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.
Overview
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:
- Segmental
- Continuous
- Mixed
- Other
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.
Anesthetic Considerations
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.
Postoperative Care and Rehabilitation
Recovery from OPLL surgery involves a combination of rest, medication, and physical therapy. The goals of rehabilitation are to restore function, reduce pain, and prevent recurrence. Patients are typically advised to:
- Follow a tailored physical therapy program to improve strength and flexibility.
- Avoid activities that put strain on the neck and spine.
- Monitor for any signs of complications, such as increased pain, numbness, or weakness, and report them to their healthcare provider immediately
Prognosis and Outcomes
The prognosis for patients with OPLL varies depending on the severity of the condition and the success of the treatment. Surgical outcomes are generally favorable, with many patients experiencing significant relief from symptoms and improved quality of life. However, some may continue to have residual symptoms or complications, particularly if the ossification is extensive or if there was significant preoperative spinal cord damage
Do you have more questions?
What causes OPLL?
The exact cause is unknown, but it is believed to be due to a combination of genetic, hormonal, and environmental factors. There are associations with conditions like diabetes and obesity, and it is more common in East Asian populations
How is OPLL diagnosed?
Diagnosis typically involves a combination of patient history, physical examination, and imaging studies like X-rays, MRI, and CT scans to identify the ossification and assess the extent of spinal cord compression
What are the symptoms of OPLL?
Symptoms include neck pain and stiffness, radiating pain to the shoulders and arms, numbness or tingling in the hands, weakness in the arms and legs, difficulty with coordination and balance, and in severe cases, paralysis or bladder and bowel dysfunction
What non-surgical treatments are available for OPLL?
Non-surgical treatments include pain relievers, anti-inflammatory drugs, muscle relaxants, physical therapy, and lifestyle modifications such as weight management and avoiding activities that exacerbate symptoms
What surgical options are available for treating OPLL?
Surgical options include anterior approaches like ACDF and corpectomy, posterior approaches like laminoplasty and laminectomy, and sometimes combined approaches for more extensive cases
When is surgery recommended for OPLL?
Surgery is recommended when conservative treatments fail to relieve symptoms or if there is significant spinal cord compression that poses a risk of severe neurological damage
What is the recovery process like after OPLL surgery?
Recovery involves rest, medication, and physical therapy. Patients are typically advised to follow a tailored physical therapy program, avoid strain on the neck and spine, and monitor for complications
How successful is OPLL surgery?
Surgical outcomes are generally favorable, with many patients experiencing significant relief from symptoms and improved quality of life. However, some may continue to have residual symptoms or complications
What are the risks associated with OPLL surgery?
Risks include infection, bleeding, spinal fluid leakage, nerve damage, and worsening of neurological symptoms due to spinal cord manipulation
Can OPLL recur after surgery?
While surgery can relieve symptoms and stabilize the spine, there is a risk of recurrence. Ongoing follow-up and possibly further treatment may be necessary
What role does genetics play in OPLL?
Genetics is believed to play a significant role in OPLL, with certain genetic markers associated with an increased risk. This is particularly evident in populations with a higher prevalence of the condition
Are there any lifestyle changes that can help manage OPLL?
Yes, weight management, proper posture, regular exercise, and avoiding activities that strain the neck and spine can help manage OPLL symptoms
How does OPLL progress over time?
OPLL can progress slowly, with gradual worsening of symptoms as the ossification increases and further compresses the spinal cord and nerves. Early intervention can help manage the progression
Can physical therapy help with OPLL?
Yes, physical therapy can help strengthen the neck muscles, improve flexibility, and reduce pain. A tailored physical therapy program is an important part of both conservative treatment and postoperative recovery
Is there a cure for OPLL?
There is no cure for OPLL, but treatments can effectively manage symptoms and prevent further progression. Research into the genetic and molecular mechanisms of OPLL may lead to new therapeutic approaches in the future
What is the difference between laminoplasty and laminectomy?
Laminoplasty involves reshaping or repositioning the lamina to relieve pressure on the spinal cord while maintaining stability. Laminectomy involves removing the lamina to create more space for the spinal cord, often combined with spinal fusion for stability
How long does it take to recover from OPLL surgery?
Recovery time varies depending on the type of surgery and the patient’s overall health, but it typically takes several weeks to months. Full recovery and return to normal activities can take up to a year
What are the potential complications of not treating OPLL?
Untreated OPLL can lead to severe spinal cord compression, resulting in chronic pain, significant neurological deficits, and in extreme cases, paralysis and loss of bladder and bowel control
Can children develop OPLL?
OPLL is rare in children and is more commonly seen in middle-aged and older adults. However, it can occur in younger individuals, particularly those with a genetic predisposition
How does OPLL differ from other spinal conditions like spondylosis or disc herniation?
OPLL involves the ossification of a specific spinal ligament, whereas spondylosis refers to general degenerative changes in the spine, and disc herniation involves the displacement of the intervertebral disc material. Each condition has distinct causes, symptoms, and treatment approaches
Are there any new treatments or research developments for OPLL?
Research is ongoing to better understand the genetic and molecular mechanisms of OPLL, which may lead to new treatments. Advances in imaging and surgical techniques are also improving the diagnosis and management of the condition
What should I do if I suspect I have OPLL?
If you have symptoms suggestive of OPLL, such as neck pain, numbness, or weakness, you should seek medical evaluation. An orthopedic surgeon or spine specialist can perform the necessary diagnostic tests and recommend appropriate treatment
Can OPLL affect other parts of the spine besides the cervical region?
Yes, while OPLL is most commonly found in the cervical spine, it can also occur in the thoracic and lumbar regions, though less frequently
How does the surgical approach for OPLL get decided?
The choice of surgical approach depends on the extent and location of ossification, the patient’s overall health, and the surgeon’s experience. Detailed imaging studies and thorough patient evaluation guide the decision-making process
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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