Ossification of the posterior longitudinal ligament
Ossification of the posterior longitudinal ligament (OPLL) is typically an entity seen in patients of Asian descent, although it is seen in all ethnic groups. It is characterized by, as the name suggests, ossification of the posterior longitudinal ligament.
There is a recognised greater prevalence in males and in the elderly 3. There is also considerable racial variation:
- incidence in the Japanese/Asian population: 2.4%
- incidence in Caucasians: 0.2-0.7%
OPLL is twice as common in men compared with women.
Patients may be asymptomatic, or have evidence of radiculopathy and/or myelopathy 11. If present, symptoms usually manifest in the 4th-6th decades of life 7,8.
The exact pathogenesis of OPLL is rather unclear 3.
OPLL is often associated with several other entities:
- diffuse idiopathic skeletal hyperostosis (DISH)
- ossification of the ligamentum flavum
- ankylosing spondylitis 3
- schizophrenia: possible (in one study) 12
DISH may be seen in up to 12% of elderly male Caucasians, with OPLL seen in about half of these, suggesting the incidence among Caucasians may be higher than the figures above.
This typically seen in the mid cervical spine and results in central canal stenosis, predisposing the patient to cord injury from minor trauma:
- cervical: 75%
- thoracic: 15%
- lumbar: 10%
Stages of spinal cord damage by OPLL
- stage 0: normal or mild compression of the anterior horn without neuronal loss
- stage 1: mild compression of the anterior horn with partial neuronal loss
- stage 2: marked deformity of anterior horn; severe neuronal loss
- stage 3: severe spinal cord damage
T2-weighted sequences are considered the most effective in the evaluation of spinal cord compression due to both the ossification and abnormal signal intensity of the spinal cord 5.
Types of OPLL
- type 1: continuous (ossification of several vertebral segments)
- type 2: segmental (several segments are affected, ossification is disrupted)
- type 3: mixed (mix of types 1 and 2)
- type 4: localised (circumscribed, only one or two segments)
Treatment and prognosis
Management can range from conservative to surgical removal. Surgical options can include an anterior, posterior or combined approach. An anterior approach (e.g. plated multilevel anterior discectomy and fusion, anterior cervical corpectomy with fusion) may provide more direct decompression and best improve myelopathy, although may cause greater soft-tissue morbidity. Posterior approaches (e.g. laminectomy and fusion and laminoplasty) may be better tolerated in older patients 8.
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- 2. Koyanagi I, Iwasaki Y, Hida K et-al. Magnetic resonance imaging findings in ossification of the posterior longitudinal ligament of the cervical spine. J. Neurosurg. 1998;88 (2): 247-54. doi:10.3171/jns.1998.88.2.0247 - Pubmed citation
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- 7. Choi BW, Song KJ, Chang H. Ossification of the posterior longitudinal ligament: a review of literature. Asian Spine J. 2011;5 (4): 267-76. doi:10.4184/asj.2011.5.4.267 - Free text at pubmed - Pubmed citation
- 8. Smith ZA, Buchanan CC, Raphael D et-al. Ossification of the posterior longitudinal ligament: pathogenesis, management, and current surgical approaches. A review. Neurosurg Focus. 2011;30 (3): E10. doi:10.3171/2011.1.FOCUS10256 - Pubmed citation
- 9. Epstein N. Diagnosis and surgical management of cervical ossification of the posterior longitudinal ligament. Spine J. 2003;2 (6): 436-49. Pubmed citation
- 10. Sato R, Uchida K, Kobayashi S, Yayama T, Kokubo Y, Nakajima H, Takamura T, Bangirana A, Itoh H, Baba H. Ossification of the posterior longitudinal ligament of the cervical spine: histopathological findings around the calcification and ossification front Journal of Neurosurgery: Spine, August 2007 / Vol. 7 / No. 2 : Pages 174-183
- 11. Abiola R, Rubery P, Mesfin A. Ossification of the Posterior Longitudinal Ligament: Etiology, Diagnosis, and Outcomes of Nonoperative and Operative Management:. (2015) Global Spine Journal. 6 (2): 195-204. doi:10.1055/s-0035-1556580 - Pubmed
- 12. Matsunaga S, Koga H, Kawabata N, Kawamura I, Otusji M, Imakiire T, Komiya S. Ossification of the posterior longitudinal ligament in dizygotic twins with schizophrenia: a case report. (2008) Modern rheumatology. 18 (3): 277-80. doi:10.1007/s10165-008-0036-1 - Pubmed