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Multilevel cervical stenosis from ossified posterior longitudinal ligaments
Introduction
Ossification of the posterior longitudinal ligament (OPLL) is one of many conditions classified as enthesopathies, which result from progressive inflammation of the tendons and ligaments of the spine followed by degeneration and calcification. Other examples of enthesopathies include ossification of the anterior longitudinal ligament, ossification of the ligamentum flavum, diffuse idiopathic skeletal hypertrophy, and ankylosing spondylitis. Since it was first recognized in 1838, there have been many identified genetic factors predisposing to OPLL. Some of these include association with human leukocyte antigen (HLA) haplotype and collagen 6A1 gene ( COLA1 ). Epidemiological studies suggest OPLL tends to be a frequent cause of cervical myelopathy in the Japanese population and is therefore thought be common in those of Asian descent. However, the frequency of OPLL in those of non-Asian descent may be more common than previously believed. OPLL can be divided into four categories depending on the continuity of the ossification. The subtypes include continuous, segmental, mixed, and localized. The OPLL leads to compression of the spinal cord resulting in cervical myelopathy. The progression of symptoms, severity of symptoms, and recovery can be somewhat variable. In addition to known factors such a kyphosis, cord signal change, length of symptoms, and number of level of compression, there is increasing evidence that genetic factors may play a role in cervical myelopathy.
Example case
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Chief complaint: gait instability
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History of present illness: A 67-year-old male with a history of numbness in his lower extremity and a gait instability for approximately 5 years has similar symptoms that worsened over the past 6 months. He has also had difficulty with dexterity in his hands. He also notes urinary urgency but denies incontinence. He also has an increasing frequency of falls ( Figs. 7.1 and 7.2 ).
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Medications: amlodipine, bethanechol, bupropion, carvedilol, fluoxetine, glimepiride, hydrocholorthiazide, synthroid, losartan, metformin, omeprazole, simvastatin
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Allergies: vancomycin
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Past medical and surgical history: chronic kidney disease, hypertension, diabetes, obesity, liver cirrhosis, obstructive sleep apnea, hypothyroidism
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Family history: noncontributory
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Social history: no smoking history, occasional alcohol
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Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
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Reflexes: 2+ in bilateral biceps/triceps/brachioradialis; 3+ in bilateral patella/ankle with no clonus or Babinski; negative Hoffman; sensation intact to light touch
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| Preoperative | ||||
| Additional tests requested |
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None |
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| Surgical approach selected | C2–5 open-door laminoplasty | Posterior C1–5 decompression and instrumented fusion with possible extension to occiput | C1-T2 posterior instrumentation, C1–7 laminectomy | C1–5 laminectomy and C2–5 fusion |
| Goal of surgery | Decompression of spinal cord | Decompression of areas affected by OPLL, preservation of neurological function | Decompression of spinal cord | Decompression of spinal cord, rapid procedure |
| Perioperative | ||||
| Positioning | Prone with Mayfield pins | Prone on four-post frame with Mayfield pins | Prone on Jackson table, with Mayfield pins | Prone on horseshoe headrest |
| Surgical equipment |
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| Medications | Steroids, maintain MAP | None | None | None |
| Anatomical considerations | Spinal cord, nerve roots, dura | Vertebral arteries, thecal sac, C2 nerve root | Spinal cord, vertebral arteries | Vertebral arteries |
| Complications feared with approach chosen | Facet joint fusion, motor deficit, CSF leak | CSF leak | Spinal cord injury | C5 palsy, CSF leak, vertebral artery injury, violation of C1–2 joints |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | C2–5 | Occiput-C5 | C1-T2 | Occiput-C5 |
| Levels decompressed | C2–5 | C1-C5 | C1–7 | C1–5 |
| Levels fused | C2–5 | Occiput-C5 | C1-T2 | C2–5 |
