  • Vivek K. Mittal
    • 1
  • Gururaj M. Sangondimath
    • 1
  1. 1.Indian Spinal Injuries Centre, Sector-CNew DelhiIndia
  2. 2.AVSARJamnagarIndia

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