Skip to main content
SpringerLink
Log in

Open posterior approach versus endoscopic approach for thoracic ligamentum flavum ossification: a systematic review and meta-analysis

  • Review Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Background

Thoracic ossification of the ligamentum flavum (TOLF), a rare condition more prevalent in East Asia, is managed through open and endoscopic surgical approaches. Determining the superior surgical option remains unclear. This study assesses the safety and clinical outcomes associated with these approaches in TOLF patients.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic literature search up to August 5, 2023, across PubMed, Scopus, EMBASE, Web of Science, Cochrane, and ClinicalTrials.gov. We included randomized controlled trials and cohort studies reporting complication rates, mJOA (modified Japanese Orthopedic Association) scores, JOA scores, VAS (Visual Analog Scale) scores, or hospitalization duration for both open and endoscopic surgeries in TOLF patients.

Results

We analyzed 37 studies encompassing 1,646 TOLF patients using a random-effects model. Our findings revealed a significant difference in complication rates (overall complication rates: 0.12; 95% CI: 0.07, 0.19; p < 0.01; I2: 69%; quality of evidence: moderate), with lower complication rates in the endoscopy group. However, no significant differences were observed in JOA scores (overall JOA: 8.35; 95% CI: 7.16, 9.54; p = 0.12; I2: 99%; quality of evidence: very low), VAS scores (overall VAS: 1.31; 95% CI: 1.03, 1.59; p = 0.35; I2: 91%; quality of evidence: very low), or hospitalization duration (hospital stay: 10.83 days; 95% CI: 6.86, 14.80; p = 0.35; I2: 91%; quality of evidence: very low) between the open and endoscopic groups.

Conclusions

This meta-analysis reports lower complication rates and improved postoperative mJOA scores for endoscopic surgery in TOLF patients compared to open surgery. It represents the first comprehensive evaluation of clinical outcomes and safety of different surgical approaches for TOLF patients. Further randomized controlled trials are essential to validate these findings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12

Similar content being viewed by others

Data availability

All the data in this study were reported in the article. For further information, please contact the corresponding author.

References

  1. 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 25:1912–1919. https://doi.org/10.1007/s00586-015-4158-9

    Article  PubMed  Google Scholar 

  2. Moon BJ, Kuh SU, Kim S et al (2015) Prevalence, distribution, and significance of incidental thoracic ossification of the ligamentum flavum in Korean patients with back or leg pain : MR-based cross sectional study. J Korean Neurosurg Soc 58:112–118. https://doi.org/10.3340/jkns.2015.58.2.112

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Guo JJ, Luk KDK, 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 35:51–56. https://doi.org/10.1097/BRS.0b013e3181b3f779

    Article  CAS  PubMed  Google Scholar 

  4. Lang N, Yuan HS, Wang HL et al (2013) Epidemiological survey of ossification of the ligamentum flavum in thoracic spine: CT imaging observation of 993 cases. Eur Spine J 22:857–862. https://doi.org/10.1007/s00586-012-2492-8

    Article  PubMed  Google Scholar 

  5. Du P, Ma L, Ding W (2022) The influence of ossification morphology on surgery outcomes in patients with thoracic ossification of ligamentum flavum (TOLF). J Orthop Surg Res 17:229. https://doi.org/10.1186/s13018-022-03064-x

    Article  PubMed  PubMed Central  Google Scholar 

  6. Hirabayashi S (2017) Ossification of the ligamentum flavum. Spine Surg Relat Res 1:158–163. https://doi.org/10.22603/ssrr.1.2016-0031

  7. Hur H, Lee J-K, Lee J-H et al (2009) Thoracic myelopathy caused by ossification of the ligamentum flavum. J Korean Neurosurg Soc 46:189–194. https://doi.org/10.3340/jkns.2009.46.3.189

