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Background: The incidence of spinal cord injury without radiological abnormality (SCIWORA) is increasing among older adults in developed countries. SCIWORA is commonly associated with ossification of the spinal ligament, specifically the ossification of the posterior longitudinal ligament (OPLL) and ossification of the anterior longitudinal ligament (OALL). OALL induces segmental spinal fusion and alters the biomechanical properties of the cervical spine; however, whether OALL modulates the severity of SCIWORA remains unknown. This study aimed to investigate the influence of OALL on the severity and distribution of neurological deficits following SCIWORA., Methods: This retrospective study included 122 patients with SCIWORA who were admitted to our hospital from April 2008 to March 2022. The neurological function of all the included patients was assessed via the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at admission. Magnetic resonance imaging (MRI) and computed tomography were performed within 48 h of trauma. Central cord syndrome (CCS) was defined as the upper-extremity ASIA motor score being at least 10 points lesser than the lower-extremity motor score., Results: The study included 122 patients with a mean age of 65.1 years. Comparing mild (AIS grades C or D) and severe (AIS grades A or B) neurological deficits revealed that the former was independently associated with ground-level falls, OALL, and absence of prevertebral T2 high-intensity area on MRI. Although 39% of patients with SCIWORA exhibited OPLL as an etiology of cervical stenosis, OPLL demonstrated no significant effect on the severity of neurological deficits. CCS occurrence was independently associated with OALL and a larger cross-sectional cord area on MRI. Patients with OALL had significantly higher lower-extremity ASIA motor scores than those without OALL., Conclusions: OALL was significantly associated with mild neurological deficits in the lower extremities and with the occurrence of CCS after SCIWORA., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Cervical spondylotic myelopathy (CSM) is a prevalent cause of spinal cord dysfunction in adults, primarily from degenerative changes. The efficacy of treatment strategies, especially surgical approaches, remains debated., Objective: This study aimed to assess the long-term impact of posterior fusion laminectomy on the posterior longitudinal ligament (PLL) thickness, disc complex, and myelomalacia signal changes in CSM patients., Methods: A single-centre, prospective study from January 2020 to December 2021 included CSM patients without ossified posterior longitudinal ligament (OPLL). Magnetic resonance imaging (MRI) data from baseline, 6, and 12 months postoperatively were collected. Measurements on the MRI were performed using the Osirix MD software, focusing on the PLL width, myelopathic foci dimensions, and canal diameter., Results: Out of the 82 initially enrolled patients, 64 were considered for analysis. Postoperatively, a significant reduction in PLL width and myelopathic foci dimensions was observed, alongside a considerable increase in the canal diameter. Clinical outcomes based on the Modified Japanese Orthopaedic Association (mJOA) scale also showcased marked improvements post-surgery., Conclusions: Posterior fusion laminectomy effectively reduces anterior pressure in CSM patients. This treatment may represent an optimal surgical approach for selected CSM cases. Furthermore, more extensive studies with extended follow-up are advocated., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Intervertebral disc calcification (IDC) combined with calcification in children has been sporadically reported, while ossification of the posterior longitudinal ligament (OPLL) in the cervical spine in pediatric patients is exceedingly rare. The aim of this study is to investigate the potential prognosis and outcomes associated with this condition., Case Presentation: We present an unusual case involving a 10-year-old Chinese child diagnosed with calcified cervical disc herniation and ossification of the posterior longitudinal ligament. Conservative treatment measures were implemented, and at the 1-month and 6-month follow-up, the patient's pain exhibited significant improvement. Subsequent cervical MRI and CT scans revealed the complete disappearance of OPLL and substantial absorption of the calcified disc. During the three-month follow-up, CT demonstrated slight residual disc calcification, however, the patient remained asymptomatic with no discernible limitation in cervical motion., Conclusions: We conducted a comprehensive review of several cases presenting with the same diagnosis. It is noteworthy that IDC combined with OPLL in children constitutes a rare clinical entity. Despite imaging indications of potential spinal canal occupation, the majority of such cases demonstrate complete absorption following conservative treatment, with OPLL exhibiting a faster absorption rate than calcified discs., (© 2024. The Author(s).)

Background: In patients with cervical spondylotic myelopathy caused by ossification of the posterior longitudinal ligament, high cord signal (HCS) is frequently observed. However, limited research has investigated the variations in HCS improvement resulting from different surgical approaches. This study aims to explore the potential relationship between the choice of surgical approach and the postoperative improvement of intramedullary high signal in ossification of the posterior longitudinal ligament (OPLL) patients., Methods: We extensively reviewed the patients' medical records, based on which demographic information such as gender, age, and body mass index (BMI) were recorded, and assessed the severity of the patients' neurological status preoperatively and postoperatively by using the Japanese Orthopedic Association score (JOAs), focusing on consecutive preoperative and postoperative Magnetic resonance imaging (MRI) T2WI measurements, to study the statistical correlation between the improvement of HCS and the choice of surgical approach., Results: There were no significant differences in demographic, imaging parameters, and clinical symptoms between patients undergoing anterior and posterior surgery (p > 0.05, Table 1). However, both improvement in JOAs (Recovery2) and improvement in HCS (CR2) were significantly better in the anterior surgery group two years after surgery (p < 0.05, Table 1). Multifactorial logistic regression analysis revealed that posterior surgery and higher preoperative signal change ratio (SCR) were identified as risk factors for poor HCS improvement at the two-year postoperative period (p < 0.05, Table 2). Table 1 Differences in demographic, imaging parameters, and clinical symptoms in patients with anterior and posterior approach Anterior approach Posterior approach P-Values Demographic data  Sex (male/female) 10/12 6/17 0.175  Age 58.59 ± 5.68 61.43 ± 9.04 0.215  Hypertension 14/8 14/9 0.848  Diabetes 16/6 19/4 0.425  BMI 25.58 ± 4.72 26.95 ± 4.58 0.331  Smoking history 19/3 16/7 0.175 Preoperative measured imaging parameters  Preoperative SCR 1.615 ± 0.369 1.668 ± 0.356 0.623  CR1 0.106 ± 0.125 0.011 ± 0.246 0.08  CNR 0.33 ± 0.073 0.368 ± 0.096 0.15  C2-7 Cobb angle 8.977 ± 10.818 13.862 ± 13.191 0.182  SVA 15.212 ± 8.024 17.46 ± 8.91 0.38  mK-line INT 3.694 ± 3.291 4.527 ± 2.227 0.323 Imaging follow-up  6 months postoperative SCR 1.45 ± 0.44 1.63 ± 0.397 0.149  2 years postoperative SCR 1.26 ± 0.19 1.65 ± 0.35 0.000**  CR2 0.219 ± 0.14 - 0.012 ± 0.237 0.000** Clinical symptoms  Preoperative JOAs 10.64 ± 1.59 10.83 ± 1.47 0.679  6 months postoperative JOAs 11.82 ± 1.37 11.65 ± 1.4 0.69  2 years postoperative JOAs 14.18 ± 1.01 12.52 ± 2.06 0.001**  Recovery1 0.181 ± 0.109 0.128 ± 0.154 0.189  Recovery2 0.536 ± 0.178 0.278 ± 0.307 0.001** * , statistical significance (p < 0.05). **, statistical significance (p < 0.01) BMI = body mass index. SCR = the signal change ratio between the localized high signal and normal spinal cord signal at the C7-T1 levels. CR1 = the regression of high cord signals at 6 months postoperatively (i.e., CR1 = (Preoperative SCR-SCR at 6 months postoperatively)/ Preoperative SCR). CR2 = the regression of high cord signal at 2 years postoperatively (i.e., CR2 = (Preoperative SCR-SCR at 2 years postoperatively)/ Preoperative SCR). CNR = canal narrowing ratio. SVA = sagittal vertical axis. mK-line INT = modified K-line interval. JOAs = Japanese Orthopedic Association score. Recovery1 = degree of JOAs recovery at 6 months postoperatively (i.e., Recover1 = (JOAs at 6 months postoperatively-Preoperative JOAs)/ (17- Preoperative JOAs)). Recovery2 = degree of JOAs recovery at 2 years postoperatively (i.e., Recover2 = (JOAs at 2 years postoperatively-Preoperative JOAs)/ (17-Preoperative JOAs)) Table 2 Linear regression analyses for lower CR2 values 95% CI P value Uni-variable analyses Demographic data  Sex (male/female) - 0.01 0.221 0.924  Age - 0.015 0.003 0.195  Hypertension - 0.071 0.204 0.334  Diabetes - 0.195 0.135 0.716  BMI - 0.375 0.422 0.905  Smoking history - 0.249 0.077 0.295  Surgical approach - 0.349 - 0.113 0.000 # Preoperative measured imaging parameters  C2-7 Cobb angle - 0.009 0.002 0.185  SVA - 0.008 0.008 0.995  mK-line INT - 0.043 0.005 0.122  Preoperative SCR 0.092 0.445 0.004 #  CR1 0.156 0.784 0.004 #  CNR - 0.76 0.844 0.918 Multi-variable analyses  Surgical approach - 0.321 - 0.118 0.000**  Preoperative SCR 0.127 0.41 0.000**  CR1 - 0.018 0.501 0.067 # , variables that achieved a significance level of p < 0.1 in the univariate analysis *statistical significance (p < 0.05). **statistical significance (p < 0.01) BMI = body mass index. SCR = the signal change ratio between the localized high signal and normal spinal cord signal at the C7-T1 levels. CR1 = the regression of high cord signals at 6 months postoperatively (i.e., CR1 = (Preoperative SCR-SCR at 6 months postoperatively)/ Preoperative SCR). CR2 = the regression of high cord signal at 2 years postoperatively (i.e., CR2 = (Preoperative SCR-SCR at 2 years postoperatively)/ Preoperative SCR). CNR = canal narrowing ratio. SVA = sagittal vertical axis. mK-line INT = modified K-line interval CONCLUSIONS: For patients with OPLL-induced cervical spondylotic myelopathy and intramedullary high signal, anterior removal of the ossified posterior longitudinal ligament and direct decompression offer a greater potential for regression of intramedullary high signal. At the same time, this anterior surgical strategy improves clinical neurologic function better than indirect decompression in the posterior approach., (© 2023. The Author(s).)

