Understanding a New Surgical Strategy for Cervical Spine Conditions
Cervical myelopathy caused by Ossification of the Posterior Longitudinal Ligament (OPLL) represents a challenging clinical scenario for spine surgeons across the globe. Patients with severely localized OPLL experience significant spinal cord and nerve root compression, requiring decompression to regain function and alleviate symptoms. A team led by Hironori Arima and his colleagues from Osaka City University Graduate School of Medicine recently published a breakthrough study exploring the efficacy of combined anterior and posterior segmental decompression and fusion in patients with severely localized OPLL (DOI: 10.2176/nmc.tn.2018-0324).
Study Background and Techniques
The study, published in “Neurologia Medico-Chirurgica”, includes an in-depth technical note on an extended anterior cervical discectomy and fusion (ACDF) approach that incorporates a trans-unco-discal method and partial oblique corpectomy. This technique enables significant neural decompression at the most prominent level of OPLL. Following the anterior phase, a posterior cervical segmental decompression and fusion (PCDF) is performed to secure decompression of critical neural elements and spinal stability.
The innovative approach targets the reduction of the axial occupying ratio of the OPLL, avoiding any breach of an imaginary line connecting the midpoint between C2 and C7 on sagittal images – a critical factor considering the complexity of treating OPLL. Highlighted in the study are five patients who showcased an OPLL occupying ratio exceeding 60%, representing a severe condition that often necessitates a nuanced surgical intervention.
Results and Outcomes
Each of the five patients described in the study underwent the anterior and posterior procedures, with one patient managing a one-stage surgery while the other four underwent two-stage surgeries. Impressively, none of the patients required spinal cerebrospinal fluid drainage or experienced CSF leakage post-surgery. Functionally, every individual demonstrated either acceptable or satisfactory recovery without encountering instrumentation-related complications.
More importantly, the postoperative radiological analysis indicated improvements in various spinal parameters, including local angle, C2-7 angle, and cervical tilt angle, in nearly all patients. The exception was one patient with concomitant ankylosing spinal hyperostosis, highlighting the technique’s overall effectiveness and the complexities of managing combined spinal diseases.
Comparison with Previous Studies
In the complex landscape of cervical myelopathy treatment, anterior, posterior, and combined approaches have been scrutinized extensively to determine the most effective surgical strategies. This study reveals the potential advantages of anterior decompression and fusion, as discussed in previous works by Iwasaki et al. (Spine, 2007), and the need to move beyond laminoplasty, as proposed by Matsumoto et al. (Spine, 2012). The combined approach aligns with the suggestions of Seichi et al. (Spine, 2011), who noted potential neurological complications with cervical laminoplasty in patients with OPLL.
Implications for Future Surgical Procedures
The detailed surgical maneuvers described in this study, including the trans-unco-discal approach first discussed by Hakuba (J Neurosurg, 1976), elucidate an advanced operative technique that aligns well with contemporary practices and the critical importance of thorough preoperative planning. As spinal surgeries evolve, it is becoming increasingly vital for surgeons to have an armamentarium that includes both anterior and posterior approaches to tailor their techniques to specific patient conditions.
Future Directions and Conclusions
While this study adds a crucial chapter to the growing literature on OPLL treatment, further research is warranted to validate these findings and to optimize the surgical management strategies. To continually improve patient outcomes, spine surgeons must maintain a willingness to adopt new techniques and to refine them based on clinical experience and emerging evidence.
References
1. Arima, H., Naito, K., Yamagata, T., Kawahara, S., Ohata, K., & Takami, T. (2019). Anterior and Posterior Segmental Decompression and Fusion for Severely Localized Ossification of the Posterior Longitudinal Ligament of the Cervical Spine: Technical Note. Neurol Med Chir (Tokyo), 59(6), 238-245. doi: 10.2176/nmc.tn.2018-0324
2. Hirabayashi, K., et al.
Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976) 6: 354–364, 1981.
3. Iwasaki, M., 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: 647–653, 2007.
4. Matsumoto, M., Chiba, K., Toyama, Y.
Surgical treatment of ossification of the posterior longitudinal ligament and its outcomes: posterior surgery by laminoplasty. Spine (Phila Pa 1976) 37: E303–E308, 2012.
5. Seichi, A., Hoshino, Y., Kimura, A., et al.
Neurological complications of cervical laminoplasty for patients with ossification of the posterior longitudinal ligament-a multi-institutional retrospective study. Spine (Phila Pa 1976) 36: E998–E1003, 2011.
Keywords
1. Ossification of the Posterior Longitudinal Ligament
2. Anterior Cervical Discectomy Fusion (ACDF)
3. Cervical Myelopathy Surgery
4. Spinal Cord Compression Treatment
5. Posterior Cervical Segmental Decompression Fusion