    Article  PubMed  PubMed Central  Google Scholar 

  8. Park B-C, Min W-K, Oh C-W et al (2007) Surgical outcome of thoracic myelopathy secondary to ossification of ligamentum flavum. Joint Bone Spine 74:600–605. https://doi.org/10.1016/j.jbspin.2007.01.033

    Article  PubMed  Google Scholar 

  9. 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–E707. https://doi.org/10.1097/BRS.0b013e31824586a8

    Article  PubMed  Google Scholar 

  10. Lin Y-P, Lin R, Chen S, et al (2021) Thoracic full-endoscopic unilateral laminotomy with bilateral decompression for treating ossification of the ligamentum flavum with myelopathy. Ann Transl Med 9:977. https://doi.org/10.21037/atm-21-2181

  11. Kim HS, Wu PH, Kim J-Y et al (2022) Comparative clinical and radiographic cohort study: uniportal thoracic endoscopic laminotomy with bilateral decompression by using the 1-block resection technique and thoracic open laminotomy with bilateral decompression for thoracic ossified ligamentum flavum. Oper Neurosurg (Hagerstown) 22:391–399. https://doi.org/10.1227/ons.0000000000000145

    Article  PubMed  Google Scholar 

  12. Kim JY, Ha JS, Lee CK, et al (2023) Biportal endoscopic posterior thoracic laminectomy for thoracic spondylotic myelopathy caused by ossification of the ligamentum flavum: technical developments and outcomes. Neurospine 20:129–140. https://doi.org/10.14245/ns.2346060.030

  13. Choi C-M (2020) Biportal endoscopic spine surgery (BESS): considering merits and pitfalls. J Spine Surg 6:457–465. https://doi.org/10.21037/jss.2019.09.29

  14. Wu PH, Chin BZJ, Kim HS et al (2023) Uniportal thoracic endoscopic unilateral laminotomy with bilateral decompression of thoracic ossification of ligamentum flavum: a systematic review of current literature. World Neurosurg. https://doi.org/10.1016/j.wneu.2023.07.066

    Article  PubMed  Google Scholar 

  15. Lee YH (2018) An overview of meta-analysis for clinicians. Korean J Intern Med 33:277–283. https://doi.org/10.3904/kjim.2016.195

    Article  PubMed  Google Scholar 

  16. Sterne JA, Hernán MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919. https://doi.org/10.1136/bmj.i4919

    Article  PubMed  PubMed Central  Google Scholar 

  17. Goldet G, Howick J (2013) Understanding GRADE: an introduction. J Evid Based Med 6:50–54. https://doi.org/10.1111/jebm.12018

    Article  PubMed  Google Scholar 

  18. Freeman MF, Tukey JW (1950) Transformations related to the angular and the square root. Ann Math Stat 21:607–611

    Article  Google Scholar 

  19. Wilson DB, Lipsey MW (2001) The role of method in treatment effectiveness research: evidence from meta-analysis. Psychol Methods 6:413–429

    Article  CAS  PubMed  Google Scholar 

  20. Schwarzer G, Carpenter JR, Rücker G (2015) Meta-analysis with R. Springer

    Book  Google Scholar 

  21. 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 20:205–215. https://doi.org/10.1007/s00586-010-1423-9

    Article  PubMed  Google Scholar 

  22. An B, Li X-C, Zhou C-P et al (2019) Percutaneous full endoscopic posterior decompression of thoracic myelopathy caused by ossification of the ligamentum flavum. Eur Spine J 28:492–501. https://doi.org/10.1007/s00586-018-05866-2

    Article  PubMed  Google Scholar 

  23. Bian F, Zhang J, Bian G et al (2023) Comparison of the short-term efficacy of percutaneous endoscopic thoracic decompression and laminectomy in the treatment of thoracic ossification of the ligamentum flavum. World Neurosurg 170:e666–e672. https://doi.org/10.1016/j.wneu.2022.11.093