Study Design: A prospective multicenter study., Objective: The objective of this study was to investigate the incidence of loss of cervical lordosis after laminoplasty for cervical ossification of the posterior longitudinal ligament (OPLL). We also sought to determine associated risk factors and the relationship with patient-reported outcomes., Summary of Background Data: Loss of cervical lordosis is a sequelae often observed after laminoplasty, which may adversely impact surgical outcomes. Cervical kyphosis, especially in OPLL, is associated with reoperation, but risk factors and relationship to postoperative outcomes remain understudied at this time., Materials and Methods: This study was conducted by the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament. We included 165 patients who underwent laminoplasty and completed Japanese Orthopaedic Association (JOA) score or Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaires (JOACMEQ), as well as Visual Analog Scales (VAS) for pain, with imaging. The participants were divided into two groups: those with loss of cervical lordosis of >10° or 20° after surgery and those without loss of cervical lordosis. A paired t test was applied to evaluate the association between changes in cervical spinal angles, range of motion, and cervical JOA and VAS scores before and at 2 years postoperatively. Mann-Whitney U test was used for JOACMEQ., Results: Postoperative loss of cervical lordosis >10° and >20° was observed in 32 (19.4%) and 7 (4.2%), respectively. JOA, JOACMEQ, and VAS scores were not significantly different between those with, and without, loss of cervical lordosis. Preoperative small extension range of motion (eROM) was significantly associated with postoperative loss of cervical lordosis, and the cutoff values of eROM were 7.4° [area under the curve (AUC): 0.76] and 8.2° (AUC: 0.92) for loss of cervical lordosis >10° and >20°, respectively. A large occupation ratio of OPLL was also associated with loss of cervical lordosis, with a cutoff value of 39.9% (AUC: 0.94). Laminoplasty resulted in functional improvement in most patient-reported outcomes; however, neck pain and bladder function tended to become worse postoperatively in cases with postoperative loss of cervical lordosis >20°., Conclusions: JOA, JOACMEQ, and VAS scores were not significantly different between those with, and without, loss of cervical lordosis. Preoperative small eROM and large OPLL may represent factors associated with loss of cervical lordosis after laminoplasty in patients with OPLL., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The occurrence of concurrent hypertrophied posterior longitudinal ligament (HPLL) and hypertrophied ligamentum flavum (HLF) in the thoracic spine is a very rare presentation. This case report describes a young female who developed thoracic myelopathy secondary to a combination of both thoracic HPLL and HLF., Case Presentation: A 30-year-old previously well female was referred for an MRI scan of the thoraco-lumbar spine. She was having lower limb weakness and difficulty in walking, which had progressed over 3 months. On examination, she was found to have spastic lower limbs with associated motor weakness. Her biochemical investigations were unremarkable. The MRI scan showed HPLL, which was uniformly hypointense on T2W images and was isointense on T1W images. The hypertrophied segment was extending from T2 level to T7 level. Similarly, the ligamentum flavum was hypertrophied from T1 level to T8 level. The thoracic spinal cord was seen compressed between the hypertrophied ligaments. The compressed cord showed central hyperintense signal pattern in T2W images. CT scan of the thoracic spine did not show any calcifications or ossifications along the ligaments. Patient underwent posterior decompressive surgery and she had an uneventful recovery., Discussion: Although few cases of HPLL and HLF were reported in older patients in literature, both these conditions were found in this patient at a younger age. HPLL and HLF are thought to be precursors of ossification of these ligaments and these patients need long-term follow-up., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Study Design: Biomechanical study., Objective: Cervical ossification of the posterior longitudinal ligament (C-OPLL) causes myelopathy. Though posterior decompression for C-OPLL showed positive results, poor outcomes were seen in patients with a kyphotic alignment. Posterior decompression with fusion (PDF) tends to show better results compared to posterior decompression. The aim of this study is to evaluate the effects of the posterior procedures for C-OPLL., Setting: Yamaguchi University., Methods: Based on 3D finite element C2-C7 spine created from medical images and a spinal cord, the following compression models were created: the intact model, K-line 0 mm model, and K-line 2 mm model. These models were used to analyze the effects of posterior decompression with varied lengths of fixation. The stress of the spinal cord was calculated for intact, K-line 0 mm, and K-line 2 mm as preoperative models, and laminectomy (LN)-K-line 0 mm, PDF (C4-C5)-K-line 0 mm, PDF (C3-C6)-K-line 0 mm, LN-K-line 2 mm, PDF (C4-C5)-K-line 2 mm, and PDF (C3-C6)-K-line 2 mm model as operative models in a neutral, flexion, and extension., Results: As the compression increased, stress on the spinal cord increased compared to the intact model. In the neutral, posterior decompression decreased the stress of the spinal cord. However, in flexion and extension, the stress on the spinal cord for LN-K-line 0 or 2 mm, PDF (C4-C5)-K-line 0 or 2 mm, and PDF (C3-C6)-K-line 0 or 2 mm models decreased by more than 40%, 43%, and 70% respectively compared to the K-line 0 or 2 mm model., Conclusions: In kyphotic C-OPLL, it is essential to control intervertebral mobility in the posterior approach., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Obesity and metabolic disturbances are prevalent in ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF); however, the involvement of dyslipidemia (DL) in OPLL/OLF remains uncertain. We investigated the association between dyslipidemia and OPLL/OLF using a dataset of 458 individuals receiving health screening tests, including computed tomography. Subjects were grouped according to the presence or location of OPLL/OLF: controls (no OPLL/OLF, n = 230), OLF (n = 167), cervical OPLL (n = 28), and thoracic OPLL (n = 33). They were also grouped according to the presence of dyslipidemia (DL[+], n = 215; DL[-], n = 243). The proportion of dyslipidemia in the OLF and OPLL groups was 1.6-2.2 times higher than that in the control group. The proportion of OLF and OPLL in the DL(+) group was significantly higher than that in the DL(-) group (OLF, 43% vs. 29%; cervical OPLL, 14.4% vs. 3.2%; thoracic OPLL, 11.1% vs. 3.7%). Multivariate logistic regression analysis showed an association between all ossification types and dyslipidemia. This study demonstrated an association of dyslipidemia with OPLL/OLF; further investigation on the causal relationship between dyslipidemia and ectopic spinal ligament ossification is warranted to develop a therapeutic intervention for OPLL/OLF., (© 2022. The Author(s).)

Purpose: To analyze risk factors of titanium mesh cage (TMC) subsidence in single-level anterior cervical corpectomy and fusion (ACCF) for cervical ossification of the posterior longitudinal ligament (OPLL)., Methods: TMC subsidence is defined as the reduction of the adjacent vertebral bodies by ≥ 2 mm. Patients with cervical OPLL who were treated with single-level ACCF between January 2019 and May 2021 were retrospectively analyzed in two groups: patients with TMC subsidence as Group S and patients with no TMC subsidence as Group N during the one-year follow-up period. The degree of distraction of surgical segment and correction of the cervical curvature was measured to analyze their relationship with TMC subsidence., Results: A total of 128 patients were included in Group S, and 138 patients were included in Group N. There was no significant difference in patient demographics and complications between the two groups. The degree of distraction in Group S was significantly higher than that in Group N (11.4% ± 7.6% vs. 4.7% ± 9.7%, P < 0.01). The change of C2 to C7 Cobb angle (α) in Group S was significantly greater than that in Group N (5.7 ± 2.7 vs. 1.4 ± 4.7, P < 0.01), and the change of interspinous process distance (SPD) in Group S was also significantly greater than that in Group N (7.0 ± 4.2 vs. 4.1 ± 2.7, P < 0.01). The JOA score and JOA recovery rate were not statistically different between the two groups., Conclusions: Intraoperative selection of overlength TMC in single-level ACCF for OPLL, over-distraction and excessive correction of the cervical curvature may cause TMC subsidence after surgery. No significant impact of TMC subsidence on the surgical outcome was observed during the 1-year follow-up period., (© 2022. The Author(s).)

