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Ossification of the posterior longitudinal ligament in the cervical spine: a review

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Abstract

Ossification of the posterior longitudinal ligament (OPLL) is a rare pathologic process of lamellar bone deposition that can result in spinal cord compression. While multiple genetic and environmental factors have been related to the development of OPLL, the pathophysiology remains poorly understood. Asymptomatic patients may be managed conservatively and patients with radiculopathy or myelopathy should be considered for surgical decompression. Multiple studies have demonstrated the morphology and size of the OPLL as well as the cervical alignment have significant implications for the appropriate surgical approach and technique. In this review, we aim to address all the available literature on the etiology, history, presentation, and management of OPLL in an effort to better understand OPLL and give our recommendations for the treatment of patients presenting with OPLL.

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References

  1. Ehara S, Shimamura T, Nakamura R, Yamazaki K (1998) Paravertebral ligamentous ossification: DISH, OPLL and OLF. Eur J Radiol 27:196–205

    Article  CAS  PubMed  Google Scholar 

  2. Matsunaga S, Sakou T (2012) Ossification of the posterior longitudinal ligament of the cervical spine: etiology and natural history. Spine 37:E309–E314. https://doi.org/10.1097/BRS.0b013e318241ad33

    Article  Google Scholar 

  3. Ohtsuka K, Terayama K, Yanagihara M, Wada K, Kasuga K, Machida T, Furukawa K (1986) An epidemiological survey on ossification of ligaments in the cervical and thoracic spine in individuals over 50 years of age. Nihon Seikeigeka Gakkai Zasshi 60:1087–1098

    CAS  PubMed  Google Scholar 

  4. McAfee PC, Regan JJ, Bohlman HH (1987) Cervical cord compression from ossification of the posterior longitudinal ligament in non-orientals. J Bone Joint Surgery British Volume 69:569–575

    Article  CAS  Google Scholar 

  5. Epstein NE (1994) The surgical management of ossification of the posterior longitudinal ligament in 43 north Americans. Spine 19:664–672

    Article  CAS  PubMed  Google Scholar 

  6. Belanger TA, Roh JS, Hanks SE, Kang JD, Emery SE, Bohlman HH (2005) Ossification of the posterior longitudinal ligament. Results of anterior cervical decompression and arthrodesis in sixty-one North American patients. J Bone Joint Surgery Am Volume 87:610–615. https://doi.org/10.2106/jbjs.c.01711

    Article  Google Scholar 

  7. Maeda S, Koga H, Matsunaga S, Numasawa T, Ikari K, Furushima K, Harata S, Takeda J, Sakou T, Komiya S, Inoue I (2001) Gender-specific haplotype association of collagen alpha2 (XI) gene in ossification of the posterior longitudinal ligament of the spine. J Hum Genet 46:1–4. https://doi.org/10.1007/s100380170117

    Article  CAS  PubMed  Google Scholar 

  8. Ren Y, Liu ZZ, Feng J, Wan H, Li JH, Wang H, Lin X (2012) Association of a BMP9 haplotype with ossification of the posterior longitudinal ligament (OPLL) in a Chinese population. PLoS One 7:e40587. https://doi.org/10.1371/journal.pone.0040587

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Song J, Mizuno J, Hashizume Y, Nakagawa H (2006) Immunohistochemistry of symptomatic hypertrophy of the posterior longitudinal ligament with special reference to ligamentous ossification. Spinal Cord 44:576–581. https://doi.org/10.1038/sj.sc.3101881

    Article  CAS  PubMed  Google Scholar 

  10. Tanaka T, Ikari K, Furushima K, Okada A, Tanaka H, Furukawa K, Yoshida K, Ikeda T, Ikegawa S, Hunt SC, Takeda J, Toh S, Harata S, Nakajima T, Inoue I (2003) Genomewide linkage and linkage disequilibrium analyses identify COL6A1, on chromosome 21, as the locus for ossification of the posterior longitudinal ligament of the spine. Am J Hum Genet 73:812–822

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Ikegawa S (2014) Genetics of ossification of the posterior longitudinal ligament of the spine: a mini review. J Bone Metab 21:127–132. https://doi.org/10.11005/jbm.2014.21.2.127