    Article  PubMed  Google Scholar 

  24. Yan C, Jia H-C, Xu J-X, et al (2019) Computer-based 3D simulations to formulate preoperative planning of bridge crane technique for thoracic ossification of the ligamentum flavum. Med Sci Monit 25:9666–9678. https://doi.org/10.12659/MSM.918387

  25. Yang F-K, Li P-F, Dou C-T et al (2022) Comparison of percutaneous endoscopic thoracic decompression and posterior thoracic laminectomy for treating thoracic ossification of the ligamentum flavum: a retrospective study. BMC Surg 22:85. https://doi.org/10.1186/s12893-022-01532-z

    Article  PubMed  PubMed Central  Google Scholar 

  26. Zhang C, Yang S, Wang L et al (2023) Preoperative magnetic resonance imaging signal intensity classification is associated with clinical presentation and surgical outcomes in myelopathy CAUSED by thoracic ossification of ligamentum flavum: a multicenter study. Global Spine J 13:1971–1980. https://doi.org/10.1177/21925682211067752

    Article  PubMed  Google Scholar 

  27. Ma J, Lu Z, Zhou X et al (2021) Comparing Thoracic Extensive Laminoplasty (TELP) and laminectomy in treating severe thoracic ligamentum flavum ossification: a proposed novel technique and case-control study. Biomed Res Int 2021:8410317. https://doi.org/10.1155/2021/8410317

    Article  PubMed  PubMed Central  Google Scholar 

  28. He J-L, Du Q, Hu W-D et al (2023) CT-based radiographic measurements and effectiveness estimates of full-endoscopic surgery in thoracic myelopathy caused by ossification of ligamentum flavum. BMC Surg 23:84. https://doi.org/10.1186/s12893-023-01989-6

    Article  PubMed  PubMed Central  Google Scholar 

  29. Yang J-S, Gong H-L, Chen H et al (2021) Full-endoscopic decompression with the application of an endoscopic-matched ultrasonic osteotome for removal of ossification of the thoracic ligamentum flavum. Pain Physician 24:275–281

    PubMed  Google Scholar 

  30. Sun K, Sun X, Zhu J et al (2023) Comparison of surgical results of the bridge crane technique versus laminectomy for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum. Global Spine J 13:384–392. https://doi.org/10.1177/2192568221996689

    Article  PubMed  Google Scholar 

  31. Miura I, Kubota M, Kawamata T, Yuzurihara M (2021) Effect of asymptomatic postoperative epidural hematoma on recovery rate after surgery for myelopathy caused by thoracic ossified ligamentum flavum. Turk Neurosurg. https://doi.org/10.5137/1019-5149.JTN.35036-21.3

    Article  PubMed  Google Scholar 

  32. Liu T, Yang S, Tian S et al (2022) Analysis of the surgical strategy and postoperative clinical effect of thoracic ossification of ligament flavum with dural ossification. Front Surg 9:1036253. https://doi.org/10.3389/fsurg.2022.1036253

    Article  PubMed  PubMed Central  Google Scholar 

  33. Liu Y, Li X, Hou Y et al (2023) Surgical outcomes of percutaneous endoscopic thoracic decompression in the treatment of multi-segment thoracic ossification of the ligamentum flavum. Acta Neurochir. https://doi.org/10.1007/s00701-023-05603-9

    Article  PubMed  Google Scholar 

  34. 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 12:1093–1102. https://doi.org/10.1016/j.spinee.2012.10.022

    Article  PubMed  Google Scholar 

  35. Wu PH, Kim HS, Kim J-Y et al (2021) Uniportal thoracic endoscopic decompression using one block resection technique for thoracic ossified ligamentum flavum technical report. Interdisciplinary Neurosurgery 23:100963. https://doi.org/10.1016/j.inat.2020.100963

    Article  Google Scholar 

  36. Pan Q, Zhu Y, Zhang Z et al (2023) Novel therapeutic strategy in the treatment of ossification of the ligamentum flavum associated with dural ossification. Eur Spine J 32:1068–1076. https://doi.org/10.1007/s00586-023-07549-z