Study Design: Retrospective radiological analysis., Objective: To demonstrate the radiological outcome after a modified anterior column realignment (mACR) with partial anterior longitudinal ligament (ALL) release in oblique lateral interbody fusion (OLIF)., Summary of Background Data: Anterior column realignment (ACR) remains a powerful sagittal correction technique in minimally invasive adult spinal deformity surgery and is often combined with posterior column osteotomy (PCO) to achieve more lordosis. OLIF is ideal for ACR because the anterior-to-psoas corridor typically involves the anterolateral half of the disk., Methods: This study included 112 operated disk levels of 101 consecutive patients who underwent OLIF between L2-L3 and L4-L5 using a 12° lateral cage. The mACR was performed at 73 (65.2%) levels with 30% to 50% sectioning of the ALL. Each operated level was grouped according to the mACR and additional PCO as: (1) no mACR, OLIF only (n=39); (2) mACR with no PCO (n=18); (3) mACR with grade 1 PCO (n=27); (4) mACR with grade 2 PCO (n=22); or (5) mACR with grade 3 PCO (n=6)., Results: At the last follow-up, the mean disk lordotic angles were 10.9±2.9°, 12.6±3.0°, 13.3±3.9°, 16.7±3.2°, and 16.8±2.4° in the no mACR, mACR with no PCO, mACR with grade 1 PCO, mACR with grade 2 PCO, and mACR with grade 3 PCO groups, respectively ( P <0.001). The mean increases in disk lordotic angle were 5.8±4.1°, 12.1±6.1°, 13.5±8.7°, 15.8±6.7°, and 17.9±6.2° in each group, respectively ( P <0.001)., Conclusions: ACR can be performed with partial ALL release under direct vision in OLIF without deep dissection into the ventral disk space. The mACR in OLIF is a simple, safe, and effective technique for anterior column lengthening., Level of Evidence: 4., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Expansion of the anterior column and compression of the posterior column restores lordosis and sagittal imbalance. Anterior longitudinal ligament (ALL) release has been described from lateral and anterior approaches as a technique to improve lumbar lordosis; however, posterior approach to release the ALL has not been adequately assessed., Methods: We demonstrate a case series of ALL release using a posterior approach performed in conjunction with posterior column osteotomy (PCO), with or without transforaminal lumbar interbody fusion (TLIF) for spinal deformity. Eleven cases were identified from billing records between 2010 and 2019. Retrospective review was conducted for perioperative complications and revision surgery. Overall and segmental lumbar lordosis (LL) correction was measured from pre- and postoperative imaging., Results: Eleven patients underwent ALL release with a PCO. Kyphosis, scoliosis, and flat back syndrome were the most common spinal deformities. On average, patients had 9 ± 3 levels fused and a single level ALL release. ALL release was most commonly performed at L1-L2 and L2-L3 levels. An overall LL correction of 28.6° ± 19.8 o was achieved; ALL release introduced 16.7° ± 11.9° of lordotic correction and accounted for 49.2 ± 30.4% of the overall lordotic correction. Average blood loss was 1030 ± 573 mL., Conclusions: ALL release as an adjunct to PCO and TLIF is a viable technique for providing increased deformity correction without subjecting the patient to a more invasive three-column osteotomy. While this approach may not be appropriate for all patients, it represents a useful option in spinal deformity correction while limiting blood loss and additional anterior surgery., Level of Evidence: IV., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background Context: Multilevel ossification of the posterior longitudinal ligament in thoracic spine (mT-OPLL) is a rare but clinically significant spinal condition. Various surgical methods have been developed to address this disease. However, the outcomes are commonly unfavorable, and no standard surgical strategy has been established. To solve this problem, we introduced a new surgical strategy based on an innovative decompression concept, namely "de-tension.", Purpose: This study aimed to investigate the safety and efficacy of this new treatment, and to establish an improved surgical strategy., Study Design: A prospective observational study with at least 3 years of follow-up., Patient Sample: Fifty-one patients with consecutive mT-OPLL who were treated between August-2012 and June-2018 were enrolled in this study., Outcome Measures: A modified Japanese Orthopedic Association (mJOA) scale assessing thoracic spine, recovery rate (RR), and surgical complications., Methods: All patients underwent 1-stage thoracic posterior laminectomy, selective OPLL resection, and spinal column shortening with/without reduction of kyphosis (dekyphosis). Initially, we recommended that when thoracic kyphosis of T1-T12 in sagittal reconstruction CT (TK) was less than 20°, no dekyphosis should be performed; when this angle was greater than 20°, dekyphosis could be conducted. Patients' demographic data, radiological findings, and intra/postoperative complications were recorded and analyzed. Neurological status was evaluated with mJOA score and RR. The correlation of preoperative TK or kyphosis angle in fusion area (FSK) with postoperative dekyphosis angle and spinal column shortening distance (SD) were respectively evaluated by Pearson correlation analysis., Results: Cerebrospinal fluid leakage (58.8%) and neurological deterioration (15.7%) were the most common complications. Average mJOA score was improved from preoperative 4.0±2.1 to 8.9±2.4 at the last follow-up, and the mean RR was 71.3±33.7%. There was no correlation between preoperative TK and SD (p=.56) or between preoperative FSK and SD (p=.21), but dekyphosis angle was significantly correlated with TK (r=0.504, p<.01) and FSK (r=0.5734, p<.01). TK of 24.6° and FSK of 23.0° were determined as the critical angles for dekyphosis, and a modified surgical strategy was formulated., Conclusions: This new strategy provided a novel solution for mT-OPLL, and was proved to be safe and effective during long-term follow-up. Further rigorously designed large-scale prospective studies are needed to validate our findings., (Copyright © 2022. Published by Elsevier Inc.)

Background: Since the first description of paediatric intervertebral disc calcification (IDC) by Báron in 1924, only approximately 400 cases have been reported in the literature. Paediatric IDC combined with ossification of the posterior longitudinal ligament (OPLL) is an even rarer condition, with only 8 cases described in detail to date. In this paper, we present a review of the disease characteristics described in the relevant English language literature and discuss the possible mechanisms of lesion enhancement in contrast-enhanced magnetic resonance imaging (MRI)., Case Presentation: In May 2020, a 6-year-old Han nationality girl presented with the chief complaint of neck pain that had lasted for a week. She did not report a history of trauma or a past illness. On admission, there was no personal and family history, congenital diseases, or non-specific infections such as tuberculosis, among others. Further physical examination revealed that the movement of her cervical spine was limited. Computed tomography (CT) and MRI revealed ossification of the intervertebral discs and posterior longitudinal ligament (PLL) at the C4/5 levels and an absence of obvious spinal cord compression. When contrast-enhanced MRI was performed, significant enhancement was observed in the intervertebral discs and PLL at the C4/5 level. We adopted a non-interventional approach and performed an imaging re-examination 8 months later. Both the plain and contrast-enhanced MRI scans indicated swelling in the C4/5 intervertebral discs and disappearance of the previously observed enhancement in the nucleus pulposus (NP) and PLL at the corresponding levels; CT examination revealed that the ossified lesions had been completely resorbed., Conclusion: Obvious lesion enhancement in contrast-enhanced MRI is an extremely rare manifestation of paediatric IDC combined with OPLL. However, the exact mechanisms of this phenomenon remain unclear. We surmise that it may be caused by a series of biophysical changes related to vertebral endplate injury and repair, but further research will be required for in-depth investigation., (© 2022. The Author(s).)

Positive association between ossification of the posterior longitudinal ligament of the spine (OPLL) and obesity is widely recognized; however, few studies focused on the effects of obesity on treatment of cervical OPLL. The effects of obesity on surgical treatment of cervical OPLL were investigated by a Japanese nationwide, prospective study. Overall, 478 patients with cervical myelopathy due to OPLL were prospectively enrolled. To clarify the effects of obesity on the surgical treatment for cervical OPLL, patients were stratified into two groups, non-obese (< BMI 30.0 kg/m 2 ) and obese (≥ BMI 30.0 kg/m 2 ) groups. The mean age of the obese group was significantly younger than that of non-obese group. There were no significant differences between the two groups in other demographic information, medical history, and clinical and radiographical findings. Alternatively, the obese group had a significantly higher rate of surgical site infection (SSI) than that of non-obese group. Approach-specific analyses revealed that the SSI was significantly higher in the obese group than in the non-obese group. A logistic regression analysis revealed that age, BMI, and duration of symptoms were significant factors affecting the postoperative minimum clinically important difference success. The result of this study provides useful information for future cervical OPLL treatment., (© 2022. The Author(s).)

