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1/27. Surgical approach to ossification of the thoracic yellow ligament.

    BACKGROUND: Symptomatic ossification of the yellow ligament (OYL) at the lower thoracic level is uncommon. Although wide laminectomy has, until now, been the primary treatment for this disease, we propose a less invasive technique based on a new method of three-dimensional computed tomography (CT). methods: The clinical features and radiologic imaging findings of 37 patients with OYL (mean age, 54 years) were analyzed. The surgical approach was selected based on the position of the depicted OYL on 3D CT scan in each patient. RESULTS: The male-to-female ratio was 3:1. Involvement of the upper thoracic region was seen 11 times; of the middle region 8 times, and of the lower region 40 times (several patients had involvement in more than one region). About half of the patients complained of gait disturbance on admission caused by the markedly enlarged OYL. No postoperative complications were found. Neurologic deterioration was observed in only one patient. CONCLUSIONS: OYL should be treated as early as possible, using the least invasive technique available. By using 3D CT, we were able to perform limited surgery consisting of foraminotomy or extended partial laminectomy at the affected level after confirming the anatomic location of the OYL. In laterally extended OYL, it is necessary to decompress the radicular artery in order to prevent ischemic damage to the spinal cord.
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2/27. Sternal splitting approach to upper thoracic lesions located anterior to the spinal cord.

    The sternal splitting approach for upper thoracic lesions located anterior to the spinal cord is described. The sternal splitting approach can be effectively applied to lesions from the T-1 to T-3 levels. The aortic arch prevents procedures below this level. The approach is straight toward the T1-3 vertebral bodies and provides good surgical orientation. The sternal splitting approach was applied to five patients with metastatic spinal tumors at the C7-T3 levels and three patients with ossification of the posterior longitudinal ligament at the T1-3 levels. No postoperative neurological deterioration occurred. Two patients had postoperative hoarseness. The sternal splitting approach to the upper thoracic spine is recommended for hard lesions, extensive lesions requiring radical resection, and lesions requiring postoperative stabilization with spinal instrumentation.
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3/27. Symptomatic ossification of the posterior longitudinal ligament of the lumbar spine. Case report.

    The authors report a case of focal ossification of the posterior longitudinal ligament (OPLL) behind the L-3 vertebral body. This is relatively rare among previously reported cases in the literature. Magnetic resonance (MR) imaging revealed that the ossifying portion of the PLL was impinging on the left L-3 nerve root. Contrast enhancing hypertrophic PLL was also demonstrated around the ossification and along the lumbosacral PLL. Via a laminectomy and wide excision of the PLL the lesion was removed. Pathological examination revealed a nodule composed of fibrous cartilage, lamina bone, and mature fat marrow. Enchondral ossification could be identified under a microscope. The authors believe that preoperative MR imaging evaluation is important for the detection of the relationship between an OPLL and the neural structure. Excision of the symptomatic OPLL should be performed when needed to obtain adequate nerve root decompression.
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4/27. Anterior cervical micro-dural repair of cerebrospinal fluid fistula after surgery for ossification of the posterior longitudinal ligament. Technical note.

    BACKGROUND: cerebrospinal fluid (CSF) fistulas may occur during anterior cervical surgery performed for the resection of ossification of the posterior longitudinal ligament (OPLL), as OPLL occasionally erodes to and through the dura. These fistulas have been variously managed with gelfoam, dural substitutes sutured in place, fibrin glue, lumbar drains, and lumboperitoneal shunts. However, more adequate dural repair is now feasible with the 1.4-mm microdural titanium stapler. methods: A 59-year-old female with OPLL and moderate to severe myelopathy (Nurick Grade IV) had a C3-C7 anterior corpectomy with fusion using Orion plates followed by a C3-T1 posterior wiring and fusion with halo application. During the anterior approach, a 5-mm CSF fistula at C4-C5 was directly repaired under the operating microscope using a 1.4-mm microdural stapler, bovine pericardial graft, and fibrin glue. Immediately postoperatively, a lumboperitoneal shunt was also placed. RESULTS: Postoperatively, her myelopathy improved to a mild to moderate level (Nurick Grade II). Her acute left deltoid plegia resolved within 3 months. CONCLUSIONS: The 1.4-mm microdural stapler makes "watertight" closure of anterior cervical CSF fistulas more feasible.
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5/27. Simultaneous cervical diffuse idiopathic skeletal hyperostosis and ossification of the posterior longitudinal ligament resulting in dysphagia or myelopathy in two geriatric North Americans.

