Acta Neurochirurgica

, Volume 155, Issue 7, pp 1169–1177 | Cite as

Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentum flavum: posterior surgery by laminectomy

  • Shunzhi Yu
  • Dajiang Wu
  • Fengning Li
  • Tiesheng Hou
Clinical Article - Spine



Thoracic ossification of ligamentum flavum (TOLF) of the spine is characterized by a heterotopic bone formation in the thoracic ligamentum flavum, which causes slowly progressing spinal cord injury. Surgical decompression is the most common treatment of choice for patients with compressive myelopathy due to TOLF. However, the surgical outcome is not always satisfactory.


To identify the predictors of surgical outcome, we retrospectively studied the associations between various clinical and radiological parameters and postoperative recovery in 78 patients who underwent decompressive laminectomy for thoracic myelopathy due to TOLF between October 1998 and June 2011. Surgical outcomes were assessed using modified Japanese Orthopedic Association (mJOA) recovery rate (RR)/outcome scores.


At a minimum of 1 year after surgery for TOLF treatment, the postoperative clinical scores showed statistically significant changes with improvement in the JOA scores. The results indicated that a longer duration of preoperative symptoms, fused-type TOLF, and the degree of compression of the anteroposterior diameter and ossified region (middle thoracic OLF) was related to poor prognosis.


Early diagnosis and sufficient surgical decompression improved the functional outcomes of TOLF patients. The surgical risk is relatively higher due to the tenuous blood supply of the spinal cord and the limited spinal canal volume of the middle thoracic spine extending from T4 to T9.


Thoracic ossification of ligamentum flavum Compressive myelopathy Prognostic factor Middle thoracic spine 


Ethics statement

The study has been approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards established in the 1964 Declaration of Helsinki and its later amendments. All participants provided informed consent prior to their inclusion in the study.

