Abstract
Background
Thoracic ossification of ligamentum flavum (TOLF) can be asymptomatic and progress insidiously. But, long-term follow-up results of clinical progression of TOLF are still unknown.
Methods
The clinical progression of 81 patients with TOLF at our center, followed for 10 to 11 (mean, 10.3) years from May 2010 to November 2021, were analyzed. Among them, 51 patients with thoracic myelopathy were caused by single- or multi-segment TOLF, and received partial TOLF resection (30 patients) or total TOLF resection (21 patients). The remaining 30 patients showed TOLF on imaging examinations, but TOLF was not the responsible compressing factor causing myelopathy and with no TOLF resection. The mJOA score (total 11 scores) and spinal operation were used to evaluate the clinical progression at follow-up.
Results
During the 10- to 11-year follow-up of 81 TOLF patients, 71 (87.7%) had no deterioration of neurological function, and 10 (12.3%) patients had deterioration of neurological function and had another spinal operation, including only 4 (4.9%) suffered thoracic myelopathy caused by the progression of TOLF; 6 (7.4%) for other spinal diseases: 2 (2.5%) had fall damage and acute spinal cord injury at the TOLF level; 2 (2.5%) had thoracic myelopathy caused by ossification of posterior longitudinal ligament (OPLL); 2 (2.5%) had cervical spondylosis and received cervical operation.
Conclusions
Most TOLF (87.7%) patients had no clinical progression and received no reoperations for TOLF in the ten-year dimension (mean, 10.3 years). Narrow spinal canal for TOLF increases the risk of traumatic paraplegia.
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References
Lee BJ, Park JH, Jeon SR, Rhim SC, Roh SW (2019) Clinically significant radiographic parameter for thoracic myelopathy caused by ossification of the ligamentum flavum. Eur Spine J 28(8):1846–1854. https://doi.org/10.1007/s00586-018-5750-6
Yan C, Tan HY, Ji CL, Yu XW, Jia HC, Li FD, Jiang GC, Li WS, Zhou FF, Ye Z, Sun JC, Shi JG (2021) The clinical value of three-dimensional measurement in the diagnosis of thoracic myelopathy caused by ossification of the ligamentum flavum. Quant Imaging Med Surg 11(5):2040–2051. https://doi.org/10.21037/qims-20-713
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) 51–6. https://doi.org/10.1097/BRS.0b013e3181b3f779
Lang N, Yuan HS, Wang HL, Liao J, Li M, Guo FX, Shi S, Chen ZQ (2013) Epidemiological survey of ossification of the ligamentum flavum in thoracic spine: CT imaging observation of 993 cases. Eur Spine J 22(4):857–862. https://doi.org/10.1007/s00586-012-2492-8
Z.Q. Chen, C.G. Sun, A. Spine Surgery Group of Chinese Orthopedic (2015) Clinical guideline for treatment of symptomatic thoracic spinal stenosis. Orthop Surg 7(3):208–212. https://doi.org/10.1111/os.12190
Chaput CD, Siddiqui M, Rahm MD (2019) Obesity and calcification of the ligaments of the spine: a comprehensive CT analysis of the entire spine in a random trauma population. Spine J 19(8):1346–1353. https://doi.org/10.1016/j.spinee.2019.03.003
Chen G, Fan T, Yang X, Sun C, Fan D, Chen Z (2020) The prevalence and clinical characteristics of thoracic spinal stenosis: a systematic review. Eur Spine J 29(9):2164–2172. https://doi.org/10.1007/s00586-020-06520-6
Hou X, Sun C, Liu X, Liu Z, Qi Q, Guo Z, Li W, Zeng Y, Chen Z (2016) Clinical features of thoracic spinal stenosis-associated myelopathy: a retrospective analysis of 427 cases. Clin Spine Surg 29(2):86–89. https://doi.org/10.1097/BSD.0000000000000081
