Updated: 6/24/2021

Ossification Posterior Longitudinal Ligament

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https://upload.orthobullets.com/topic/2046/images/ct sagittal_moved.jpg
https://upload.orthobullets.com/topic/2046/images/xray lateral.jpg
  • summary
    • Ossification Posterior Longitudinal Ligament 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 in but not limited to
      • men > women
    • Anatomic location
      • most common levels are C4-C6
      • 95% of ossification is located in C spine
  • Etiology
    • Pathophysiology
      • cause is unclear but likely multifactorial
      • associated factors
        • diabetes
        • obesity
        • high salt-low meat diet
        • poor calcium absorption
        • mechanical stress on posterior longitudinal ligament
  • Presentation
    • Symptoms
      • often asymptomatic
      • symptoms and exam findings consistent with symptoms of myelopathy
    • Physical exam
      • findings of myelopathy
  • Imaging
    • Radiographs
      • lateral radiograph often shows ossification of PLL
      • important to evaluate sagittal alignment of cervical spine
    • MRI
      • study of choice to evaluate spinal cord compression
    • CT
      • study of choice to delineate bony anatomy of ossified posterior longitudinal ligament
  • Treatment
    • Nonoperative
      • observation
        • indicated only in patient with mild symptoms who are not candidates for surgery
    • Operative
      • direct or indirect surgical decompression followed by stabilization
        • indications
          • indicated in most patients with significant symptoms
  • Techniques
    • Interbody fusion without decompression
      • indications
        • in patients with dynamic myelopathy
      • technique
        • theory behind technique is that by removing motion at stenotic levels trauma to the cord is eliminated
    • Anterior corpectomy with or without OPLL resection
      • indications
        • indicated in patient with 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 lordotic spine as it allows the spinal cord to drift away from the anterior compression of 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 be performed with laminectomy to avoid post-laminectomy kyphosis
      • complications
        • there is a risk of postoperative OPLL growth
  • Complications
    • Recurrence of OPLL
      • recurrance reduced with
        • complete resection
        • leaving OPLL to float in corpectomy site

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