    Article  PubMed  PubMed Central  Google Scholar 

  12. Kalb S, Martirosyan NL, Perez-Orribo L, Kalani MY, Theodore N (2011) Analysis of demographics, risk factors, clinical presentation, and surgical treatment modalities for the ossified posterior longitudinal ligament. Neurosurg Focus 30:E11. https://doi.org/10.3171/2010.12.FOCUS10265

    Article  PubMed  Google Scholar 

  13. Li H, Jiang LS, Dai LY (2007) Hormones and growth factors in the pathogenesis of spinal ligament ossification. Eur Spine J 16:1075–1084. https://doi.org/10.1007/s00586-007-0356-4

    Article  PubMed  PubMed Central  Google Scholar 

  14. Saetia K, Cho D, Lee S, Kim DH, Kim SD (2011) Ossification of the posterior longitudinal ligament: a review. Neurosurgical focus, 30:E1. DOI https://doi.org/10.3171/2010.11.focus10276. https://doi.org/10.3171/2011.2.FOC-SpinePeriphSectionabstracts

  15. Terayama K (1989) Genetic studies on ossification of the posterior longitudinal ligament of the spine. Spine (Phila Pa 1976) 14:1184–1191

    Article  CAS  Google Scholar 

  16. Matsunaga S, Yamaguchi M, Hayashi K, Sakou T (1999) Genetic analysis of ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976) 24:937–938 discussion 939

    Article  CAS  Google Scholar 

  17. Abiola R, Rubery P, Mesfin A (2016) Ossification of the posterior longitudinal ligament: etiology, diagnosis, and outcomes of nonoperative and operative management. Global Spine J 6:195–204. https://doi.org/10.1055/s-0035-1556580

    Article  PubMed  Google Scholar 

  18. Okazaki T, Takuwa Y, Yamamoto M, Matsumoto T, Igarashi T, Kurokawa T, Ogata E (1984) Ossification of the paravertebral ligaments: a frequent complication of hypoparathyroidism. Metabolism 33:710–713

    Article  CAS  PubMed  Google Scholar 

  19. Chang H, Song KJ, Kim HY, Choi BW (2012) Factors related to the development of myelopathy in patients with cervical ossification of the posterior longitudinal ligament. J Bone Joint Surgery British Volume 94:946–949. https://doi.org/10.1302/0301-620x.94b7.29018

    Article  CAS  Google Scholar 

  20. Matsunaga S, Komiya S, Toyama Y (2015) Risk factors for development of myelopathy in patients with cervical spondylotic cord compression. European Spine J: Official Publication European Spine Soc, European Spinal Deformity Soc, European Section Cervical Spine Res Soc 24(Suppl 2):142–149. https://doi.org/10.1007/s00586-013-2839-9

    Article  Google Scholar 

  21. 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 96:168–172

    PubMed  Google Scholar 

  22. Matsunaga S, Nakamura K, Seichi A, Yokoyama T, Toh S, Ichimura S, Satomi K, Endo K, Yamamoto K, Kato Y, Ito T, Tokuhashi Y, Uchida K, Baba H, Kawahara N, Tomita K, Matsuyama Y, Ishiguro N, Iwasaki M, Yoshikawa H, Yonenobu K, Kawakami M, Yoshida M, Inoue S, Tani T, Kaneko K, Taguchi T, Imakiire T, Komiya S (2008) Radiographic predictors for the development of myelopathy in patients with ossification of the posterior longitudinal ligament: a multicenter cohort study. Spine 33:2648–2650. https://doi.org/10.1097/BRS.0b013e31817f988c

    Article  PubMed  Google Scholar 

  23. Tsuyama N (1984) Ossification of the posterior longitudinal ligament of the spine. Clinical orthopaedics and related research:71–84

  24. Fujiyoshi T, Yamazaki M, Kawabe J, Endo T, Furuya T, Koda M, Okawa A, Takahashi K, Konishi H (2008) A new concept for making decisions regarding the surgical approach for cervical ossification of the posterior longitudinal ligament: the K-line. Spine 33:E990–E993. https://doi.org/10.1097/BRS.0b013e318188b300