    Article  PubMed  Google Scholar 

  37. Yuan Q, Zheng S, Tian W (2014) Computer-assisted minimally invasive spine surgery for resection of ossification of the ligamentum flavum in the thoracic spine. Chin Med J 127:2043–2047

    Article  PubMed  Google Scholar 

  38. Bagga RS, Shetty AP, Viswanathan VK et al (2023) Thoracic myelopathy in ossified ligamentum flavum: surgical management and long-term outcome following 2 different techniques of surgical decompression. Global Spine J 13:659–667. https://doi.org/10.1177/21925682211003061

    Article  PubMed  Google Scholar 

  39. Baba S, Shiboi R, Yokosuka J, et al (2020) Microendoscopic posterior decompression for treating thoracic myelopathy caused by ossification of the ligamentum flavum: case series. Medicina 56. https://doi.org/10.3390/medicina56120684

  40. Fan T, Sun C, Chen G et al (2023) 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. https://doi.org/10.1007/s00586-022-07468-5

    Article  PubMed  Google Scholar 

  41. Wang T, Du C, Zheng X et al (2017) Surgical strategies for thoracic myelopathy due to ossification of ligamentum flavum: a technical note based on radiological type. Turk Neurosurg. https://doi.org/10.5137/1019-5149.JTN.20391-17.1

    Article  PubMed  Google Scholar 

  42. Chandra VVR, Prasad BCM, Rajesh P et al (2022) Factors predicting poor surgical outcome in patients with thoracic ossified ligamentum flavum-analysis of 106 patients in a tertiary care hospital in South India. Neurol India 70:175

    Article  Google Scholar 

  43. Li W, Gao S, Zhang L et al (2020) Full-endoscopic decompression for thoracic ossification of ligamentum flavum: surgical techniques and clinical outcomes: A retrospective clinical study. Medicine 99:e22997. https://doi.org/10.1097/MD.0000000000022997

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Wang W, Kong L, Zhao H et al (2007) Thoracic ossification of ligamentum flavum caused by skeletal fluorosis. Eur Spine J 16:1119–1128. https://doi.org/10.1007/s00586-006-0242-5

    Article  PubMed  Google Scholar 

  45. Wu W, Diao W, Yang S et al (2019) The effect of using visual trepan to treat single-segment ossification of ligamentum flavum under the endoscope. World Neurosurg 131:e550–e556. https://doi.org/10.1016/j.wneu.2019.07.223

    Article  PubMed  Google Scholar 

  46. 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 12:96–105. https://doi.org/10.5114/wiitm.2017.66473

    Article  PubMed  PubMed Central  Google Scholar 

  47. Huo X, Zhou J, Liu S et al (2020) Clinical efficacy of single intraoperative 500 mg methylprednisolone management therapy for thoracic myelopathy caused by ossification of the ligamentum flavum. BMC Musculoskelet Disord 21:177. https://doi.org/10.1186/s12891-020-03216-2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Li X, An B, Gao H et al (2020) Surgical results and prognostic factors following percutaneous full endoscopic posterior decompression for thoracic myelopathy caused by ossification of the ligamentum flavum. Sci Rep 10:1305. https://doi.org/10.1038/s41598-020-58198-x

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Deng Y, Yang M, Xia C et al (2022) Unilateral biportal endoscopic decompression for symptomatic thoracic ossification of the ligamentum flavum: a case control study. Int Orthop 46:2071–2080. https://doi.org/10.1007/s00264-022-05484-0

    Article  PubMed  Google Scholar 

  50. Hu Y, Dong Y, Qi J et al (2023) Learning curve and clinical outcomes of ultrasonic osteotome-based en bloc laminectomy for thoracic ossification of the ligamentum flavum. Orthop Surg 15:2318–2327. https://doi.org/10.1111/os.13804

