Elsevier

The Spine Journal

Volume 18, Issue 6, June 2018, Pages 1099-1105
The Spine Journal

Technical Report
A novel anterior decompression technique (vertebral body sliding osteotomy) for ossification of posterior longitudinal ligament of the cervical spine

https://doi.org/10.1016/j.spinee.2018.02.022Get rights and content

Abstract

Background Context

Conventional anterior decompression surgery for cervical myelopathy, including anterior corpectomy and fusion, is technically demanding and is known to be associated with a higher incidence of surgery-related complications, including cerebrospinal fluid (CSF) leakage, neurologic deterioration, and graft failure compared with posterior surgery.

Purpose

We introduce a novel anterior decompression technique (vertebral body sliding osteotomy [VBSO]) for cervical myelopathy caused by ossification of posterior longitudinal ligament (OPLL) and evaluate the efficacy and safety of this procedure.

Study Design

This is a case series for novel surgical technique.

Patient Sample

Fourteen patients (M:F=11:3, mean age 56.9±10) with cervical myelopathy caused by OPLL who underwent VBSO by a single surgeon were included.

Outcome Measures

The surgical outcome was evaluated according to the Japanese Orthopaedic Association score for cervical myelopathy (C-JOA score), and the recovery rate of the C-JOA score was calculated. Patients were also evaluated radiographically with plain and dynamic cervical spine radiographs and pre- and postoperative computed tomography images.

Methods

Fourteen patients were followed up for more than 24 months, and operation time, estimated blood loss, neurologic outcomes, and surgery-related complications were investigated. Radiological measurements were also performed to analyze the following parameters: (1) canal-occupying ratio and postoperative canal widening, and (2) pre- and postoperative sagittal alignment.

Results

The mean recovery rate of C-JOA score at the final follow-up was 68.65±17.8%. There were no perioperative complications, including neurologic deterioration, vertebral artery injury, esophageal injury, graft dislodgement, and CSF leaks, after surgery except for pseudarthrosis in one case. An average spinal canal compromised ratio by OPLL decreased from 61.5±8.1% preoperatively to 16.5±11.2% postoperatively. An average postoperative canal widening was 5.15±1.39 mm, and improvement of cervical alignment was observed in all patients, with average recovery angle of 7.3±6.1° postoperatively.

Conclusions

The VBSO allows sufficient decompression of spinal cord and provides excellent neurologic outcomes. Because surgeons do not need to manipulate the OPLL mass directly, this technique could significantly decrease surgery-related complications. Furthermore, as VBSO is based on the multilevel discectomy and fusion technique, it would be more helpful to restore a physiological lordosis.

Introduction

Ossification of the posterior longitudinal ligament (OPLL) results from pathologic replacement of the posterior longitudinal ligament with lamellar bone, potentially causing spinal cord compression and neurologic deterioration. Surgical decompression via an anterior or posterior approach is the treatment of choice for myelopathic patients with severe compression observed on computed tomography (CT) or magnetic resonance imaging (MRI) [1], [2].

Although anterior decompression, such as cervical corpectomy, is an excellent option along with direct removal of the OPLL mass, when more than two or three cervical levels are affected, posterior surgery, such as laminoplasty or laminectomy with or without fusion, is preferred because of the technical ease and lower rate of complications. However, in patients with a high occupying ratio of OPLL, hill-shaped ossification, or kyphotic alignment, posterior decompression will not achieve an adequate posterior shift of the spinal cord, and sufficient neurologic improvement cannot be expected [3].

In contrast, conventional anterior decompression surgery, such as anterior corpectomy and fusion, is technically demanding and is associated with a higher incidence of surgery-related complications, including dysphagia, cerebrospinal fluid (CSF) leakage, implant dislodgement, or pseudarthrosis of the grafting bone, compared with posterior surgery [4], [5], [6], [7].

Dural tear is also more common with anterior surgery, which can be dangerous for both surgeons and patients. Particularly when the dura mater is ossified or severely adheres to the posterior longitudinal ligament, complete removal of the ossified lesion may lead to dural tear and subsequent CSF leakage.

To prevent these complications and achieve effective anterior decompression, we developed a novel anterior decompression technique, called vertebral body sliding osteotomy (VBSO). Its basic concept is to expand the spinal canal by anteriorly translating the involved vertebral bodies and any ossified masses. The aims of the present study were (1) to reveal the technical plausibility of this technique and (2) to evaluate the efficacy and safety of this procedure.

Section snippets

Materials and methods

The present study was a case series to evaluate our new surgical technique for treatment of cervical myelopathy caused by segmental-type OPLL. Fourteen patients (11 men, 3 women) with cervical myelopathy caused by OPLL who underwent VBSO between January 2012 and December 2014 at our institution were included. As a surgical indication, myelopathic patients with more than moderate gait impairment underwent surgical treatment. Ossification of posterior longitudinal ligament lesions with a high

Results

Clinical data and surgical outcomes of the 14 patients who underwent VBSO are listed in the Table. There were 12 men and 2 women, with a mean age of 56.9±10 years. All patients were followed up for more than 24 months, with an average follow-up period of 36.6±7.2 months.

The mean C-JOA score improved from 12.4±2.9 preoperatively to 16±1.4 at the final follow-up (p<.01). The mean recovery rate of the C-JOA score at the final follow-up was 68.65±17.8% and no patient showed neurologic deterioration

Discussion

Some studies have reported that anterior surgery for OPLL is more effective for decompression of the spinal canal, allowing direct removal of the ossified mass. Furthermore, cervical corpectomy and fusion is one of the most widely used techniques via an anterior approach for cervical myelopathy caused by OPLL. However, surgical removal of the OPLL mass through an anterior approach is technically demanding and is associated with a higher incidence of perioperative complications compared with

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Author disclosures: DHL: Nothing to disclose. JHC: Nothing to disclose. CSL: Nothing to disclose. CJH: Nothing to disclose. SHC: Nothing to disclose. CGH: Nothing to disclose.

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