    Article  PubMed  Google Scholar 

  25. Chang H, Kong CG, Won HY, Kim JH, Park JB (2010) Inter- and intra-observer variability of a cervical OPLL classification using reconstructed CT images. Clinics Orthopedic Surgery 2:8–12. https://doi.org/10.4055/cios.2010.2.1.8

    Article  Google Scholar 

  26. An HS, Al-Shihabi L, Kurd M (2014) Surgical treatment for ossification of the posterior longitudinal ligament in the cervical spine. J Am Academy Orthopaedic Surgeons 22:420–429. https://doi.org/10.5435/jaaos-22-07-420

    Article  Google Scholar 

  27. Mizuno J, Nakagawa H, Matsuo N, Song J (2005) Dural ossification associated with cervical ossification of the posterior longitudinal ligament: frequency of dural ossification and comparison of neuroimaging modalities in ability to identify the disease. J Neurosurgery Spine 2:425–430. https://doi.org/10.3171/spi.2005.2.4.0425

    Article  Google Scholar 

  28. Min JH, Jang JS, Lee SH (2007) Significance of the double- and single-layer signs in the ossification of the posterior longitudinal ligament of the thoracic spine. Neurosurgery 61:118–121; discussion 121–112. https://doi.org/10.1227/01.neu.0000279731.21145.45

    Article  PubMed  Google Scholar 

  29. Koyanagi I, Iwasaki Y, Hida K, Imamura H, Abe H (1998) Magnetic resonance imaging findings in ossification of the posterior longitudinal ligament of the cervical spine. J Neurosurg 88:247–254. https://doi.org/10.3171/jns.1998.88.2.0247

    Article  CAS  PubMed  Google Scholar 

  30. Yagi M, Ninomiya K, Kihara M, Horiuchi Y (2010) Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on magnetic resonance imaging. J Neurosurgery Spine 12:59–65. https://doi.org/10.3171/2009.5.spine08940

    Article  Google Scholar 

  31. Matsuyama Y, Kawakami N, Yanase M, Yoshihara H, Ishiguro N, Kameyama T, Hashizume Y (2004) Cervical myelopathy due to OPLL: clinical evaluation by MRI and intraoperative spinal sonography. J Spinal Disord Tech 17:401–404

    Article  PubMed  Google Scholar 

  32. Pham MH, Attenello FJ, Lucas J, He S, Stapleton CJ, Hsieh PC (2011) Conservative management of ossification of the posterior longitudinal ligament. A review. Neurosurg Focus 30:E2. https://doi.org/10.3171/2011.1.focus10273

    Article  PubMed  Google Scholar 

  33. Yonenobu K (2012) Is surgery indicated for asymptomatic or mildly myelopathic patients with significant ossification of the posterior longitudinal ligament? Spine 37:E315–E317. https://doi.org/10.1097/BRS.0b013e318239ccbd

    Article  PubMed  Google Scholar 

  34. Wu JC, Chen YC, Liu L, Huang WC, Chen TJ, Lo SS, Thien PF, Cheng H (2012) Conservatively treated ossification of the posterior longitudinal ligament increases the risk of spinal cord injury: a nationwide cohort study. J Neurotrauma 29:462–468. https://doi.org/10.1089/neu.2011.2095

    Article  PubMed  Google Scholar 

  35. Chen LF, Tu TH, Chen YC, Wu JC, Chang PY, Liu L, Huang WC, Lo SS, Cheng H (2016) Risk of spinal cord injury in patients with cervical spondylotic myelopathy and ossification of posterior longitudinal ligament: a national cohort study. Neurosurg Focus 40:E4. https://doi.org/10.3171/2016.3.focus1663

    Article  PubMed  Google Scholar 

  36. Kato Y, Iwasaki M, Fuji T, Yonenobu K, Ochi T (1998) Long-term follow-up results of laminectomy for cervical myelopathy caused by ossification of the posterior longitudinal ligament. J Neurosurg 89:217–223. https://doi.org/10.3171/jns.1998.89.2.0217

