Novel Algorithm for Surgical Management of Cervical Ossification of Posterior Longitudinal Ligament: A Retrospective Cohort Study With 2-Year Follow-Up

Abstract

Object: With the development of new technologies, the surgical algorithm for ossification of posterior longitudinal ligament (OPLL) in the cervical spine also needs to be updated. The aim of this study is to elucidate a new surgical classification algorithm to guide the choice of surgical approaches for cervical OPLL based on its location and extent. In this algorithm, anterior controllable antedisplacement and fusion (ACAF) will be used as a new surgical option.

Methods: This is a single-centered, retrospective, cohort study utilizing a novel algorithm based on the following three criteria: (1) the positional relationship between ossification and uncinate process (UP), (2) the K-line, and (3) the ossification segment for surgical decision-making. Patients diagnosed with cervical OPLL who received surgical intervention guided by the algorithm were included. Patient demographics, Japanese Orthopedic Association (JOA) scores, surgical time, imaging data before and 2 years after surgery, and the occurrence of complications were extracted from the database. Paired t-test was used for intragroup comparison, and one-way ANOVA test was used for the intergroup analyses.

Results: Based on this novel algorithm, 15 patients with Type I, 8 patients with Type II a, 2 patients with Type II b1, 5 patients with Type II b2 were included. The decision-making for the surgical techniques used in each patient followed the recommendation of the novel algorithm. The postoperative JOA scores of all types of patients improved significantly (p < 0.05), and the invasion rates of vertebral canal had also been significantly reduced (p < 0.05). In terms of restoring cervical curvature, patients with Type I (receiving ACAF) and Type II b2 (receiving laminectomy with instrumented fusion) benefited more from surgery (p < 0.05).

Conclusion: A new algorithm guiding the choice of surgical approach for cervical OPLL was validated in a series of 30 patients. Through this analysis, we obtained on their clinical outcomes and complications. ACAF surgery is an ideal choice for Type I patients, with ossification located between UPs, while for patients with ossification exceeding UPs, it is better to perform anterior cervical corpectomy and fusion or posterior surgery.

Keywords

ACAF / algorithm / classification / K-line / OPLL

References

[1] S. Matsunaga and T. Sakou, “Ossification of the Posterior Longitudinal Ligament of the Cervical Spine: Etiology and Natural History,” Spine (Phila Pa 1976) 37, no. 5 (2012): E309–E314.

[2] T. Fujiyoshi, M. Yamazaki, J. Kawabe, et al., “A New Concept for Making Decisions Regarding the Surgical Approach for Cervical Ossification of the Posterior Longitudinal Ligament,” Spine (Phila Pa 1976) 33, no. 26 (2008): E990–E993.

[3] L. H. Han, K. Q. Sun, C. Yan, J. C. Sun, and J. G. Shi, “The Effect of K-Line Classification in Different Cervical Dynamic Position on Surgical Outcomes in Patients With Ossification of the Posterior Longitudinal Ligament After Anterior Controllable Antedisplacement and Fusion,” Frontiers in Surgery 9 (2022): 987622.

[4] J. Sun, K. Sun, Y. Chen, Y. Wang, X. Xu, and J. Shi, “Anterior Cervical Controllable Antedisplacement and Fusion (ACAF): Improving Outcomes for Severe Cervical Ossification of the Posterior Longitudinal Ligament,” JBJS Essential Surgical Techniques 12, no. 2 (2022): e20.00056.

[5] J. J. Lee, H. C. Kim, H. S. Jeon, et al., “Laminectomy With Instrumented Fusion vs. Laminoplasty in the Surgical Treatment of Cervical Ossification of the Posterior Longitudinal Ligament: A Multicenter Retrospective Study,” Journal of Clinical Neuroscience 94 (2021): 271–280.

[6] Q. J. Kong, X. F. Sun, Y. Wang, et al., “Risk Assessment of Vertebral Artery Injury in Anterior Controllable Antedisplacement and Fusion (ACAF) Surgery: A Cadaveric and Radiologic Study,” European Spine Journal 28, no. 10 (2019): 2417–2424.

[7] N. Tsuyama, “Ossification of the Posterior Longitudinal Ligament of the Spine,” Clinical Orthopaedics and Related Research 184 (1984): 71–84.

[8] L. Tetreault, H. Nakashima, S. Kato, et al., “A Systematic Review of Classification Systems for Cervical Ossification of the Posterior Longitudinal Ligament,” Global Spine Journal 9, no. 1 (2019): 85–103.

[9] M. Koda, M. Mochizuki, H. Konishi, et al., “Comparison of Clinical Outcomes Between Laminoplasty, Posterior Decompression With Instrumented Fusion, and Anterior Decompression With Fusion for K-Line (–) Cervical Ossification of the Posterior Longitudinal Ligament,” European Spine Journal 25, no. 7 (2016): 2294–2301.

[10] J. Saito, S. Maki, K. Kamiya, et al., “Outcome of Posterior Decompression With Instrumented Fusion Surgery for K-Line (–) Cervical Ossification of the Longitudinal Ligament,” Journal of Clinical Neuroscience 32 (2016): 57–60.