    BACKGROUND: Cervical diffuse idiopathic skeletal hyperostosis (DISH) and ossification of the posterior longitudinal ligament (OPLL) rarely coexist in the North American population. Here, different surgical strategies were used to manage simultaneous DISH and OPLL resulting in dysphagia or myelopathy in two geriatric patients. methods: A 74-year-old male with esophageal compression and dysphagia attributed to DISH, and cord compression with myelopathy due to OPLL, was treated with a cervical laminectomy followed by anterior DISH resection. On the other hand, an 80-year-old male with asymptomatic DISH but moderate myelopathy (Nurick Grade III) secondary to OPLL required only a cervical laminectomy. RESULTS: In the first patient, dysphagia resolved within 3 months of surgery, while in the second individual, myelopathy improved to Nurick Grade I (mild myelopathy) within 6 months postoperatively. Improvement in both patients was maintained 1 year after surgery. CONCLUSIONS: While DISH and OPLL may coexist in geriatric patients, only those with dysphagia should undergo DISH resection, while others demonstrating myelopathy should have laminectomy alone.
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6/27. Impact of longitudinal distance of the cervical spine on the results of expansive open-door laminoplasty.

    STUDY DESIGN: A retrospective study in patients who underwent expansive open-door laminoplasty (ELAP) for cervical myelopathy and in whom the cervical alignment was nonlordotic at the final follow-up to analyze the correlation between the longitudinal distance of the cervical spine and surgical results. OBJECTIVES: To determine the impact of longitudinal distance of the cervical spine on surgical results of ELAP and to propose a new concept, the redundant spinal cord, that may influence patient selection for ELAP. SUMMARY OF BACKGROUND DATA: Results in many studies have demonstrated that postoperative cervical alignment has significant effect on surgical results, and spines that are malaligned are thought to deteriorate. The current surgical data showed that not all patients with postoperative malalignment had poor surgical results. patients with cervical spondylotic myelopathy (CSM) tended to have better clinical results than those with ossification of the posterior longitudinal ligament (OPLL). methods: Results in 70 patients who underwent ELAP for cervical myelopathy with postoperative cervical malalignment were investigated. The longitudinal distance index (LDI) was defined as the length of a vertical line between the posteroinferior edges of C2 and C7 divided by the anteroposterior diameter of C4 and was measured on lateral neutral radiographs at final follow-up. Correlation between LDI and surgical results represented by Japanese Orthopedic association scores and percentage of recovery were analyzed statistically in each patient. RESULTS: patients with CSM had smaller LDI and better surgical results than those with OPLL. Weak but significant negative correlation was detected between LDI and percentage of recovery, indicating that longitudinal distance of the cervical spine may have some degree of impact on the surgical results of ELAP. CONCLUSION: A decrease in LDI represents shortening of the cervical spine caused by multiple disc degeneration and may influence surgical results of ELAP by inducing redundancy of the spinal cord in patients with postoperative malalignment.
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ranking = 4
keywords = operative
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7/27. Identification of ossification of the posterior longitudinal ligament extending through the dura on preoperative computed tomographic examinations of the cervical spine.

    STUDY DESIGN: To establish the diagnosis of dural penetration on preoperative computed tomographic studies of the cervical spine in patients with ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: To define before surgery the pathognomonic computed tomographic findings of OPLL extending to and through the dura. SUMMARY OF BACKGROUND DATA: On preoperative computed tomographic studies, Hida et al have described the single-layer sign characterized by a solid mass of hyperdense OPLL and the double-layer sign defined by two (anterior and posterior) ossified rims surrounding a central nonossified but hypertrophied posterior longitudinal ligament. Only 1 of the 9 patients exhibiting the single-layer sign but 10 of 12 patients showing the double-layer sign had no separate dural plane identified at surgery. methods: Only 2 of 54 patients undergoing multilevel cervical circumferential OPLL procedures had absent dura at surgery. Computed tomographic examinations for all patients were retrospectively reviewed to determine unique signs of dural penetration. RESULTS: Dura was absent in 1 of 12 patients who had the single-layer CT sign that was additionally characterized by an irregular C angular configuration. Only 1 of 4 patients exhibiting the double-layer computed tomographic sign had absent dura at surgery. The remaining 38 patients had the smooth-layer sign, characterized by more regular margins of classic (22 patients) or early OPLL (16 patients). CONCLUSIONS: The double-layer computed tomographic sign is more pathognomonic for dural penetration than the single-layer sign. The smooth-layer sign, indicating a clean dural plane, is more typical in North American patients.
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ranking = 6
keywords = operative
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8/27. Bilateral phrenic nerve palsy as a complication of anterior decompression and fusion for cervical ossification of the posterior longitudinal ligament.