Background: The purpose of this study was to investigate the surgical efficacy of crossing the cervicothoracic junction during posterior cervical laminectomy and fusion for the treatment of multilevel cervical ossification of the posterior longitudinal ligament (OPLL)., Methods: From October 2009 to October 2017, 46 consecutive patients with multilevel cervical OPLL underwent posterior cervical laminectomy and crossing the cervicothoracic junction fusion were obtained in the study. Their medical records were retrospectively collected. Cervical lordosis and cervical sagittal balance were used to assess radiographic outcomes. Japanese Orthopedic Association (JOA), axial symptom, C5 root palsy, blood loss, and operation time were used to assess clinical outcomes. The mean follow-up period was 20.7 ± 8.3 months., Results: The operation time was 205.2 ± 39.8 min and the intraoperative blood loss was 352.2 ± 143.7 ml. Analysis of the final follow-up data showed significant differences in JOA score (P < 0.01), C2-C7 lordosis angle (P < 0.01), and C2-C7 SVA (P < 0.01). CT confirmed that grafted bone was completely fused in all patients and progression of OPLL was observed in two patients (4.3%) at final follow-up. No adjacent segment disease (ASD) or instrument failure occurred in any patients., Conclusions: Cervical laminectomy and crossing the cervicothoracic junction fusion are effective and safe methods to treat multilevel cervical OPLL. Randomized controlled studies compared constructs ending at cervical vertebrae or thoracic vertebrae are needed to confirm these results., (© 2022. The Author(s).)

Vertebral body sliding osteotomy has been reported as a technique to manage cervical myelopathy caused by ossification of the posterior longitudinal ligament. It involves mobilization and anteriorly translating the vertebral body and ossified mass as a whole. The main advantage of the procedure is decreased rate of complication such as dural tear, implant dislodgement, and pseudarthrosis, which demonstrates high rate in anterior cervical corpectomy and fusion. Vertebral body rotational osteotomy is a modification of vertebral body sliding osteotomy. It is indicated for laterally deviated ossified mass to achieve further decompression. This is a technical note describing the procedures of vertebral body rotational osteotomy., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Anterior longitudinal ligament release is a proven method for restoring spinopelvic parameters. This technique is mostly described using either lateral or anterior approaches with paucity regarding a posterior method. This paper is the first to provide descriptive analysis of the neurovascular anatomy in the context of planning for a posterior endoscopic ALL release. A retrospective chart review was performed on patients underwent any lumbar surgery by a single surgeon. Anatomical data was obtained from pre-operative CT to describe the location of key neurovascular structures in relation to the ALL with focus on posterior approach. A total of 20 patients were included in data analysis. A posterior approach with endoscopic assistance would be feasible at L4/5 and L5/S1, where the bifurcation of the abdominal aorta has occurred with a vessel window that ranges from 18.85 mm to 33.45 mm with at least 2 mm space between the vessels and the corresponding disc spaces in the anterior-posterior dimension with slight predilection of the left side at the L5/S1 level to avoid any neurovascular structures. Our study confirmed the findings of previous studies examining the vascular anatomy associated with the lumbar spine. Interestingly, we found that direct midline would likely not be the best location for a posterior annulotomy, and that both the window between the iliac vessels as well as the distance in AP dimension between the spine and vessels increases as you descend the lumbar spine. This information will help guide future efforts to fully develop a safe and reproducible posterior endoscopic ALL release., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Ossification of the posterior longitudinal ligament (OPLL) causes serious problems, such as myelopathy and acute spinal cord injury. The early and accurate diagnosis of OPLL would hence prevent the miserable prognoses. Plain lateral radiography is an essential method for the evaluation of OPLL. Therefore, minimizing the diagnostic errors of OPLL on radiography is crucial. Image identification based on a residual neural network (RNN) has been recognized to be potentially effective as a diagnostic strategy for orthopedic diseases; however, the accuracy of detecting OPLL using RNN has remained unclear. An RNN was trained with plain lateral cervical radiography images of 2,318 images from 672 patients (535 images from 304 patients with OPLL and 1,773 images from 368 patients of Negative). The accuracy, sensitivity, specificity, false positive rate, and false negative rate of diagnosis of the RNN were calculated. The mean accuracy, sensitivity, specificity, false positive rate, and false negative rate of the model were 98.9%, 97.0%, 99.4%, 2.2%, and 1.0%, respectively. The model achieved an overall area under the curve of 0.99 (95% confidence interval, 0.97-1.00) in which AUC in each fold estimated was 0.99, 0.99, 0.98, 0.98, and 0.99, respectively. An algorithm trained by an RNN could make binary classification of OPLL on cervical lateral X-ray images. RNN may hence be useful as a screening tool to assist physicians in identifying patients with OPLL in future setting. To achieve accurate identification of OPLL patients clinically, RNN has to be trained with other cause of myelopathy., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Magnetic resonance imaging (MRI) is effective in identifying cervical spine injury after trauma. However, cervical instability without major bone injury or dislocation is challenging to assess. Hence, the current study aimed to investigate and compare the MRI and radiography findings of segmental instability in patients with cervical spine injury. We investigated 34 participants with cervical spine injury without vertebral fracture. Based on the radiography findings, the participants were categorized into two: group A with segmental instability (n = 11) and group B without segmental instability (n = 23). Both groups were compared in terms of the presence of segmental instability on radiography and MRI. Anterior longitudinal ligament (ALL) injury, disc injury, and bilateral facet effusion were observed in 6/11, 5/11, and 7/11 patients in group A and in 5/23, 2/23 and 7/23 patients in group B, respectively. The results showed significant differences (p < 0.05). Moreover, 2 and 10 of 11 patients in group A and 16 and 7 of 23 patients in group B presented with hemi lateral facet effusion and paravertebral muscle injury, respectively. However, the results did not significantly differ. According to a logistic regression analysis, bilateral facet effusion after trauma was associated with cervical segmental instability (odd ratio: 10.6, 95% confidence interval: 1.31-84.7). Facet joint effusion might be caused by capsule injury during trauma. Most participants with segmental instability had ALL, disc, and flavum injury and bilateral facet effusion. Therefore, we need to consider bilateral facet effusion with other soft tissue damage of the cervical spine as an association factor to show the instability.

Purpose: We aimed to evaluate the feasibility of 3D broadband inversion-recovery-prepared ultrashort echo-time (3D IRP UTE) imaging for assessing ossification of the posterior longitudinal ligament (OPLL)., Materials and Methods: The study consisted of 25 consecutive patients with cervical OPLL [13 women, 12 men; mean age 66.3 (47-84) years] who underwent CT, 3T conventional MR, and 3D IRP UTE imaging studies. Two readers independently assessed the 3D IRP UTE images for the type (mixed, continuous, circumscribed, segmental) and distribution of OPLL. All readers consensually assessed the diagnostic certainty of OPLL on conventional MR and 3D IRP UTE images by using a 3-point scale system. Interobserver and intermodality agreement was assessed by κ statistics. A Wilcoxon signed-rank test was used to evaluate the difference of diagnostic certainty between conventional MR and 3D IRP UTE imaging., Results: Interobserver and intermodality agreements were good (κ = 0.73) and excellent (κ = 0.81) for the OPLL type, and excellent (κ = 0.85) and good (κ = 0.76) for the assessment of the distribution of OPLL, respectively. The mean level of the diagnostic certainty of OPLL was significantly higher for 3D IRP UTE than conventional MR imaging (p = 0.002)., Conclusion: 3D IRP UTE imaging may be useful for assessing OPLL.

Ossification of the posterior longitudinal ligament (OPLL) of the lumbar spine is rare relative to that of the cervical spine but is often associated with more severe symptoms. Continuous lumbar OPLL is extremely rare. We herein describe a 48-year-old Chinese woman with lumbar spinal stenosis caused by continuous OPLL. She presented with a 5-year history of lower back pain and intermittent claudication. We performed percutaneous transforaminal endoscopic decompression by the posterolateral approach to achieve adequate decompression of the spinal canal up to the lower 1/3 level (0.9 cm) of the L1 vertebral body and down to the upper 1/2 level (1.3 cm) of the L2 vertebral body. After surgery, the patient's neurological function substantially improved, and her visual analog scale scores for the lower back and both lower extremities and her Oswestry disability index were significantly lower than those in the preoperative period. During the 12-month clinical follow-up period, the patient's neurological function was fully restored, and she regained her ability to walk normally. No surgery-related complications were observed. This case report describes a novel surgical approach that may be an effective treatment alternative for continuous lumbar OPLL.

Background: Lumbar disc herniation (LDH) occurs owing to the inability of the posterior longitudinal ligament (PLL) to preserve the disc material within the intervertebral space. There is apparently no study that has investigated the histopathological changes occurring in both PLL and disc material in patients with LDH., Objective: Investigate and compare the histopathological changes occurring in PLL and disc material of the patients who underwent a surgical operation for LDH., Design: Descriptive, cross-sectional., Setting: Pathology and neurosurgery departments of a tertiary health care institution PATIENTS AND METHODS: The study included patients who underwent surgical operation for LDH from January 2018 to May 2019 and whose PLL and disc material were removed together, and had disc degeneration findings that were radiologically and histologically concordant., Main Outcome Measures: PLL degeneration scores according to the histopathological findings, changes in disc materials according to the MRI findings, disc degeneration scores according to the histo-pathological findings., Sample Size: 50., Results: MRI and histological examinations showed fully degenerated black discs (Grade 2) in 12 patients, partially degenerated discs (Grade 1) in 29 patients and fresh/acute discs (Grade 0) in 9 patients. The PLL showed grade 0 degeneration in 2 patients, grade 1 degeneration in 23 patients, and grade 2 degeneration in 25 patients. PLL degeneration grades were higher than the disc degeneration grades ( P =.002)., Conclusion: Longitudinal ligament degeneration can play a significant role in the pathogenesis of LDH. To the best of our knowledge, this study represents the first to focus on the histopathological changes occurring in both the PLL and disc material in patients with LDH., Limitations: Small sample, retrospective CONFLICT OF INTEREST: None.