[11] M. J. Fields, K. Hoshijima, A. H. Feng, W. J. Richardson, and B. S. Myers, “A Biomechanical, Radiologic, and Clinical Comparison of Outcome After Multilevel Cervical Laminectomy or Laminoplasty in the Rabbit,” Spine (Phila Pa 1976) 25, no. 22 (2000): 2925–2931.

[12] Y. Chen, J. Sun, X. Yuan, et al., “Comparison of Anterior Controllable Antedisplacement and Fusion With Posterior Laminoplasty in the Treatment of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament: A Prospective, Randomized, and Control Study With at Least 1-Year Follow Up,” Spine (Phila Pa 1976) 45, no. 16 (2020): 1091–1101.

[13] Y. Chen, J. Sun, D. Han, et al., “An Open-Label Randomized Multi-Centre Study to Evaluate Anterior Controllable Antedisplacement and Fusion Versus Posterior Laminoplasty in Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Study Design and Analysis Plan (STAR),” BMC Musculoskeletal Disorders 22, no. 1 (2021): 765.

[14] J. Sun, J. Shi, X. Xu, et al., “Anterior Controllable Antidisplacement and Fusion Surgery for the Treatment of Multilevel Severe Ossification of the Posterior Longitudinal Ligament With Myelopathy: Preliminary Clinical Results of a Novel Technique,” European Spine Journal 27, no. 6 (2018): 1469–1478.

[15] J. C. Sun, B. Zhang, J. Shi, et al., “Can K-Line Predict the Clinical Outcome of Anterior Controllable Antedisplacement and Fusion Surgery for Cervical Myelopathy Caused by Multisegmental Ossification of the Posterior Longitudinal Ligament?,” World Neurosurgery 116 (2018): e118–e127.

[16] Q. Pang, S. Ling, B. Zhang, J. Zhu, and J. Sun, “Cervical Anatomical Landmarks Indicate the Amount of Vertebra Resection During ACAF Surgery: A Semi-Quantitative Anatomical Parameter Study on Imaging Data,” Orthopaedic Surgery 14, no. 10 (2022): 2641–2647.

[17] J. Sun, X. Xu, Y. Wang, et al., “How to Avoid Postoperative Remaining Ossification Mass in Anterior Controllable Antedisplacement and Fusion Surgery,” World Neurosurgery: X 3 (2019): 100034.

[18] T. Yongjun, X. Yaming, C. Biao, Y. Yonghong, and Z. Xinhua, “Delayed Hemorrhage Followed by Vertebral Artery Injury During Cervical Anterior Controllable Antedisplacement and Fusion Surgery: Case Report and Literature Review,” Orthopaedic Surgery 14, no. 10 (2022): 2788–2795.

[19] M. Iwasaki, S. Okuda, A. Miyauchi, et al., “Surgical Strategy for Cervical Myelopathy due to Ossification of the Posterior Longitudinal Ligament Part 1: Clinical Results and Limitations of Laminoplasty,” Spine (Phila Pa 1976) 32, no. 6 (2007): 647–653.

[20] M. Iwasaki, S. Okuda, A. Miyauchi, et al., “Surgical Strategy for Cervical Myelopathy due to Ossification of the Posterior Longitudinal Ligament Part 2: Advantages of Anterior Decompression and Fusion Over Laminoplasty,” Spine (Phila Pa 1976) 32, no. 6 (2007): 654–660.

[21] B. W. Ng, J. A. Tan, S. Sabri, A. Baharuddin, and M. H. Muhamad Ariffin, “Surgical Management of Cervical Ossification of Posterior Longitudinal Ligament: The Treatment Algorithm and Outcome,” Cureus 15, no. 3 (2023): e36517.

[22] J. Liu, J. Wang, Z. Ding, et al., “Effect of K-Line on Posterior Cervical Surgery Versus Anterior Cervical Surgery in Patients With Multi-Level Ossification of Posterior Longitudinal Ligament,” European Spine Journal 32, no. 7 (2023): 2396–2401.

[23] N. Nagoshi, T. Yoshii, S. Egawa, et al., “Comparison of Surgical Outcomes of Anterior and Posterior Fusion Surgeries for K-Line (–) Cervical Ossification of the Posterior Longitudinal Ligament: A Prospective Multicenter Study,” Spine (Phila Pa 1976) 48, no. 13 (2023): 937–943.

[24] H. Yu, X. Li, S. Chen, et al., “Comparative Effectiveness and Safety of Anterior Cervical Corpectomy With Fusion, Laminoplasty, and Laminectomy and Instrumented Fusion for Ossification of the Posterior Longitudinal Ligament: A Systematic Review and Network Meta-Analysis,” Journal of Investigative Surgery 35, no. 3 (2022): 667–676.

[25] C. Li, G. Zha, Z. Yang, et al., “K-Line in Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Relationship With Change in Sagittal Cervical Curvature and Laminoplasty Outcomes,” Archives of Orthopaedic and Trauma Surgery 142, no. 8 (2022): 1743–1751.

[26] N. Nishida, M. Mumtaz, S. Tripathi, et al., “Biomechanical Analysis of Laminectomy, Laminoplasty, Posterior Decompression With Instrumented Fusion, and Anterior Decompression With Fusion for the Kyphotic Cervical Spine,” International Journal of Computer Assisted Radiology and Surgery 17, no. 9 (2022): 1531–1541.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.