    Article  CAS  PubMed  Google Scholar 

  37. Li H, Dai LY (2011) A systematic review of complications in cervical spine surgery for ossification of the posterior longitudinal ligament. Spine J: Official J North Am Spine Soc 11:1049–1057. https://doi.org/10.1016/j.spinee.2011.09.008

    Article  Google Scholar 

  38. Mizuno J, Nakagawa H (2001) Outcome analysis of anterior decompressive surgery and fusion for cervical ossification of the posterior longitudinal ligament: report of 107 cases and review of the literature. Neurosurg Focus 10:E6

    Article  CAS  PubMed  Google Scholar 

  39. Sakai K, Okawa A, Takahashi M, Arai Y, Kawabata S, Enomoto M, Kato T, Hirai T, Shinomiya K (2012) Five-year follow-up evaluation of surgical treatment for cervical myelopathy caused by ossification of the posterior longitudinal ligament: a prospective comparative study of anterior decompression and fusion with floating method versus laminoplasty. Spine 37:367–376. https://doi.org/10.1097/BRS.0b013e31821f4a51

    Article  PubMed  Google Scholar 

  40. Fujimori T, Iwasaki M, Okuda S, Takenaka S, Kashii M, Kaito T, Yoshikawa H (2014) Long-term results of cervical myelopathy due to ossification of the posterior longitudinal ligament with an occupying ratio of 60% or more. Spine 39:58–67. https://doi.org/10.1097/brs.0000000000000054

    Article  PubMed  Google Scholar 

  41. Iwasaki M, Okuda S, Miyauchi A, Sakaura H, Mukai Y, Yonenobu K, Yoshikawa H (2007) Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: part 2: advantages of anterior decompression and fusion over laminoplasty. Spine 32:654–660. https://doi.org/10.1097/01.brs.0000257566.91177.cb

    Article  Google Scholar 

  42. Yamaura I, Kurosa Y, Matuoka T, Shindo S (1999) Anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament. Clinical Orthopaedics and Related Research:27–34

  43. Matsuoka T, Yamaura I, Kurosa Y, Nakai O, Shindo S, Shinomiya K (2001) Long-term results of the anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament. Spine 26:241–248

    Article  CAS  PubMed  Google Scholar 

  44. Son S, Lee SG, Yoo CJ, Park CW, Kim WK (2010) Single stage circumferential cervical surgery (selective anterior cervical corpectomy with fusion and laminoplasty) for multilevel ossification of the posterior longitudinal ligament with spinal cord ischemia on MRI. J Korean Neurosurgical Soc 48:335–341. https://doi.org/10.3340/jkns.2010.48.4.335

    Article  Google Scholar 

  45. Manzano GR, Casella G, Wang MY, Vanni S, Levi AD (2012) A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery 70:264–277. https://doi.org/10.1227/NEU.0b013e3182305669

    Article  PubMed  Google Scholar 

  46. Cho WS, Chung CK, Jahng TA, Kim HJ (2008) Post-laminectomy kyphosis in patients with cervical ossification of the posterior longitudinal ligament: does it cause neurological deterioration? J Korean Neurosurgical Soc 43:259–264. https://doi.org/10.3340/jkns.2008.43.6.259

    Article  Google Scholar 

  47. Chiba K, Yamamoto I, Hirabayashi H, Iwasaki M, Goto H, Yonenobu K, Toyama Y (2005) Multicenter study investigating the postoperative progression of ossification of the posterior longitudinal ligament in the cervical spine: a new computer-assisted measurement. J Neurosurgery Spine 3:17–23. https://doi.org/10.3171/spi.2005.3.1.0017

    Article  Google Scholar 

  48. Chen Y, Guo Y, Chen D, Wang X, Lu X, Yuan W (2009) Long-term outcome of laminectomy and instrumented fusion for cervical ossification of the posterior longitudinal ligament. Int Orthop 33:1075–1080. https://doi.org/10.1007/s00264-008-0609-9

    Article  PubMed  Google Scholar 

  49. Matsumoto M, Chiba K, Toyama Y (2012) Surgical treatment of ossification of the posterior longitudinal ligament and its outcomes: posterior surgery by laminoplasty. Spine 37:E303–E308. https://doi.org/10.1097/BRS.0b013e318239cca0