The anterior decompression technique, including vertebral body sliding osteotomy1 and anterior controllable antedisplacement fusion (ACAF),2 treats ossified posterior longitudinal ligament (OPLL) without actual excision of the OPLL.3 The fundamental strategy is to separate the mid-portion of the vertebral body along with the OPLL using bilateral anterior osteotomies followed by controllable antedisplacement. These techniques restore the space of the spinal canal anteriorly by anterior translation of the OPLL, avoiding excision and dural manipulation.4 We illustrate the case of a patient who had failed laminoplasty and the surgical decision making for ACAF. We discuss the other surgical options regarding patient selection, present preoperative and postoperative imaging, to demonstrate the efficacy of ACAF and show strategies of ACAF to make it a safe and effective procedure. We demonstrate our technique of ACAF using the intraoperative microscope and models in this video to illustrate the steps of ACAF. A written consent to the procedure was obtained from the patient., (Copyright © 2020 by the Congress of Neurological Surgeons.)

Aim: To evaluate the usefulness of the rostral line (R-line) as a new index for determining the degree of C2 lamina decompression in the context of ossification of the posterior longitudinal ligament (OPLL) extending to the C2 level., Material and Methods: The R-line was devised based on the mechanism by which the cord is shifted backward following cervical posterior decompression. According to their R-line status, 36 patients with cervical OPLL extending to the C2 level were divided into two groups of R-line (+) and R-line (?) cases, where the R-line touched the upper half of the posterior C2 lamina in the R-line (+) group and the inferior half of the posterior C2 lamina in the R-line (?) group, respectively., Results: Eighteen patients were classified as R-line (+) and 18 patients were classified as R-line (?). Total laminectomy of the C2 lamina was more common in the R-line (+) group, while dome-shape C2 laminectomy was more common in the R-line (?) group. All patients requiring reoperation were included in the R-line (+) group. Only the operation type showed a statistically significant difference according to the need for reoperation in the R-line (+) group; specifically, all patients who underwent reoperation in the R-line (+) group had dome-shape C2 laminectomy. It was determined that the risk factor for reoperation in the R-line (+) group was a history of dome-shape C2 laminectomy., Conclusion: If the R-line touches the upper half of the posterior C2 lamina, total decompression of the C2 lamina should be performed.

The authors describe the result of combined surgical treatment of a patient with symptomatic multiple-level cervical spine stenosis following ossification of posterior longitudinal ligament. The first stage included decompressive laminectomy and cervical spine fusion using a screw. At the second stage, C IV -C V -C VI -C VII corporectomy with total resection of the ossified posterior longitudinal ligament and C III -Th I corporodesis with a bone autograft were carried out. This approach was valuable to minimize the risk of iatrogenic damage to the spinal cord, eliminate long spinal stenosis and perform circular fusion of the cervical spine. These measures led to regression of cervical myelopathy symptoms. A brief review is presented.

Study Design: A retrospective study., Objective: The aim of this study was to describe a novel posterior approach, circumspinal decompression technique "IV+V+VI" for ossification of the posterior longitudinal ligament (OPLL) or hard disc herniation (HDH) in thoracic spine and assess its safety and efficacy., Summary of Background Data: Thoracic myelopathy caused by OPLL or HDH is a rare but intractable disorder that can only be effectively treated with surgery. Nevertheless, few studies have reported on a detailed resection of OPLL or HDH using a single posterior approach and no consistent procedures have been established., Methods: Fifteen consecutive patients with single-level OPLL or HDH who were treated with this novel technique at our center between January 2016 and June 2017 were recruited. The perioperative complications, operation time, blood loss, pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale and the neurological recovery rate was calculated using the Hirabayashi's Method., Results: All the included patients underwent one-stage posterior circumferential decompression. The average age at surgery was 43.3 ± 12.8 years. Eight cases were diagnosed with HDH, four with OPLL, and three with OPLL+OLF (ossification of the ligamentum flavum). The mean operation time was 109.9 ± 25.3 minutes with an average blood loss of 433.3 ± 221.8 mL. The mean follow-up period was 33.1 ± 7.5 months. Five patients experienced a dural tear, whereas another case experienced a transient numbness in the right lower limb. All these patients were treated conservatively and their neurological function recovered well at the final follow-up. The average JOA score increased from 5.8 ± 1.9 before surgery to 10.2 ± 1.0 postoperatively, and the average recovery rate was 87.2%., Conclusion: The "IV+V+VI" technique is a safe and effective method for thoracic OPLL and HDH resection. It can be used as a standard surgical procedure for thoracic spinal circumferential decompression., Level of Evidence: 4.

Objective: This article aimed to introduce a novel technique, the "seesaw technique," for failed anterior cervical corpectomy and fusion (ACCF) in the treatment of cervical ossification of the posterior longitudinal ligament., Methods: A patient who underwent ACCF 12 years ago and suffered gradually deteriorating neurologic function was referred to our institution. Preoperative imaging showed residual ossified mass at C5/6 level, causing compression to his spinal cord. He patient was treated by the seesaw technique. The main surgical procedures include removal of the plate and screws, removal of the osteophytes and diskectomy of C4/5, resection of the anterior part of C5 vertebral body, establishment of a transverse hinge at C7 vertebral body, installation of cervical plate and hoisting tool, and antedisplacement of C5 vertebral body and titanium mesh. Images were investigated before and after the procedure. The Japanese Orthopaedic Association score was used to evaluate his neurologic function, and surgery-related complications were also analyzed., Results: The patient acquired significant improvement of his neurologic function 2 days after the surgery, and he could walk by himself without assistance. Postoperative images showed his spinal canal was enlarged sufficiently and the compression at C5/6 level was also released. At 13 months follow-up, his Japanese Orthopaedic Association score increased from 9 before surgery to 14, with an improvement rate of 62.5%. No surgery-related complications were observed during the whole follow-up., Conclusion: The seesaw technique provides satisfactory outcomes with wide enough decompression window and serves as a safe, effective surgical alternative for patients with failed ACCF., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: A prospective, randomized, controlled study., Objective: To compare anterior controllable antidisplacement and fusion (ACAF) with laminoplasty in the treatment of multilevel ossification of the posterior longitudinal ligament (OPLL), and evaluate the efficacy and safety of this procedure., Summary of Background Data: The optimal approach for the treatment of OPLL still remains controversial. Both anterior and posterior approaches have their advantages and disadvantages., Methods: Between September 2016 and April 2018, a total of 80 patients with multilevel OPLL were randomized in a 1:1 ratio to ACAF group and laminoplasty group. All patients were followed up at least 1 year. Clinical and radiological results were compared between ACAF group and laminoplasty group., Results: ACAF took a longer operation time. C5 palsy and axial pain occurred more commonly in laminoplasty group, whereas dysphagia and hoarseness appeared easily in ACAF group. At 1-year follow-up, the final Japanese Orthopedic Association (JOA) score and recovery rate were significant higher in ACAF group than those in laminoplasty group, when occupying rate (OR) was not less than 60%, or K-line was negative. ACAF was also good at preservation of cervical lordosis and sagittal balance, but range of movement of cervical spine in both groups decreased significantly., Conclusion: Generally speaking, ACAF is a safe and effective alternative for multilevel OPLL. Compared with laminoplasty, ACAF is more effective in the cases when OR is not less than 60%, or K-line is negative., Level of Evidence: 2.

We conducted a retrospective study to compare the clinical and radiological results of anterior cervical discectomy and fusion (ACDF) and posterior laminoplasty for two-level localized ossification of the posterior longitudinal ligament (OPLL).ACDF and posterior laminoplasty are performed for localized OPLL at the disc and vertebral body levels, respectively.Eighty six patients with two-level localized OPLL who underwent surgery from January 2011 to December 2016 were retrospectively investigated (41, ACDF group; 45, laminoplasty group). Clinical outcomes were reviewed, and radiologic results such as occupying ratio (OR), space available in the spinal cord, cranial and caudal OPLL-to-disc distance (ODD)/posterior body height (PBH) ratios, segmental angle, C2-C7 Cobb angle, T1 slope, C2-C7 sagittal vertical axis (SVA), and range of motion were investigated.Patients were followed-up for an average of 42.7 ± 10.5 months. Clinical outcomes, postoperative OR, and space available in the spinal cord were significantly improved at the final follow-up in both groups. Preoperatively, the OR and cranial and caudal ODD/PBH ratios were not significantly different between the groups. Compared to pre-operative values, differences in the segmental and C2-C7 Cobb angles at the final follow-up were statistically significant for the ACDF group (P < .05). The mean operative time, bleeding volume, and the duration of hospitalization were significantly lower in the ACDF group than in the laminoplasty group (P < .05). Complications occurred in 1 ACDF case and in 5 laminoplasty cases.Both ACDF and laminoplasty provided satisfactory clinical and radiologic outcomes for two-level localized OPLL. However, ACDF was associated with a lower operation time, bleeding loss, duration of hospitalization, and complications.