Sun C, Chen G, Fan T, Li W, Guo Z, Qi Q, Zeng Y, Zhong W, Chen Z (2020) Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note. J Orthop Surg Res 15(1):309. https://doi.org/10.1186/s13018-020-01838-9
Chen G, Chen Z, Li W, Zeng Y, Zhong W, Sun C (2020) "IV+V+VI" circumferential decompression technique for thoracic myelopathy caused by the ossification of posterior longitudinal ligament or hard disc herniation. Spine (Phila Pa 1976) 45(22) 1605–1612. https://doi.org/10.1097/BRS.0000000000003617
Ando K, Imagama S, Kobayashi K, Hida T, Ito K, Tsushima M, Ishikawa Y, Matsumoto A, Nishida Y, Ishiguro N (2017) Comparative study of surgical treatment and nonsurgical follow up for thoracic ossification of the posterior longitudinal ligament: radiological and clinical evaluation. Spine (Phila Pa 1976) 42(6) 407–410. https://doi.org/10.1097/BRS.0000000000001769
Tang CYK, Cheung KMC, Samartzis D, Cheung JPY (2021) The Natural history of ossification of yellow ligament of the thoracic spine on MRI: a population-based cohort study. Global Spine J 11(3):321–330. https://doi.org/10.1177/2192568220903766
Consultation WHOE (2004) Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363(9403):157–163. https://doi.org/10.1016/S0140-6736(03)15268-3
Zhang C, Chen Z, Meng X, Li M, Zhang L, Huang A (2017) The involvement and possible mechanism of pro-inflammatory tumor necrosis factor alpha (TNF-alpha) in thoracic ossification of the ligamentum flavum. PLoS ONE 12(6):e0178986. https://doi.org/10.1371/journal.pone.0178986
Fan D, Chen Z, Chen Y, Shang Y (2007) Mechanistic roles of leptin in osteogenic stimulation in thoracic ligament flavum cells. J Biol Chem 282(41):29958–29966. https://doi.org/10.1074/jbc.M611779200
Ning S, Chen Z, Fan D, Sun C, Zhang C, Zeng Y, Li W, Hou X, Qu X, Ma Y, Yu H (2017) Genetic differences in osteogenic differentiation potency in the thoracic ossification of the ligamentum flavum under cyclic mechanical stress. Int J Mol Med 39(1):135–143. https://doi.org/10.3892/ijmm.2016.2803
Fan T, Meng X, Sun C, Yang X, Chen G, Li W, Chen Z (2020) Genome-wide DNA methylation profile analysis in thoracic ossification of the ligamentum flavum. J Cell Mol Med 24(15):8753–8762. https://doi.org/10.1111/jcmm.15509
Sun CG, Chen ZQ, Liu ZJ, Liu XG, Qi Q, Guo ZQ, Li WS, Zeng Y (2012) Longterm outcome after the decompressive surgery for thoracic myelopathy due to the ossification of the ligamentum flavum. Zhonghua Wai Ke Za Zhi 50(5) 426–9. [Article in Chinese]
Cai HX, Yayama T, Uchida K, Nakajima H, Sugita D, Guerrero AR, Yoshida A, Baba H (2012) Cyclic tensile strain facilitates the ossification of ligamentum flavum through beta-catenin signaling pathway: in vitro analysis. Spine (Phila Pa 1976) 37(11) E639–46. https://doi.org/10.1097/BRS.0b013e318242a132
Gao R, Shi C, Yang C, Zhao Y, Chen X, Zhou X (2020) Cyclic stretch promotes the ossification of ligamentum flavum by modulating the Indian hedgehog signaling pathway. Mol Med Rep 22(2):1119–1128. https://doi.org/10.3892/mmr.2020.11200
Kobashi G, Washio M, Okamoto K, Sasaki S, Yokoyama T, Miyake Y, Sakamoto N, Ohta K, Inaba Y, Tanaka H, R. Japan Collaborative Epidemiological Study Group for Evaluation of Ossification of the Posterior Longitudinal Ligament of the Spine (2004) High body mass index after age 20 and diabetes mellitus are independent risk factors for ossification of the posterior longitudinal ligament of the spine in Japanese subjects: a case-control study in multiple hospitals. Spine (Phila Pa 1976) 29(9) 1006–10. https://doi.org/10.1097/00007632-200405010-00011
