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Percutaneous full endoscopic posterior decompression of thoracic myelopathy caused by ossification of the ligamentum flavum

  • Bo An
  • Xing-Chen Li
  • Cheng-Pei Zhou
  • Bi-Sheng Wang
  • Hao-Ran Gao
  • Hai-Jun Ma
  • Yi He
  • Hong-Gang Zhou
  • He-Jun YangEmail author
  • Ji-Xian QianEmail author
Original Article

Abstract

Purpose

Ossification of ligamentum flavum (OLF) is the leading cause of progressive thoracic myelopathy (TM) in East Asian countries. Surgical decompression is the general treatment for TM. This study investigated the application of percutaneous full endoscopic posterior decompression (PEPD) for the treatment of thoracic OLF.

Methods

Eighteen patients with TM were treated by PEPD under local anaesthesia. Patients had an average age of 59.1 years and single-level lesions mostly at the lower thoracic vertebrae. Computed tomography and magnetic resonance imaging were used to classify the OLF. The pre- and postoperative neurological statuses were evaluated using the American Spinal Injury Association (ASIA) sensory and motor score, modified Japanese Orthopaedic Association (mJOA) score and Frankel grade.

Results

OLF for all patients was classed as lateral, extended, and enlarged types without comma and tram track signs. Decompression was completed, and a dome-shaped laminotomy was performed through limited laminectomy and flavectomy. Dural tears in 2 patients were the only observed complication. The average score of ASIA sensory and motor, mJOA, as well as the Frankel grade improved significantly after surgery at an average follow-up time of 17.4 months. The average recovery rate (RR) was 47.5% as calculated from the mJOA scores. According to RR, 10 cases were classified as good, 4 cases fair, and 4 cases unchanged.

Conclusions

For patients with thoracic OLF at a single level and lateral, extended, and enlarged types without comma and tram track signs, it is safe and reliable to perform PEPD, which has satisfactory clinical results.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

Keywords

Ossification of the ligamentum flavum Thoracic myelopathy Percutaneous full endoscopic posterior decompression Minimally invasive 

Notes

Compliance with ethical standards

Conflict of interest

All authors have declared that they have no conflicts of interest.

Supplementary material

586_2018_5866_MOESM1_ESM.ppt (7.1 mb)
Supplementary material 1 (PPT 7283 kb)