    Article  PubMed  PubMed Central  Google Scholar 

  51. Zhao Y, Xue Y, Shi N et al (2014) The CT and intraoperative observation of pedicel-ossification tunnel in 151 cases of thoracic spinal stenosis from ossification of ligamentum flavum. Eur Spine J 23:1325–1331. https://doi.org/10.1007/s00586-014-3261-7

    Article  PubMed  Google Scholar 

  52. Xue Y-D, Zhang Z-C, Ma C, Dai W-X (2021) Preliminary report of modified expansive laminoplasty in the treatment of thoracic ossification of the ligamentum flavum. J Int Med Res 49:300060520985383. https://doi.org/10.1177/0300060520985383

    Article  CAS  PubMed  Google Scholar 

  53. Xiaobing Z, Xingchen L, Honggang Z et al (2019) “U” route transforaminal percutaneous endoscopic thoracic discectomy as a new treatment for thoracic spinal stenosis. Int Orthop 43:825–832. https://doi.org/10.1007/s00264-018-4145-y

    Article  PubMed  Google Scholar 

  54. Xin Z, Kong W, Cai M et al (2020) Translaminar Osseous Channel-Assisted full-endoscopic flavectomy decompression of thoracic myelopathy caused by ossification of the ligamentum flavum: surgical technique and results. Pain Physician 23:E475–E486

    PubMed  Google Scholar 

  55. Zheng C, Liao Z, Chen H-Z (2021) Percutaneous endoscopic posterior decompression for therapy of spinal cord compression due to ossification of the ligamentum flavum: a long-term follow-up. World Neurosurg 156:e249–e253. https://doi.org/10.1016/j.wneu.2021.09.044

    Article  PubMed  Google Scholar 

  56. Li Z-Z, Cao Z, Zhao H-L et al (2021) Ultrasonic osteotome assisted full-endoscopic en block resection of thoracic ossified ligamentum flavum: technical note and 2 years follow-up. Pain Physician 24:E239–E248

    PubMed  Google Scholar 

  57. Wang W, Kong L, Zhao H et al (2007) Thoracic myelopathy caused by ossification of ligamentum flavum of which fluorosis as an etiology factor. J Orthop Surg Res 2:6. https://doi.org/10.1186/1749-799X-2-6

    Article  PubMed  PubMed Central  Google Scholar 

  58. Tsai SHL, Chang C-W, Lin T-Y, et al (2023) The use of Ultrasonic Bone Scalpel (UBS) in Unilateral Biportal Endoscopic Spine Surgery (UBESS): technical notes and outcomes. J Clin Med Res 12. https://doi.org/10.3390/jcm12031180

  59. Kim JY, Hong HJ, Lee DC, et al (2022) Comparative analysis of 3 types of minimally invasive posterior cervical foraminotomy for foraminal stenosis, uniportal-, biportal endoscopy, and microsurgery: radiologic and midterm clinical outcomes. Neurospine 19:212–223. https://doi.org/10.14245/ns.2142942.471

  60. 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 23:229–236. https://doi.org/10.1016/j.jos.2017.10.015

    Article  PubMed  Google Scholar 

  61. Yonenobu K, Abumi K, Nagata K, et al (2001) Interobserver and intraobserver reliability of the japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine 26:1890–1894; discussion 1895. https://doi.org/10.1097/00007632-200109010-00014

  62. Kato S, Oshima Y, Oka H et al (2015) Comparison of the Japanese Orthopaedic Association (JOA) score and modified JOA (mJOA) score for the assessment of cervical myelopathy: a multicenter observational study. PLoS ONE 10:e0123022. https://doi.org/10.1371/journal.pone.0123022

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Oshima Y, Takeshita K, Kato S et al (2022) Comparison between the Japanese Orthopaedic Association (JOA) score and Patient-Reported JOA (PRO-JOA) score to evaluate surgical outcomes of degenerative cervical myelopathy. Global Spine J 12:795–800. https://doi.org/10.1177/2192568220964167