| Surgical narrative | Positioned prone with Mayfield pins with slight flexion, vertical midline posterior incision from C2–5, central splitting of nuchal ligament to spinous process, subperiosteal dissection with preservation of semispinalis attachments to C2 spinous process, shorten spinous process to use as autograft spacers, gutter created on right side because narrowest along lamina-facet interface from C2–5, open lamina bilaterally with diamond bit drill and Kerrison rongeurs, open lamina-facet interface down to ligamentum flavum with preservation of interspinous ligament, a hinge is created on the left side in the same way, ligamentum flavum at upper and lower ends transversely cut, lamina elevated on right side (open-door), autografts can be used to increase anterior-posterior diameter, autografts are placed between lamina and facets to keep hinge open, place laminoplasty plate and screws, nonabsorbable sutures are used to fix cranial and caudal interspinal ligaments and along left side, reconnect semispinalis to C2 spinous process with nonabsorbable suture, layered closure with drain | Fiberoptic intubation, position prone with no hyperextension, positioned confirmed by fluoroscopy, midline posterior incision, place C1 lateral mass screws/C2 pars vs. translaminar vs. pedicle based on preoperative imaging, place C3–5 lateral mass screws, decompress from C1–5, contour rods to reduce motion around open canal, place rods and set screws, place vancomycin powder in cavity, closure in layers with deep drain, focus on fascial layer closure | Position prone, lateral x-ray to plan incision, midline posterior incision, expose from C1-C6, navigation array on T1 spinous process, obtain intraoperative CT and register with navigation system, plan entry points for C3-T1 using navigation, decorticate entry points/drill screw tracks/and place lateral mass screws from C3-C7 and T1 pedicle screws bilaterally, ligate C2 nerve roots proximal to ganglion and section, attach navigation array to skull clamp, obtain intraoperative CT and register while checking C3-T1 screws, place C1 lateral mass and C2 pars screws under navigation, C1-T1 laminectomy and care to minimize traction according to the spinal cord, MEP after laminectomy, obtain another intraoperative CT to confirm C1–2 screw placement, placement of rods connecting screws, cap and final tighten once hardware confirmed in good location, place local bone autograft from laminectomies along decorticated surfaces lateral to screw heads, layered closure with subfascial drains | Awake fiberoptic intubation with avoiding neck manipulation, baseline IOM preflip, log-roll with collar on horseshoe head rest, keep neutral position, postflip IOM, midline incision, subperiosteal dissection exposing occiput down to C5, O-arm spine, place C2 pars screws and C3–5 lateral mass screws, C1–5 laminectomy with bone scalpel and high-speed drill, look for posterior displacement of thecal sac and normal pulsations, O-arm to evaluate position of screws, place rods, layered closure |
| Complication avoidance | Preserve semispinalis attachments to C1 spinous process to minimize postoperative kyphosis, spinous processes used as autograft spacers, open-door laminoplasty, reattach semispinalis to C2 spinous process | Confirm position with fluoroscopy, C2 screw type based on preoperative imaging, limit motions around open canal | Surgical navigation, expose C1 lateral mass by ligating and sectioning C2 nerve roots, repeated intraoperative CT to confirm hardware location, minimize traction on spinal cord | Pre- and postflip IOM, O-arm and surgical navigation, look for posterior displacement of thecal sac and normal pulsations to evaluate adequacy of decompression |
| Postoperative | ||||
| Admission | Floor | Floor | Floor | ICU |
| Postoperative complications feared | Hematoma, CSF leak, nerve palsy, neck pain, kyphotic deformity, displacement of lamina, restricted neck motion from facet joint fusion | Hematoma, CSF leak, neurological deterioration, instrument malposition, vertebral artery injury | C5 palsy | C5 palsy, CSF leak, vertebral artery injury, violation of C1–2 joints |
| Anticipated length of stay | 3 days | 3–4 days | 3 days | 3–5 days |
| Follow-up testing | CT C-spine within 24 hours and 3 months after surgery | Standing x-rays within 48 hours of surgery, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery | AP and lateral C-spine x-rays prior to discharge, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery | C-spine x-ray within 24 hours, and 3 months after surgery |
| Bracing | Rigid neck collar for 4–6 weeks | Aspen or Miami J for comfort for maximum of 6 weeks | Miami J for 6 weeks | Philadelphia collar for 6 weeks |
| Follow-up visits | 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgery | 2–3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery | 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery | 10 days and 3 months after surgery |
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; CTA , computed tomography angiography; DEXA , dual-energy x-ray absorptiometry; EMG , electromyogram; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potential; MRI , magnetic resonance imaging; OPLL , ossified posterior longitudinal ligament; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potential.
Differential diagnosis
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OPLL
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Diffuse idiopathic skeletal hyperostosis
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Ankylosing spondylitis
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