Conflicts of interest



  1. 1.
    Abumi K, Panjabi MM, Kramer KM et al (1991) Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine 15:1142–1147CrossRefGoogle Scholar
  2. 2.
    Aizawa T, Sato T, Ozawa H, Morozumi N, Matsumoto F, Sasaki H, Hoshikawa T, Kawahara C, Kokubun S, Itoi E (2008) Sagittal alignment changes after thoracic laminectomy in adults. J Neurosurg Spine 8(6):510–516PubMedCrossRefGoogle Scholar
  3. 3.
    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 Spine 99:157–161CrossRefGoogle Scholar
  4. 4.
    Chang UK, Choe WJ, Chung CK, Kim HJ (2001) Surgical treatment for thoracic spinal stenosis. Spinal Cord 39:362–369PubMedCrossRefGoogle Scholar
  5. 5.
    Chen XQ, Yang HL, Wang GL, Gu Y, Pan WM, Dong RB, Qiu ZJ, Wu JB, Mei X (2009) Surgery for thoracic myelopathy caused by ossification of the ligamentum flavum. J Clin Neurosci 16(10):1316–1320PubMedCrossRefGoogle Scholar
  6. 6.
    Chen J, Wang X, Wang C, Yuan W (2011) Rotational stress: role in development of ossification of posterior longitudinal ligament and ligamentum flavum. Med Hypotheses 76(1):73–76PubMedCrossRefGoogle Scholar
  7. 7.
    Dommisse GF (1974) The blood supply of the spinal cord. A critical vascular zone in spinal surgery. J Bone Joint Surg Br 56(2):225–235PubMedGoogle Scholar
  8. 8.
    Fan D, Chen Z, Wang D, Guo Z, Qiang Q, Shang Y (2007) Osterix is a key target for mechanical signals in human thoracic ligament flavum cells. J Cell Physiol 211(3):577–584PubMedCrossRefGoogle Scholar
  9. 9.
    Fong SY, Wong HK (2004) Thoracic myelopathy secondary to ligamentum flavum ossification. Ann Acad Med Singap 33(3):340–346PubMedGoogle Scholar
  10. 10.
    Guo JJ, Luk KD, Karppinen J, Yang H, Cheung KM (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 (Phila Pa 1976) 35(1):51–56CrossRefGoogle Scholar
  11. 11.
    Hanakita J, Suwa H, Ohta F, Nishi S, Sakaida H, Iihara K (1990) Neuroradiological examination of thoracic radiculomyelopathy due to ossification of the ligamentum flavum. Neuroradiology 32:38–42PubMedCrossRefGoogle Scholar
  12. 12.
    He S, Hussain N, Li S, Hou T (2005) Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population. J Neurosurg Spine 3:348–354PubMedCrossRefGoogle Scholar
  13. 13.
    Hur H, Lee JK, Lee JH, Kim JH, Kim SH (2009) Thoracic myelopathy caused by ossification of ligamentum flavum. J Korean Neurosurg Soc 46:189–194PubMedCrossRefGoogle Scholar
  14. 14.
    Jaffan I, Abu-Serieh B, Duprez T, Cosnard G, Raftopoulos C (2006) Unusual CT/MR features of putative ligamentum flavum ossification in a North African woman. British J Radiol 79:e67–70CrossRefGoogle Scholar
  15. 15.
    Kang KC, Lee CS, Shin SK, Park SJ, Chung CH, Chung SS (2011) Ossification of the ligamentum flavum of the thoracic spine in the Korean population. J Neurosurg Spine 14(4):513–519PubMedCrossRefGoogle Scholar
  16. 16.
    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
  17. 17.
    Kudo S, Ono M, Russell WJ (1983) Ossification of thoracic ligamenta flava. AJR Am J Roentgenol 141(1):117–121PubMedCrossRefGoogle Scholar
  18. 18.
    Kuh SU, Kim YS, Cho YE, Jin BH, Kim KS, Yoon YS, Chin DK (2006) Contributing factors affecting the prognosis surgical outcome for thoracic OLF. Eur Spine J 15:485–491PubMedCrossRefGoogle Scholar
  19. 19.
    Lazorthes G, Gouaze A, Zadeh JO, Santini JJ, Lazorthes Y, Burdin P (1971) Arterial vascularization of the spinal cord. Recent studies of the anastomotic substitution pathways. J Neurosurg 35(3):253–262PubMedCrossRefGoogle Scholar
  20. 20.
    Li F, Chen Q, Xu K (2006) Surgical treatment of 40 patients with thoracic ossification of the ligamentum flavum. J Neurosurg Spine 4:191–197PubMedCrossRefGoogle Scholar
  21. 21.
    Liao CC, Chen TY, Jung SM, Chen LR (2005) Surgical experience with symptomatic thoracic ossification of the ligamentum flavum. J Neurosurg Spine 2(1):34–39PubMedCrossRefGoogle Scholar
  22. 22.
    Maigne JY, Ayral X, Guerin-Surville H (1992) Frequency and size of ossification in caudal attachments of ligamentum flavum of thoracic spine: Role of rotatory strains in their development an anatomic study of 121 spines. Surg Radiol Anat 14:119–124PubMedCrossRefGoogle Scholar
  23. 23.
    Matsunaga S, Kukita M, Hayashi K, Shinkura R, Koriyama C, Sakou T, Komiya S (2002) Pathogenesis of myelopathy in patients with ossification of the posterior longitudinal ligament. J Neurosurg 96(2 Suppl):168–172PubMedGoogle Scholar
  24. 24.
    Mika A, Unnithan VB, Mika P (2005) Differences in thoracic kyphosis and in back muscle strength in women with bone loss due to osteoporosis. Spine 30:241–246PubMedCrossRefGoogle Scholar
  25. 25.
    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):116–119PubMedCrossRefGoogle Scholar
  26. 26.