Background: Ankylosing spondylitis (AS) is an inflammatory disease that involves above all the spine and the pelvis. In the spine, the inflammatory processes cause the formation of syndesmophytes between the vertebral bodies and the ossification of ligaments, with bony overgrowth. In this setting, dysphagia is a rare but severe complication and only a few cases have been reported in the literature., Case Description: We describe the case of a 50-year-old man suffering from AS, with a 6-month history of severe dysphagia caused by bone compression of the esophagus at the C3-5 level. Because the patient underwent a 10-kg weight loss 2 months after clinical onset, a gastrostomy tube placement was needed. Complete surgical excision of the bone overgrowth via an anterior cervical approach was performed, but despite continuous intensive swallowing rehabilitation therapy, the patient failed to improve in the first following months. Surprisingly, the patient started to improve 18 months after the operation, with a complete recovery from dysphagia 24 months after., Conclusions: Among the 5 reports (including the present case) available in the current literature with a clear dysphagia recovery follow-up, the present case (the second one harboring gastrostomy) is associated with the slowest complete recovery published so far. This unusually late recovery suggests a possible role not only of the mechanical decompression of the esophagus but also of the degeneration/regeneration ratio of the myenteric plexus, along with local neurotransmitters sensitivity changes, to better understand the dysphagia recovery time course of this unique patient., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Ossification of the posterior longitudinal ligament (OPLL) presents as the development of heterotopic ossification in the posterior longitudinal ligament of the spine. The etiology of OPLL is genetically linked, as shown by its high prevalence in Asian populations. However, the molecular mechanism of the disease remains obscure. In this study, we explored the function and mechanism of OPLL-specific microRNAs. Methods: The expression levels of the ossification-related OPLL-specific miR-181 family were measured in normal or OPLL ligament tissues. The effect of miR-181a on the ossification of normal or pathogenic ligament cells was tested using real-time polymerase chain reaction (PCR), Western blot, alizarin red staining and alkaline phosphatase (ALP) staining. The candidate targets of miR-181 were screened using a dual luciferase reporter assay and functional analysis. The link between miR-181a and its target PBX1 was investigated using chromatin immunoprecipitation, followed by real-time PCR detection. Histological and immunohistochemical analysis as well as micro-CT scanning were used to evaluate the effects of miR-181 and its antagonist using both tip-toe-walking OPLL mice and in vivo bone formation assays. Results: Using bioinformatic analysis, we found that miR-181a-5p is predicted to play important roles in the development of OPLL. Overexpression of miR-181a-5p significantly increased the expression of ossification-related genes, staining level of alizarin red and ALP activity, while the inhibition of miR-181a-5p by treatment with an antagomir had the opposite effects. Functional analysis identified PBX1 as a direct target of miR-181a-5p, and we determined that PBX1 was responsible for miR-181a-5p's osteogenic phenotype. By chromatin immunoprecipitation assay, we found that miR-181a-5p controls ligament cell ossification by regulating PBX1-mediated modulation of histone methylation and acetylation levels in the promoter region of osteogenesis-related genes. Additionally, using an in vivo model, we confirmed that miR-181a-5p can substantially increase the bone formation ability of posterior ligament cells and cause increased osteophyte formation in the cervical spine of tip-toe-walking mice. Conclusions: Our data unveiled the mechanism by which the miR-181a-5p/PBX1 axis functions in the development of OPLL, and it revealed the therapeutic effects of the miR-181a-5p antagomir in preventing OPLL development both in vivo and in vitro . Our work is the first to demonstrate that microRNA perturbation could modulate the development of OPLL through epigenetic regulation., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

We compared the bone strength measured via quantitative computed tomography-based finite element method (QCT/FEM) between healthy adults with and without ossification of the posterior longitudinal ligament (OPLL). No statistically significant difference was observed in the bone strength between healthy adults with and without OPLL. Hyperostosis of the posterior longitudinal ligament in OPLL may not be associated with the systemic bone strength., Introduction: Although patients with OPLL have been reportedly associated with increased level of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA), little is known about the bone strength in OPLL subjects. The aim of this study is to investigate the bone strength measured via QCT/FEM in healthy subjects with OPLL using the medical check-up data, including whole-body CT scans., Methods: We examined 796 participants (529 men and 267 women) who underwent CT scans in a single health center between January 2008 and May 2009. We identified OPLL in whole spine and divided the subjects into two groups: non-OPLL and OPLL groups. We calculated the predicted bone strength (PBS) of the proximal femur using QCT/FEM and examined the bone mineral status of the calcaneus using quantitative ultrasound (QUS). We compared the PBS and the QUS parameters between the non-OPLL and OPLL groups., Results: Seventy-four subjects (9.3%; 57 men and 17 women) were diagnosed with OPLL in the whole spine. The OPLL group was significantly older than the non-OPLL group. No statistically significant difference was observed in the PBS and the QUS parameters between the non-OPLL and OPLL groups in both sexes. Furthermore, no statistically significant difference was noted in the PBS and the QUS parameters between two groups in age- and gender-matched analysis., Conclusions: Our results suggest that hyperostosis of the posterior longitudinal ligament in OPLL may not be associated with bone strength and bone mineral status at the extremities.

Although several risk factors have been reported for cervical ossification of the longitudinal ligament (OPLL), most evaluations made in the past were based on plain X-ray, not on computed tomography (CT) scan. In this study, we aimed to clarify novel risk factors for cervical OPLL in asymptomatic subjects undergoing CT scan as their routine medical checkups. A total of 1789 Japanese asymptomatic subjects who underwent CT scan for the whole body as their routine medical checkups were retrospectively reviewed. The medical checkup also included laboratory examinations, bone mineral status, and ultrasound of the carotid artery. As a result, cervical OPLL was seen in 120 subjects (6.7%). As we compared the demographic and clinical data between subjects with and without OPLL, OPLL group showed older age, higher proportion of male sex, higher BMI, higher incidence of hypertension, higher levels of blood HbA1c and triglyceride, and higher incidence of plaques in the carotid artery. A multivariate logistic regression analysis revealed that age (Odds ratio (OR):1.03), male sex (OR: 1.91), and the presence of plaque in the carotid artery (OR: 1.71) were risk factors for OPLL. To the best of our knowledge, this is the first report to reveal an association between OPLL and arteriosclerotic lesions.

Study Design: Retrospective cohort study., Objective: The aim of this study was to elucidate the progression of ossification of the posterior longitudinal ligament (OPLL) in conservatively managed patients and determine its risk factors SUMMARY OF BACKGROUND DATA.: Although several studies have demonstrated how OPLL progresses after laminoplasty or fusion, its progression in conservatively managed patients remains unclear., Methods: The vertical length of the ossified mass and its thickness at each segment were evaluated on sagittal computed tomography images. Patients with vertical growth >2 mm were included in the vertical progression group. Segments with a thickness progression >1 mm were classified as thickness progressed segments, and patients who had at least one progressed segment were included in the thickness progression group. Based on the characteristics at each disc level, the ossified mass at each segment was classified into four types: type 1, no disc space involvement; type 2, involving the disc space, but not crossing; type 3, crossing the disc space, but not fused; and type 4, completely fused., Results: The progression of ossified mass was observed in younger patients (P < 0.01) and in C2-C3 involvement (P < 0.01) cases. Moreover, progression in both directions was observed more frequently in the mixed-type OPLL (P < 0.01). Progression occurred most often in type 3 segments (72.0%, P < 0.01). In type 3 segments, thickness progression was found more frequently in segments with segmental range of motion (ROM) ≥5° (55.6% vs. 27.8%, P = 0.04). The proportion of segments whose initial thickness was >5 mm was significantly higher among progressed segments (60.0% vs. 35.2%, P = 0.03)., Conclusion: Young age, C2-C3 involvement, and mixed-type OPLL are risk factors for OPLL progression. Segments with morphology of crossing the segment, but without fusion (type 3), segmental ROM ≥5°, and initial thickness >5 mm need special attention., Level of Evidence: 3.