Denko CW, Malemud CJ (2006) Body mass index and blood glucose: correlations with serum insulin, growth hormone, and insulin-like growth factor-1 levels in patients with diffuse idiopathic skeletal hyperostosis (DISH). Rheumatol Int 26(4):292–297. https://doi.org/10.1007/s00296-005-0588-8
Eckertova M, Krskova K, Penesova A, Radikova Z, Zlnay D, Rovensky J, Zorad S (2009) Impaired insulin secretion and uptake in patients with diffuse idiopathic skeletal hyperostosis. Endocr Regul 43(4):149–155
Miyazawa N, Akiyama I (2006) Diffuse idiopathic skeletal hyperostosis associated with risk factors for stroke: a case-control study. Spine (Phila Pa 1976) 31(8) E225–9; discussion E230. https://doi.org/10.1097/01.brs.0000214949.75361.f4
Machino M, Imagama S, Ito K, Ando K, Kobayashi K, Kato F, Nishida Y, Ishiguro N (2019) Thoracic spinal cord injury without major bone injury associated with ossification of the ligamentum flavum. J Orthop Sci 24(1):174–177. https://doi.org/10.1016/j.jos.2016.10.002
Nagayama M, Yanagawa Y, Okuda T, Yonezawa I, Iba T, Kaneko K (2014) A case of paraparesis with thoracic ossification of the posterior longitudinal ligament and the ligamentum flavum induced by falling down on the abdomen. Acute Med Surg 1(1):54–57. https://doi.org/10.1002/ams2.3
K.K. Li, O.M. Chung, Y.P. Chang, Y.C. So (2002) Myelopathy caused by ossification of ligamentum flavum. Spine (Phila Pa 1976) 27(12) E308–12. https://doi.org/10.1097/00007632-200206150-00026
M. Rivierez, P. Vally (2001) Ossification of ligamentum flavum unmasked by acute paraplegia. Neurochirurgie 47(6) 572–5. [Article in French]
Kow CY, Chan P, Etherington G, Rosenfeld JV (2016) Acute traumatic cord injury associated with ossified ligamentum flavum. J Clin Neurosci 30:165–166. https://doi.org/10.1016/j.jocn.2016.02.008
Matsunaga S, Sakou T, Taketomi E, Komiya S (2004) Clinical course of patients with ossification of the posterior longitudinal ligament: a minimum 10-year cohort study. J Neurosurg 100(3 Suppl Spine) 245–8. https://doi.org/10.3171/spi.2004.100.3.0245
Liang H, Liu G, Lu S, Chen S, Jiang D, Shi H, Fei Q (2019) Epidemiology of ossification of the spinal ligaments and associated factors in the Chinese population: a cross-sectional study of 2000 consecutive individuals. BMC Musculoskelet Disord 20(1):253. https://doi.org/10.1186/s12891-019-2569-1
Guo Q, Ni B, Yang J, Zhu Z, Yang J (2011) Simultaneous ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum causing upper thoracic myelopathy in DISH: case report and literature review. Eur Spine J 20(Suppl 2):S195-201. https://doi.org/10.1007/s00586-010-1538-z
Wang L, Wang H, Chen Z, Sun C, Li W (2021) Surgical strategy for non-continuous thoracic spinal stenosis: one- or two-stage surgery? Int Orthop 45(7):1871–1880. https://doi.org/10.1007/s00264-020-04913-2
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National Natural Science Foundation of China, 82102615, Tianqi Fan.
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Fan, T., Sun, C., Chen, G. et al. Clinical progression of ossification of the ligamentum flavum in thoracic spine: a 10- to 11-year follow-up study. Eur Spine J 32, 495–504 (2023). https://doi.org/10.1007/s00586-022-07468-5
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DOI: https://doi.org/10.1007/s00586-022-07468-5