    Miyakoshi N, Shimada Y, Suzuki T, Hongo M, Kasukawa Y, Okada K, Itoi E (2003) Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg (3 Suppl):251–256Google Scholar
  27. 27.
    Miyasaka K, Kaneda K, Ito T, Takei H, Sugimoto S, Tsuru N (1982) Ossification of spinal ligaments causing thoracic radiculomyelopathy. Radiology 143:463–468PubMedGoogle Scholar
  28. 28.
    Mohindra S, Gupta R, Chhabra R, Gupta SK (2011) Compressive myelopathy due to ossified yellow ligament among South Asians: analysis of surgical outcome. Acta Neurochir (Wien) 153(3):581–587CrossRefGoogle Scholar
  29. 29.
    Moore WM Jr, Hollier LH (1991) The influence of severity of spinal cord ischemia in the etiology of delayed-onset paraplegia. Ann Surg 213:427–432PubMedCrossRefGoogle Scholar
  30. 30.
    Nakatani T, Marui T, Hitora T, Doita M, Nishida K, Kurosaka M (2002) Mechanical stretching force promotes collagen synthesis by cultured cells from human ligamentum flavum via transforming growth factor-beta1. J Orthop Res 20(6):1380–1386PubMedCrossRefGoogle Scholar
  31. 31.
    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 16:280–287PubMedCrossRefGoogle Scholar
  32. 32.
    Papagelopoulos PJ, Peterson HA, Ebersold MJ, Emmanuel PR, Choudhury SN, Quast LM (1997) Spinal column deformity and instability after lumbar or thoracolumbar laminectomy for intraspinal tumors in children and young adults. Spine (Phila Pa 1976) 22(4):442–451CrossRefGoogle Scholar
  33. 33.
    Park BC, Min WK, Oh CW, Jeon IH, Kim SY, Kyung HS, Oh SH (2007) Surgical outcome of thoracic myelopathy secondary to ossification of ligamentum flavum. Joint Bone Spine 74(6):600–605PubMedCrossRefGoogle Scholar
  34. 34.
    Payer M, Bruder E, Fischer JA, Benini A (2000) Thoracic myelopathy due to enlarged ossified yellow ligaments. J Neurosurg Spine 92:105–108CrossRefGoogle Scholar
  35. 35.
    Polgär F (1920) Uber interarkuelle Wirbelverkalkung. Fortschr Geb Rontgenstr Nuklearmed Erganzungsband 40:292–298Google Scholar
  36. 36.
    Sanghvi AV, Chhabra HS, Mascarenhas AA, Mittal VK, Sangondimath GM (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(2):205–215PubMedCrossRefGoogle Scholar
  37. 37.
    Sato T, Kokubun S, Tanaka Y, Ishii Y (1998) Thoracic myelopathy in the Japanese: epidemiological and clinical observations on the cases in Miyagi Prefecture. Tohoku J Exp Med 184(1):1–11PubMedCrossRefGoogle Scholar
  38. 38.
    Shafaq N, Suzuki A, Terai H, Wakitani S, Nakamura H (2012) Cellularity and cartilage matrix increased in hypertrophied ligamentum flavum: histopathological analysis focusing on the mechanical stress and bone morphogenetic protein signaling. J Spinal Disord Tech 25(2):107–115PubMedCrossRefGoogle Scholar
  39. 39.
    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
  40. 40.
    Shiraishi T, Crock HV, Lewis P (1995) Thoracic myelopathy due to isolated ossification of ligamentum flavum. J Bone Joint Surg Br 77:131–133PubMedGoogle Scholar
  41. 41.
    Trivedi P, Behari S, Paul L, Banerji D, Jain VK, Chhabra DK (2001) Thoracic myelopathy secondary to ossified ligamentum flavum. Acta Neurochir (Wien) 143(8):775–782CrossRefGoogle Scholar
  42. 42.
    Wiseman DB, Stokes JK, Toselli RM (2002) Paraparesis in a black man brought on by ossification of the ligamentum flavum: case report and review of the literature. J Spinal Disord 15:542–545CrossRefGoogle Scholar
  43. 43.
    Xiong L, Zeng QY, Jinkins JR (2001) CT and MRI characteristics of ossification of the ligamenta flava in the thoracic spine. Eur Radiol 11(9):1798–1802PubMedCrossRefGoogle Scholar
  44. 44.
    Yamaura I, Yone K, Nakahara S, Nagamine T, Baba H, Uchida K, Komiya S (2002) Mechanism of destructive pathologic changes in the spinal cord under chronic mechanical compression. Spine (Phila Pa 1976) 27(1):21–26CrossRefGoogle Scholar
  45. 45.
    Yayama T, Uchida K, Kobayashi S, Kokubo Y, Sato R, Nakajima H, Takamura T, Bangirana A, Itoh H, Baba H (2007) Thoracic ossification of the human ligamentum flavum:histopathological and immunohistochemical findings around the ossified lesion. J Neurosurg Spine 7(2):184–193PubMedCrossRefGoogle Scholar
  46. 46.
    Yoon SH, Kim WH, Chung SB, Jin YJ, Park KW, Lee JW, Chung SK, Kim KJ, Yeom JS, Jahng TA, Chung CK, Kang HS, Kim HJ (2011) Clinical analysis of thoracic ossified ligamentum flavum without ventral compressive lesion. Eur Spine J 20(2):216–223PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Wien 2013

Authors and Affiliations

  • Shunzhi Yu
    • 1
  • Dajiang Wu
    • 1
  • Fengning Li
    • 1
  • Tiesheng Hou
    • 1
  1. 1.Department of Orthopedics, Changhai HospitalSecond Military Medical UniversityShanghaiPeople’s Republic of China

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