summary Ossification of the posterior longitudinal ligament (OPLL) is an idiopathic cervical spine anomaly that is a common cause of cervical myelopathy in the Asian population Diagnosis is made with lateral radiographs of the cervical spine. CT scan is the study of choice to determine the extent and thickness of the ossification Treatment is observation in patients with minimal symptoms. Surgical decompression followed by stabilization is indicated for patients with myelopathy Epidemiology Demographics Asian (most common, but not limited to) men are more commonly affected than women Anatomic location most common levels are C4-5 and C5-6 95% of ossification is located in the cervical spine Etiology Pathophysiology cause is unclear, but likely multifactorial associated factors include: diabetes obesity high-salt, low-meat diet poor calcium absorption mechanical stress on the posterior longitudinal ligament Presentation Symptoms often asymptomatic myelopathic symptoms Physical exam myelopathy Imaging Radiographs lateral radiograph often shows ossification of PLL used to evaluate the sagittal alignment of cervical spine MRI study of choice to evaluate spinal cord compression CT study of choice to delineate the bony anatomy of the ossified posterior longitudinal ligament Treatment Nonoperative observation indicated only in patients with mild symptoms who are not candidates for surgery Operative direct or indirect surgical decompression, followed by stabilization indications most patients with significant symptoms Techniques Interbody fusion without decompression indications dynamic myelopathy technique the theory behind this technique is that eliminating motion at stenotic levels prevents trauma to the cord Anterior corpectomy with or without OPLL resection indications patients with a kyphotic cervical spine where posterior decompression is not an option technique one method to avoid a dural tear is to perform a corpectomy, and instead of removing the OPLL from the dura, allow it to "float" in the corpectomy site Posterior laminoplasty or laminectomy with fusion indications only effective in patients with a lordotic spine, as it allows the spinal cord to drift away from the anterior compression from the OPLL considered a safer and preferable approach due to the difficulty of resecting the OPLL off the dura from an anterior approach techniques fusion should accompany laminectomy to avoid post-laminectomy kyphosis complications risk of postoperative OPLL growth Complications Recurrence of OPLL reduced with complete resection leaving OPLL to float into a corpectomy site