References

  1. 1.
    Yoon SH, Kim WH, Chung SB et al (2011) Clinical analysis of thoracic ossified ligamentum flavum without ventral compressive lesion. Eur Spine J 20:216–223CrossRefGoogle Scholar
  2. 2.
    Guo JJ, Luk KD, Karppinen J et al (2010) 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 35:51–56CrossRefGoogle Scholar
  3. 3.
    Ahn DK, Lee S, Moon SH et al (2014) Ossification of the ligamentum flavum. Asian Spine J 8:89–96CrossRefGoogle Scholar
  4. 4.
    Sanghvi AV, Chhabra HS, Mascarenhas AA et al (2011) Thoracic myelopathy due to ossification of ligamentum flavum: a retrospective analysis of predictors of surgical outcome and factors affecting preoperative neurological status. Eur Spine J 20:205–215CrossRefGoogle Scholar
  5. 5.
    Jia LS, Chen XS, Zhou SY et al (2010) En bloc resection of lamina and ossified ligamentum flavum in the treatment of thoracic ossification of the ligamentum flavum. Neurosurgery 66:1181–1186CrossRefGoogle Scholar
  6. 6.
    Hirabayashi H, Ebara S, Takahashi J et al (2008) Surgery for thoracic myelopathy caused by ossification of the ligamentum flavum. Surg Neurol 69:114–116CrossRefGoogle Scholar
  7. 7.
    Ikuta K, Tarukado K, Senba H et al (2011) Decompression procedure using a microendoscopic technique for thoracic myelopathy caused by ossification of the ligamentum flavum. Minim Invasive Neurosurg 54:271–273CrossRefGoogle Scholar
  8. 8.
    Baba S, Oshima Y, Iwahori T et al (2016) Microendoscopic posterior decompression for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum: a technical report. Eur Spine J 25:1912–1919CrossRefGoogle Scholar
  9. 9.
    Zhao W, Shen C, Cai R et al (2017) Minimally invasive surgery for resection of ossification of the ligamentum flavum in the thoracic spine. Wideochir Inne Tech Maloinwazyjne 12:96–105Google Scholar
  10. 10.
    Muthukumar N (2009) Dural ossification in ossification of the ligamentum flavum: a preliminary report. Spine 34:2654–2661CrossRefGoogle Scholar
  11. 11.
    Sun X, Sun C, Liu X et al (2012) The frequency and treatment of dural tears and cerebrospinal fluid leakage in 266 patients with thoracic myelopathy caused by ossification of the ligamentum flavum. Spine 37:E702–E707CrossRefGoogle Scholar
  12. 12.
    Epstein NE (2013) A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery. Surg Neurol Int 4:S301–S317CrossRefGoogle Scholar
  13. 13.
    Wang H, Ma L, Xue R et al (2016) The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy. Medicine (Baltimore) 95:e5519CrossRefGoogle Scholar
  14. 14.
    Aizawa T, Sato T, Sasaki H et al (2006) Thoracic myelopathy caused by ossification of the ligamentum flavum: clinical features and surgical results in the Japanese population. J Neurosurg Spine 5:514–519CrossRefGoogle Scholar
  15. 15.
    Aizawa T, Sato T, Ozawa H et al (2008) Sagittal alignment changes after thoracic laminectomy in adults. J Neurosurg Spine 8:510–516CrossRefGoogle Scholar
  16. 16.
    Okada K, Oka S, Tohge K et al (1991) Thoracic myelopathy caused by ossification of the ligamentum flavum. Clinicopathologic study and surgical treatment. Spine 16:280–287CrossRefGoogle Scholar
  17. 17.
    Wang T, Yin C, Wang D et al (2017) Surgical technique for decompression of severe thoracic myelopathy due to tuberous ossification of ligamentum flavum. Clin Spine Surg 30:E7–E12CrossRefGoogle Scholar
  18. 18.
    Choi G, Pophale CS, Patel B et al (2017) Endoscopic spine surgery. J Korean Neurosurg Soc 60:485–497CrossRefGoogle Scholar
  19. 19.
    Sairyo K, Chikawa T, Nagamachi A (2018) State-of-the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: discectomy, foraminoplasty, and ventral facetectomy. J Orthop Sci 23:229–236CrossRefGoogle Scholar
  20. 20.
    Jia ZQ, He XJ, Zhao LT et al (2018) Transforaminal endoscopic decompression for thoracic spinal stenosis under local anesthesia. Eur Spine J 27:465–471CrossRefGoogle Scholar
  21. 21.
    Miao X, He D, Wu T et al (2018) Percutaneous endoscopic spine minimally invasive technique for decompression therapy of thoracic myelopathy caused by ossification of the ligamentum flavum. World Neurosurg 114:8–12CrossRefGoogle Scholar
  22. 22.
    Kuh SU, Kim YS, Cho YE et al (2006) Contributing factors affecting the prognosis surgical outcome for thoracic OLF. Eur Spine J 15:485–491CrossRefGoogle Scholar
  23. 23.
    Ando K, Imagama S, Ito Z et al (2013) Predictive factors for a poor surgical outcome with thoracic ossification of the ligamentum flavum by multivariate analysis: a multicenter study. Spine 38:E748–E754CrossRefGoogle Scholar
  24. 24.
