Surgical Considerations for Ossification of
Posterior Longitudinal Ligament (OPLL)
Our doctors at Complete Orthopedics focus on implementing ways to optimize the advantages, minimize the risks, and prevent potential problems associated with ossification of the posterior longitudinal ligament (OPLL) surgery.
In order to achieve optimal outcomes for OPLL surgery, it is crucial to carefully choose the right patients, confirm neurodiagnosis, and plan the surgery appropriately while adhering to strict intraoperative anesthetic and monitoring protocols.
When patients show signs of progressing myeloradiculopathy, it is important to conduct both MRIs (most effective in revealing soft-tissue documentation of cord/root compression and intrinsic cord abnormalities, especially through T2 weighted studies) and CTs (better suited to detect early punctate ossification centers in hypertrophied OPLL or to display the classical ossification of mature OPL) studies to identify the type of OPLL variant causing the cord/root compression.
The four classic variants of OPLL:
The suitability of anterior or posterior cervical surgery for OPLL depends on several factors. If the cervical lordosis is sufficient, posterior procedures like laminoplasty or laminectomy/fusion may be viable options.
Posterior surgery has the advantage of avoiding the significant risks associated with anterior surgery, such as cervical cerebrospinal fluid (CSF) fistulous formation (which mainly occur during anterior approaches), injuries to the carotid/vertebral arteries, esophageal issues, and other potential complications.
If there is a lack of cervical lordosis and the presence of kyphosis, anterior surgery may be necessary. In such cases, single or multi level corpectomies are usually needed to remove segmental, continuous, or mixed OPLL. Choosing the most effective surgical techniques for OPLL relies on several factors and a thorough comprehension of the particular OPLL pathology.
Symptoms and signs of OPLL
Depending on the severity of neurological and radiographic indications, the treatment approaches for progressive spastic cervical myelopathy/radiculopathy associated with OPLL may vary due to the diverse range of symptoms and signs.
There is debate about the natural progression of OPLL, which is strongly influenced by genetic predisposition, and how it leads to the development of symptoms and signs such as myelopathy and radiculopathy.
The advantages and disadvantages of surgery for cervical OPLL have also been a topic of discussion, especially for patients who have minimal or no symptoms that warrant surgical intervention. On the other hand, there are patients with OPLL who are admitted to the hospital and refuse surgery, but are at a significantly higher risk of experiencing severe spinal cord injury.
Diagnosis of OPLL
The use of CT has greatly enhanced the accuracy of the classification and diagnosis of cervical OPLL.
When considering anesthesia, there are two main options: utilizing nasotracheal fiberoptic intubation as part of an awake intubation protocol or using newer techniques such as glidoscope techniques.
When performing cervical surgery for OPLL with significant spinal cord compression, awake nasotracheal fiberoptic (NT) intubation or occasionally awake endotracheal intubation (ET) are utilized to prevent cervical manipulation.
This applies to anterior, posterior, or circumferential approaches. In cases where the surgery is more cranial, the nasotracheal (NT) route is often preferred for anterior procedures as it prevents the jaw from dropping down and obstructing the surgical site.
Posterior Surgery for OPLL with Lordosis
Without the development of kyphosis, laminectomy alone may be a sufficient long-term treatment option for cervical OPLL.
Cervical OPLL surgery is a complex process and requires careful consideration of various factors such as the patient’s neurological condition, diagnostic test results, and potential risks of different surgical approaches. The decision to perform surgery should be based on the severity of the patient’s myelopathy, their age, and the risks of neurological deterioration.
MR and CT scans are used to determine the extent of cord compression and ossification, as well as the presence of kyphosis or lordosis. It is important to be familiar with the different types of OPLL and the appropriate management strategies.
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I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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