    Article  PubMed  Google Scholar 

  64. Miyasaka K, Kaneda K, Sato S et al (1983) Myelopathy due to ossification or calcification of the ligamentum flavum: radiologic and histologic evaluations. AJNR Am J Neuroradiol 4:629–632

    CAS  PubMed  PubMed Central  Google Scholar 

  65. Payer M, Bruder E, Fischer JA, Benini A (2000) Thoracic myelopathy due to enlarged ossified yellow ligaments. Case report and review of the literature. J Neurosurg 92:105–108. https://doi.org/10.3171/spi.2000.92.1.0105

    Article  CAS  PubMed  Google Scholar 

  66. Ahn DK, Lee S, Moon SH et al (2014) Ossification of the ligamentum flavum. Asian Spine J 8:89–96. https://doi.org/10.4184/asj.2014.8.1.89

    Article  PubMed  PubMed Central  Google Scholar 

  67. Mori K, Kasahara T, Mimura T et al (2013) Prevalence, distribution, and morphology of thoracic ossification of the yellow ligament in Japanese: results of CT-based cross-sectional study. Spine 38:E1216–E1222. https://doi.org/10.1097/BRS.0b013e31829e018b

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

There was no funding in this study.

Author information

Author notes

  1. Chun-Ru Lin and Sung Huang Laurent Tsai authors contributed equally to the manuscript.

Authors and Affiliations

  1. Department of Medical Education, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fuxing Street, Guishan District, Taoyuan City, 333, Taiwan

    Chun-Ru Lin

  2. Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, and Chang Gung University, F7, No 222 Mai-King Road, Keelung, Taiwan

    Sung Huang Laurent Tsai

  3. Department of Medical Education, Kaohsiung Veterans General Hospital, No.386, Dazhong 1 Rd., Zuoying District, Kaohsiung City, 813414, Taiwan

    Ta-Wei Yu

  4. School of Medicine, College of Medicine, Fu Jen Catholic University, 510, Zhongzheng Rd., Xinzhuang District, New Taipei City, 24205, Taiwan

    Po-Cheng Lin & Zheng-Da Tsai

  5. School of Traditional Chinese Medicine, Chang Gung University, 259 Wen-Hwa 1 Road, Kwei-Shan Tao-Yuan, Taiwan

    Kuo-Hao Lee

  6. Department of Orthopaedic Surgery, Guishan District, Chang Gung Memorial Hospital, Linkou Branch, No. 5, Fuxing Street, Taoyuan City, 333, Taiwan

    Tsai-Sheng Fu, Po-Liang Lai, Tsung-Ting Tsai & Yung-Hsueh Hu

Authors
  1. Chun-Ru Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sung Huang Laurent Tsai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ta-Wei Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Po-Cheng Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zheng-Da Tsai
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kuo-Hao Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Tsai-Sheng Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Po-Liang Lai
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Tsung-Ting Tsai
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Yung-Hsueh Hu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

CRL, SHLT, and YHH designed this research. CRL, TWY, and PCL identified the studies and extracted the data. CRL and SHLT analyzed the data. CRL, TWY, and PCL wrote the draft. SHLT, ZDT, KHL, TSF, PLL, TTT, and YHH explained the data and participated in the final version of this research. The results and conclusions were approved by all authors.

Corresponding author

Correspondence to Yung-Hsueh Hu.

Ethics declarations

Conflict of interest

Financial, commercial, or other relationships were absent in this research. There was no conflict of interest in this research.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 17 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lin, CR., Tsai, S.H.L., Yu, TW. et al. Open posterior approach versus endoscopic approach for thoracic ligamentum flavum ossification: a systematic review and meta-analysis. Eur Spine J (2024). https://doi.org/10.1007/s00586-024-08164-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00586-024-08164-2

Keywords

Search

Navigation