    Ju JH, Kim SJ, Kim KH et al (2018) Clinical relation among dural adhesion, dural ossification, and dural laceration in the removal of ossification of the ligamentum flavum. Spine J 18:747–754CrossRefGoogle Scholar
  25. 25.
    Feng F, Sun C, Chen Z (2015) A diagnostic study of thoracic myelopathy due to ossification of ligamentum flavum. Eur Spine J 24:947–954CrossRefGoogle Scholar
  26. 26.
    Yamasaki R, Okuda S, Maeno T et al (2013) Surgical outcomes of posterior thoracic interbody fusion for thoracic disc herniations. Eur Spine J 22:2496–2503CrossRefGoogle Scholar
  27. 27.
    Kirshblum SC, Waring W, Biering-Sorensen F et al (2011) Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury. J Spinal Cord Med 34:547–554CrossRefGoogle Scholar
  28. 28.
    Hirabayashi K, Miyakawa J, Satomi K et al (1981) Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine 6:354–364CrossRefGoogle Scholar
  29. 29.
    Li M, Meng H, Du J et al (2012) Management of thoracic myelopathy caused by ossification of the posterior longitudinal ligament combined with ossification of the ligamentum flavum-a retrospective study. Spine J 12:1093–1102CrossRefGoogle Scholar
  30. 30.
    Palmer S, Turner R, Palmer R (2002) Bilateral decompression of lumbar spinal stenosis involving a unilateral approach with microscope and tubular retractor system. J Neurosurg 97:213–217Google Scholar
  31. 31.
    Hur H, Lee JK, Lee JH et al (2009) Thoracic myelopathy caused by ossification of the ligamentum flavum. J Korean Neurosurg Soc 46:189–194CrossRefGoogle Scholar
  32. 32.
    Gao R, Yuan W, Yang L et al (2013) Clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel ossification of the ligamentum flavum. Spine J 13:1032–1038CrossRefGoogle Scholar
  33. 33.
    Kang KC, Lee CS, Shin SK et al (2011) Ossification of the ligamentum flavum of the thoracic spine in the Korean population. J Neurosurg Spine 14:513–519CrossRefGoogle Scholar
  34. 34.
    Kawaguchi Y, Yasuda T, Seki S et al (2013) Variables affecting postsurgical prognosis of thoracic myelopathy caused by ossification of the ligamentum flavum. Spine J 13:1095–1107CrossRefGoogle Scholar
  35. 35.
    Matsumoto Y, Harimaya K, Doi T et al (2012) Clinical characteristics and surgical outcome of the symptomatic ossification of ligamentum flavum at the thoracic level with combined lumbar spinal stenosis. Arch Orthop Trauma Surg 132:465–470CrossRefGoogle Scholar
  36. 36.
    Yu S, Wu D, Li F et al (2013) Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentum flavum: posterior surgery by laminectomy. Acta Neurochir (Wien) 155:1169–1177CrossRefGoogle Scholar
  37. 37.
    Onishi E, Yasuda T, Yamamoto H et al (2016) Outcomes of surgical treatment for thoracic myelopathy: a single-institutional study of 73 patients. Spine 41:E1356–E1363CrossRefGoogle Scholar
  38. 38.
    Sun J, Zhang C, Ning G et al (2014) Surgical strategies for ossified ligamentum flavum associated with dural ossification in thoracic spinal stenosis. J Clin Neurosci 21:2102–2106CrossRefGoogle Scholar
  39. 39.
    He S, Hussain N, Li S et al (2005) Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population. J Neurosurg Spine 3:348–354CrossRefGoogle Scholar
  40. 40.
    Li Z, Ren D, Zhao Y et al (2016) Clinical characteristics and surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective analysis of 85 cases. Spinal Cord 54:188–196CrossRefGoogle Scholar
  41. 41.
    Kanno H, Takahashi T, Aizawa T et al (2018) Recurrence of ossification of ligamentum flavum at the same intervertebral level in the thoracic spine: a report of two cases and review of the literature. Eur Spine J 27:359–367CrossRefGoogle Scholar
  42. 42.
    Miyashita T, Ataka H, Tanno T (2013) Spontaneous reduction of a floated ossification of the ligamentum flavum after posterior thoracic decompression (floating method); report of a case (abridged translation of a primary publication). Spine J 13:e7–e9CrossRefGoogle Scholar
  43. 43.
    Shimamura T, Kato S, Toba T et al (2001) Sagittal splitting laminoplasty for spinal canal enlargement for ossification of the spinal ligaments (OPLL and OLF). Semin Musculoskelet Radiol 5:203–206CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Bo An
    • 1
  • Xing-Chen Li
    • 2
  • Cheng-Pei Zhou
    • 1
  • Bi-Sheng Wang
    • 2
  • Hao-Ran Gao
    • 1
  • Hai-Jun Ma
    • 2
  • Yi He
    • 2
  • Hong-Gang Zhou
    • 2
  • He-Jun Yang
    • 2
    Email author
  • Ji-Xian Qian
    • 1
    Email author
  1. 1.Department of OrthopedicsTangdu Hospital Affiliated to Air Force Medical UniversityXi’anChina
  2. 2.Department of Spinal SurgeryThird Hospital of Henan ProvinceZhengzhouChina

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