OPLL is a progressive process that can result in spinal cord compression and myelopathy. Various surgical approaches for the management of OPLL in the cervical spine exist. Our goal is to present our institution's experience in the management of OPLL over the last 20 years. Sixty-eight patients underwent surgery for cervical OPLL. Mean age at surgery was 56.9 years. No differences between demographic characteristics and surgical approach were identified. There were no significant differences between the approaches regarding the mean estimated blood loss, occurrence of durotomy, reoperation rate, positive K-line and preoperative cervical spine sagittal balance. Number of levels operated on was significantly different (anterior approach 2 ± 0.8 levels, posterior approach 4.3 ± 1.3 levels, combined approach 3.3 ± 0.9 levels, p-value <0.01), but postoperative sagittal balance was not (anterior approach Cobb angle 11.9 ± 5.8 degrees, posterior approach Cobb angle 7 ± 3.5 degrees, combined approach Cobb angle 16.7 ± 7.3 degrees, p-value = 0.09). Functional outcomes were good for 70% of patients and did not significantly differ across approaches (anterior approach 28%, posterior approach 33%, combined approach 9%, p-value = 0.46). Good functional outcomes were more commonly observed in patients with a positive K-line (OR 0.2, 95% CI 0.04-0.9, p-value 0.05) while poor outcomes were most commonly observed in patients with an occupational ratio >0.6 (OR 6.9, 95% CI 1.35-42.7, p-value 0.02). OPLL is a rare disease for which prompt referral for surgical decompression may lead to good clinical outcomes., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: To investigate the association between ossification of the posterior longitudinal ligament (OPLL) and ossification of the nuchal ligament (ONL) in terms of incidence and size., Methods: This retrospective study evaluated 297 patients who underwent CT of the cervical spine (C-spine). Two radiologists worked in consensus. The incidence of OPLL from patients with and without ONL was compared using Chi Square tests. The mean lengths of ONL from patients with and without OPLL were compared using Student t-test. The correlations between the length of ONL and the presence of OPLL and between the length of ONL and the length of OPLL were analyzed with Pearson correlations., Results: We found that OPLL occurred more frequently in patients with ONL than in patients without ONL (odd ratio = 2.524, p = 0.037); however, the mean length of ONL did not differ significantly patients with and without OPLL (p = 0.874). We found no significant correlation between the length of ONL and the length of OPLL (p = 0.233)., Conclusion: The presence of ONL was associated with the presence of OPLL. The length of OPLL and ONL showed no correlation., Competing Interests: The authors have declared that no competing interests exist.

Some localized or multisystem diseases as well as congenital anomalies occasionally involve thyroid and unusual findings will be identified during thyroid ultrasonography. Recognition of these entities will minimize unnecessary complementary examination and lead to appropriate management for patients. Therefore, we aim to review sonographic features of these extrathyroidal diseases that affect thyroid in adults. Our review derives from cases diagnosed in our hospital and published literature, with pictures accessible using as illustration. These disorders included intrathyroidal parathyroid adenoma, intrathyroidal cystic findings of nonthyroid origin, metastases to the thyroid, esophageal diverticulum, paratracheal air cysts, and ossification of anterior longitudinal ligament.

Background: Fahr's syndrome presenting multiple and symmetric calcification of basal ganglia and cerebral cortex is rare, and idiopathic hypoparatyroidism is known as one of the causes. The relationship between ossification of posterior longitudinal ligament (OPLL) and idiopathic hypoparatyroidism is also reported in a few cases. Here, we report a patient presenting concomitant Fahr's syndrome and thoracic OPLL developed by idiopathic hypoparatyroidism., Case Presentation: 53-year-old female patient presented myelopathic sign including gait disturbance and both leg weakness (Grade 3) for 4 months after slip down, and has the history of anti-epileptic medication for several years. Magnetic resonance imaging revealed cord compression by the mixed-type OPLL from T5 to T9, and decompressive surgery was planned. Sudden onset generalized tonic-clonic seizure attack developed before the surgery. Hypocalcemia (3.7 mg/dL) with QT prolongation on electrocardiogram, hypomagnesemia (1.4 mg/dL), hyperphosphatemia (7.7 mg/dL), hypoparathyroidism, and normal range of vitamin D was noted. Brain study showed Fahr's syndrome with multiple and symmetric calcification of basal ganglia, cerebral cortex, and cerebellum. Decompressive laminectomy was performed after transient correction of hypocalcemia. The myelopathic symptoms improved to normal walking by the 14-month follow-up. The cause of hypoparathyroidism was concluded to be idiopathic., Conclusion: Concomitant expression of Fahr's syndrome and OPLL related with idiopathic hypoparatyroidism is very rare. However, we recommend considering the possibility of hypoparathyroidism and Fahr's syndrome when we evaluate the patients with OPLL to avoid the risks of sudden onset seizure and cardiac arrhythmia due to cerebral lesions and hypocalcemia.

Objective: Sagittal imbalance and loss of lumbar lordosis are the main drivers of functional disability in adult degenerative scoliosis. The main limitations of the classic posterior lumbar interbody fusion technique are increased risk of neurological injury and suboptimal correction of the segmental lordosis. Here, the authors describe the radiological results of a modified posterior lumbar interbody fusion and compare the results with a historical cohort of patients., Methods: Eighty-two consecutive patients underwent surgical treatment for degenerative scoliosis/kyphosis in a single tertiary referral center for complex spinal surgery. Fifty-five patients were treated using the classic multilevel posterior lumbar interbody fusion (MPLIF) technique and 27 were treated using the modified MPLIF technique to include a release of the anterior longitudinal ligament (ALL) and the annulus. A radiographic review of both series of patients was performed by two independent observers. Functional outcomes were obtained, and patients were registered in the European Spine Tango registry., Results: The mean L4-5 disc angle increased by 3.14° in the classic MPLIF group and by 12.83° in MPLIF plus ALL and annulus release group. The mean lumbar lordosis increased by 15.23° in the first group and by 25.17° in the second group. The L4-S1 lordosis increased on average by 4.92° in the classic MPLIF group and increased by a mean of 23.7° in the MPLIF plus ALL release group when both L4-5 and L5-S1 segments were addressed. There were significant improvements in the Core Outcome Measures Index and EQ-5D score in both groups (p < 0.001). There were no vascular or neurological injuries observed in either group., Conclusions: The authors' preliminary results suggest that more correction can be achieved at the disc level using posterior-based ALL and annulus release in conjunction with posterior lumbar interbody fusion. They demonstrate that ALL and annulus release can be performed safely using a posterior-only approach with minimal risk of vascular injury. However, the authors recommend that this approach should only be used by surgeons with considerable experience in anterior and posterior spinal surgery.