    STUDY DESIGN: A case report of bilateral phrenic nerve palsy as a complication of anterior decompression and fusion for cervical ossification of the posterior longitudinal ligament (OPLL). OBJECTIVES: To present a case of a rare and serious complication of cervical spinal surgery and to investigate its cause. SUMMARY OF BACKGROUND DATA: There have been a number of reports of phrenic nerve palsy after cardiac surgery, but the authors have found no previous description of this complication related to spinal surgery. methods: The authors describe the clinical presentation and management of a case of bilateral phrenic nerve palsy subsequent to the surgery for cervical OPLL. Also, the literature is reviewed concerning surgical approaches for the treatment of OPLL and the occurrence of phrenic nerve palsy subsequent to any form of therapy. RESULTS: Bilateral phrenic nerve palsy occurred after anterior decompression and fusion for cervical OPLL. Bilateral phrenic nerve palsy was diagnosed radiographically: postoperative chest radiograph showed bilateral laxity of the diaphragm. movement of the bilateral diaphragm appeared 3 weeks after surgery. The patient successfully returned to normal daily life after ventilatory support for 3 months, although nocturnal oxygen support was still necessary at the latest follow-up, 3 years after surgery. The possible causes of this complication include bilateral C4 nerve root stretching, iatrogenic injury of the gray matter in the ventral horn, alteration of blood circulation related to spinal edema, or re-impingement on the spinal cord at the cranial part of the decompression site. CONCLUSIONS: Bilateral phrenic nerve palsy occurred after anterior decompression and fusion for cervical OPLL. Bilateral phrenic nerve palsy should be kept in mind as a serious complication of spinal surgery. It should be considered when patients unexpectedly fail to wean from the ventilator after surgery.
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ranking = 1
keywords = operative
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9/27. Myelopathy caused by ossification of ligamentum flavum.

    STUDY DESIGN: Retrospective study of seven cases of ossification of ligamentum flavum from two urban hospitals in a Chinese population. OBJECTIVES: To inspect the epidemiology, clinical presentation, pathology, and treatment outcome in these Chinese patients with ossification of ligamentum flavum. SUMMARY OF BACKGROUND DATA: Ossification of ligamentum flavum involving the lower thoracic region is relatively common in the Japanese population. It is usually presented with myelopathy of progressive nature. MATERIALS AND methods: Five patients were male and two were female. The mean age was 52 years (range 41-73 years). diagnosis was made by CT scan, MRI, and subsequent histology. Six patients have been treated by laminectomy and one by laminoplasty. The average follow-up duration is 34 months (range 26-44 months). The outcome is evaluated by Japanese Orthopaedics association (JOA) score. RESULTS: The average time of presentation from the onset of symptoms was 9 months (range 3-12 months). Most of the patients presented with lower limb numbness and gait disturbance. One case was presented after a minor trauma. Mean JOA score was 4.8 (range 2-7, of 11). The lower thoracic level was the most frequently involved region. One case was associated with ossification of the posterior longitudinal ligament. Two patients had transient postoperative neurologic deterioration, which improved subsequently. Mean percentage of recovery after surgery in terms of JOA score is 65% (25-100%), with a mean final JOA score of 7.8. CONCLUSION: Ossification of ligamentum flavum is an uncommon cause of myelopathy in the Chinese population. It can present acutely after minor trauma. Posterior decompression, especially with en bloc dissection of laminae, gives satisfactory results.
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ranking = 1
keywords = operative
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10/27. Management of cerebrospinal fluid leakage complicating anterior procedures through thoracotomy: report of three cases.

    Postoperative cerebrospinal fluid (CSF) leakage is a serious complication accompanying an anterior procedure through thoracotomy, and it is difficult to cure. In this report, we present three patients with CSF leakage in the thoracic spine complicating anterior decompression and fusion for ossification of posterior longitudinal ligament who were treated by surgical or nonsurgical methods. As a surgical method, direct closure by fixing substitute dura mater with fibrin adhesive sealant or cyanoacrylate adhesive was performed in two patients. This technique was effective but required another thoracotomy. As a nonsurgical method, intrapleural administration of OK-432 through chest drainage tubes was also effective to reduce intrapleural effusions in one patient, but with this method, care must be taken for neurotoxic reactions. Both techniques seem to be useful and effective for postoperative intrapleural CSF leakages complicating anterior procedures through thoracotomy.
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ranking = 2
keywords = operative
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