    Article  PubMed  Google Scholar 

  50. Kim B, Yoon DH, Ha Y, Yi S, Shin DA, Lee CK, Lee N, Kim KN (2016) Relationship between T1 slope and loss of lordosis after laminoplasty in patients with cervical ossification of the posterior longitudinal ligament. Spine J: Official J North Am Spine Soc 16:219–225. https://doi.org/10.1016/j.spinee.2015.10.042

    Article  Google Scholar 

  51. Kim TH, Lee SY, Kim YC, Park MS, Kim SW (2013) T1 slope as a predictor of kyphotic alignment change after laminoplasty in patients with cervical myelopathy. Spine 38:E992–E997. https://doi.org/10.1097/BRS.0b013e3182972e1b

    Article  PubMed  Google Scholar 

  52. Lee CK, Shin DA, Yi S, Kim KN, Shin HC, Yoon DH, Ha Y (2016) Correlation between cervical spine sagittal alignment and clinical outcome after cervical laminoplasty for ossification of the posterior longitudinal ligament. J Neurosurgery Spine 24:100–107. https://doi.org/10.3171/2015.4.spine141004

    Article  Google Scholar 

  53. Maruo K, Moriyama T, Tachibana T, Inoue S, Arizumi F, Daimon T, Yoshiya S (2014) The impact of dynamic factors on surgical outcomes after double-door laminoplasty for ossification of the posterior longitudinal ligament of the cervical spine. J Neurosurgery Spine 21:938–943. https://doi.org/10.3171/2014.8.spine131197

    Article  Google Scholar 

  54. Liu X, Chen Y, Yang H, Li T, Xu B, Chen D (2017) Expansive open-door laminoplasty versus laminectomy and instrumented fusion for cases with cervical ossification of the posterior longitudinal ligament and straight lordosis. European Spine J: Official Publication European Spine Soc European Spinal Deformity Soc, European Section Cervical Spine Res Soc 26:1173–1180. https://doi.org/10.1007/s00586-016-4912-7

    Article  Google Scholar 

  55. Iwasaki M, Kawaguchi Y, Kimura T, Yonenobu K (2002) Long-term results of expansive laminoplasty for ossification of the posterior longitudinal ligament of the cervical spine: more than 10 years follow up. J Neurosurg 96:180–189

    PubMed  Google Scholar 

  56. Hori T, Kawaguchi Y, Kimura T (2006) How does the ossification area of the posterior longitudinal ligament progress after cervical laminoplasty? Spine 31:2807–2812. https://doi.org/10.1097/01.brs.0000245870.97231.65

    Article  PubMed  Google Scholar 

  57. Hori T, Kawaguchi Y, Kimura T (2007) How does the ossification area of the posterior longitudinal ligament thicken following cervical laminoplasty? Spine 32:E551–E556. https://doi.org/10.1097/BRS.0b013e31814614f3

    Article  PubMed  Google Scholar 

  58. Takeuchi K, Yokoyama T, Numasawa T, Yamasaki Y, Kudo H, Itabashi T, Chin S, Wada KI (2016) K-line (−) in the neck-flexed position in patients with ossification of the posterior longitudinal ligament is a risk factor for poor clinical outcome after cervical laminoplasty. Spine 41:1891–1895. https://doi.org/10.1097/brs.0000000000001660

    Article  PubMed  Google Scholar 

  59. Lee GW, Cho CW, Shin JH, Ahn MW (2017) Which technique is better option for C3 segment in multilevel open-door laminoplasty of the cervical spine?: laminectomy versus Laminoplasty. Spine 42:E833–e840. https://doi.org/10.1097/brs.0000000000001974

    Article  PubMed  Google Scholar 

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Correspondence to Mayan Lendner.

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Boody, B.S., Lendner, M. & Vaccaro, A.R. Ossification of the posterior longitudinal ligament in the cervical spine: a review. International Orthopaedics (SICOT) 43, 797–805 (2019). https://doi.org/10.1007/s00264-018-4106-5

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