Objective: We investigated whether the cerebrospinal fluid (CSF) space on magnetic resonance imaging (MRI) correlates with the outcomes of anterior controllable antedisplacement and fusion (ACAF) for ossification of the posterior longitudinal ligament (OPLL)., Methods: A total of 53 patients with OPLL who had undergone ACAF were enrolled. The Japanese Orthopaedic Association (JOA) scale, visual analog scale, and neck disability index were used to evaluate the clinical outcomes. The area of CSF space and spinal cord on T2-weighted MRI, the occupying rate of the CSF space and spinal cord, and the postoperative MRI score of the CSF space were measured. The patients were divided into 2 groups according to the JOA score improvement rate (IR). The relationship between the postoperative MRI score and the JOA score IR was analyzed., Results: The patients in group A experienced better recovery compared with those in group B regarding the JOA, visual analog scale, and neck disability index score at the final follow-up visit. On both axial and sagittal T2-weighed MRI, patients in group A experienced lower improvement of the area of the spinal cord than in group B (P > 0.05). However, the mean improvement in the CSF space in group A was better than that in group B (62.86 ± 30.05 mm 2 vs. -6.36 ± 24.58 mm 2 ; P < 0.05), with a greater occupying rate of CSF space in group A at the final visit. A strong correlation was noted between the JOA score IR and postoperative CSF space score (P < 0.01)., Conclusion: These results suggest that ACAF could provide good decompression of the spinal cord and neurological improvement. Also, recovery of the CSF space correlated closely with the surgical ACAF outcomes for cervical myelopathy due to OPLL., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to compare the mean lengths of the posterior longitudinal ligament (PLL) as the acoustic window during the thoracic paramedian epidural approach after shoulder rotation, while subjects were in the lateral decubitus or in the sitting position., Methods: Thirty-two adult male volunteers were placed in the right decubitus position or sitting position on a horizontal operating table. To obtain an optimal ultrasound view for the PLL on the right side, thoracic spinal ultrasonography was performed at the T6/7 interspace using the paramedian oblique sagittal plane. PLL length was measured on the ultrasound image before and after right shoulder rotation., Results: Before shoulder rotation, the difference in mean PLL length between the sitting (11.1±1.3mm) and lateral decubitus (10.7±1.2mm) positions was not statistically significant (P=0.05). Within-position, the before and after comparison revealed that after shoulder rotation, PLL length was significantly increased to 12.2±1.4mm (P<0.001) and 12.0±1.5mm (P<0.001) in the sitting and lateral decubitus positions, respectively. However, after shoulder rotation the between-position difference in mean PLL length was not statistically significant (P=0.50) CONCLUSIONS: Shoulder rotation did not result in a statistically significant difference in the dimension of the acoustic target window for paramedian thoracic epidural access in the sitting compared to the lateral decubitus position., (Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: The development and etiology of diffuse idiopathic skeletal hyperostosis (DISH) were far from complete understanding. Even the precise mechanism of the development of its typical right-sided ossification of the anterior longitudinal ligament (OALL) frequently compared to 'flowing candle wax', a hallmark of DISH, remains unknown., Methods: The participants of this study were 261 individuals (31 females and 230 males) diagnosed as DISH according to the criteria established by Resnick and Niwayama extracted from a consecutive 3013 patients who have undergone chest CT for the examination of pulmonary diseases in our institute. The patients with previous thoracic spine surgery and younger than 15 years old were excluded. Chest CT data were converted to the condition suitable for bone evaluation by the software application. The positional relationship between thoracic aorta and OALL, the morphology of the OALL adjacent to the aorta and the presence of calcification of the aortic wall adjacent to the OALL were studied., Results: Of 261 individuals with DISH, we found that thoracic aorta was localized adjacent to the OALL (AD-group) in 123 cases (47%), whereas 138 cases (53%) were not (NAD-group). All OALL in AD-group was localized between T6 and T12. The shape of the OALL adjacent to the aorta was either flat or concave except for one. No case showed obvious calcification of the aortic wall adjacent to the OALL in AD-group., Conclusions: The aortic pulsation might play an important role in inhibit the development of the OALL toward the aorta in DISH. It is likely that establishment of the optimal condition of the pulsation stress simulating aortic pulsation and its delivery system can achieve arresting, slowing the progression and/or changing the morphology of the ossified lesions., (Copyright © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Previous studies have shown that patients with cervical ossification of the posterior longitudinal ligament (OPLL) often have co-existing ossification of the nuchal ligament (ONL). However, no studies have focused on ONL and its relevance to the severity of OPLL or ossification of other spinal ligaments, such as anterior longitudinal ligament (OALL), ligamentum flavum (OLF), and supraspinous/interspinous ligament (OSIL)., Methods: In this multicenter study, we investigated ossification of the spinal ligaments in the whole spine computed tomography (CT) images of 233 cervical OPLL patients. The severity of ossification was evaluated using ossification index for each spinal ligament, calculated as the sum of the level of ossification. We compared the severity of ossification in each spinal ligament between patients with ONL and those without ONL. Furthermore, we investigated how the number of segments, where ONL exists, affects the severity of ossification in each spinal ligament., Results: One hundred thirty patients (55.8%) had co-existing ONL in the cervical OPLL patients included in this study. The ONL (+) group included more male and aged patients. The cervical ossification indexes of OPLL and OALL were higher in ONL (+) patients than in ONL (-) patients. The thoracolumbar ossification indexes of OALL and OSIL were also higher in ONL (+) patients. Logistic regression analysis revealed that age, gender and cervical OA-index were independent factors correlating to the existence of ONL. In the cervical spine, both the ossification indexes of OALL and OPLL increased as the levels of ONL increased. Similarly, in the thoracolumbar spine, both the ossification indexes of OALL and OSIL were increased as the levels of cervical ONL increased. In the multiple regression analysis, cervical OA-index and thoracolumbar OSI-index showed significant correlation with the number of ONL levels., Conclusions: Co-existence of ONL in cervical OPLL patients was associated with the severity of spinal hyperostosis especially in cervical OPLL, OALL, thoracolumbar OALL and OSIL., (Copyright © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Purpose: This study aims to determine whether secondary CT findings can predict posterior ligament complex (PLC) injury in patients with acute thoracic (T) or lumbar (L) spine fractures., Methods: This is a retrospective study of 105 patients with acute thoracic and lumbar spine fractures on CT, with MRI as the reference standard for PLC injury. Three readers graded CT for facet joint alignment (FJA), widening (FJW), pedicle or lamina fracture (PLF), spinous fracture (SPF), interspinous widening (ISW), vertebral translation (VBT), and posterior endplate fracture (PEF). Univariate and multivariate logistic regression analyses were performed separately for each reader to test for associations between CT and PLC injury, and diagnostic performance of CT was calculated., Results: Fifty-three of 105 patients had PLC injury by MRI. Statistically significant predictors of PLC injury were VBT, PLF, ISW, and SPF. Using these four CT findings, odds of PLC injury ranged from 3.8 to 5.6 for one positive finding, but increased to 13.6-25.1 for two or more. At least one positive CT finding was found to yield average sensitivity of 82% and specificity 59%, while two or more yielded sensitivity 46% and specificity 88%., Conclusion: While no individual CT finding is sufficiently accurate to diagnose or exclude PLC injury, greater the number of positive CT findings (VBT, PLF, ISW, and SPF), the higher the odds of PLC injury. The presence of a single abnormal CT finding may warrant confirmatory MRI for PLC injury, while two or more CT findings may have adequate specificity to avoid need for MRI prior to surgical intervention. These slides can be retrieved under Electronic Supplementary Material.

Objective: To define radiologic parameters and the diagnostic accuracy of computed tomography (CT) scan on posterior ligamentous complex (PLC) injury, identified by magnetic resonance imaging (MRI) in patients with thoracolumbar (TL) fracture., Methods: We retrospectively analyzed 88 patients with TL fractures divided into 2 groups by PLC status evident on MRI: intact and ruptured. The parameters assessed included the anterior fractured vertebral body height (AVH) and posterior fractured vertebral body height, upper and lower AVH, anterior/posterior vertebral height ratio, AVH ratio, local kyphotic angle (LKA), region angle (RA), sagittal index (SI), Gardner angle (GA), Gardner index (GI), Cobb angle, interspinous distance (ISD), upper and lower ISD, ISD ratio, interspinous distance minus (ISDM), interspinous angle (ISA), and upper and lower ISA. The t test, Pearson χ 2 test, and multivariate logistic regression were used., Results: PLC rupture (vs. intact) was associated with RA, GA, GI, ISD, ISD ratio, and ISDM. The positive risk factors for PLC rupture were GA, LKA, SI, and RA. The negative risk factors for PLC rupture were SI greater than 20° and GI. PLC rupture was associated with the SI, upper interspinous distance, ISD ratio, ISDM, and ISA in those with type A1/A2 fractures and the GA, GI, ISD, ISD ratio, and ISDM in those with type A3/A4 fractures., Conclusions: An RA greater than 16°, SI greater than 20°, and GI greater than 24° were associated with PLC injury in patients with type A TL fractures, and an RA greater than 16° and SI greater than 20° predicted PLC injury in type A1 and A2 fractures. An SI greater than 20°, GI greater than 24°, LKA greater than 26°, and ISD ratio greater than 56% predicted PLC injury in type A3 and A4 fractures., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Despite the fact that ossification of posterior longitudinal ligament (OPLL) is a three-dimensional disease, conventional studies have focused mainly on a two-dimensional measurement, and it is difficult to accurately determine the volume of OPLL growth and analyze the factors affecting OPLL growth after posterior decompression (laminoplasty or laminectomy and fusion)., Purpose: The present study aimed to investigate the factors affecting OPLL volume growth using a three-dimensional measurement., Study Design/setting: This was a retrospective case study., Patient Sample: Eighty-three patients with cervical OPLL who were diagnosed as having multilevel cervical OPLL of more than three levels on cervical computed tomography (CT) scans were retrospectively reviewed from June 1, 1998, to December 31, 2015., Outcome Measures: The OPLL volume from the C1 vertebrae to the C7 vertebrae was measured on preoperative and the most recent follow-up CT scans., Methods: Eighty-three patients were retrospectively examined for age, gender, body mass index, hypertension, diabetes, type of OPLL, surgical method, preoperative cervical curvature, and preoperative and postoperative cervical range of motion. Preoperative cervical CT and the most recent follow-up cervical CT scans were converted to Digital Imaging and Communications in Medicine data, and the OPLL volume was three-dimensionally measured using the Mimics program (Materialise, Leuven, Belgium). The OPLL volume growth was analyzed using univariate and multivariate analyses., Results: The average follow-up period was 32.36 (±23.39) months. Patients' mean age was 54.92 (±8.21) years. In univariate analysis, younger age (p=.037) and laminoplasty (p=.012) were significantly associated with a higher mean annual growth rate of OPLL (%/y). In multivariate analysis, only laminoplasty (p=.027) was significantly associated with a higher mean annual growth rate of OPLL (%/y). The mean annual growth rate of OPLL was about seven times faster with laminoplasty (8.00±13.06%/y) than with laminectomy and fusion (1.16±9.23%/y)., Conclusions: Posterior instrumented fusion has the effect of reducing OPLL growth rate compared with motion-preserving laminoplasty. Patients' age and the surgical method need to be considered in surgically managing the multilevel OPLL., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Diffuse idiopathic skeletal hyperostosis (DISH) is often theorized to be an ossification of the anterior longitudinal ligament (ALL). Using computed tomography (CT) imaging and cryomacrotome sectioning, we investigated the spatial relationship between the ALL and newly formed bone in DISH to test this hypothesis. In the current study, four human cadaveric spines diagnosed with DISH using CT imaging were frozen and sectioned using a cryomacrotome. Photographs were obtained of the specimen at 125 µm intervals. Manual segmentations of the ALL on cryomacrotome photographs were projected onto the three-dimensional reconstructed CT scans. The presence and location of newly formed bone were assessed in relationship to the location of the ALL. The ALL could be identified and segmented on the photographs at all levels. The ALL was located at the midline at levels where no new bone had formed. At the locations where new bone had abundantly formed, the ALL was displaced towards to the contralateral side and not replaced by bony tissue. The displacement of the-morphologically normal appearing-ALL away from the newly formed bone implies that newly formed bone in DISH may not originate from the ALL. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society J Orthop Res 36:2491-2496, 2018., (© 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society.)