Ossification of the Posterior Longitudinal Ligament (OPLL) Opinion on Surgical and Medication Management Volume 50- Issue 5

Celeste R Lucero*

• SMFLC Educational Consultancy and Development Center, Applied/ Academic Research Department, Philippines

Received: May 30, 2023;   Published: June 08, 2023

*Corresponding author: Celeste R Lucero, SMFLC Educational Consultancy and Development Center, Applied/ Academic Research Department, Philippines

DOI: 10.26717/BJSTR.2023.50.008028

Abstract PDF

My journey with Ossification of the Posterior Longitudinal Ligament (OPLL) and the resultant spinal stenosis has been one of endurance and perseverance. Never in my childhood did I experience any trauma that could have precipitated this condition? My initial brush with discomfort began one fateful night in 2009 while working for a USAID contractor in Iraq. A seemingly innocuous incident of being pushed against an armored vehicle due to an evacuation procedure set off a cascade of symptoms – intense pain in the legs and an inability to urinate the following morning, signaling the advent of a significant health concern. Despite receiving pain medication, the relief was ephemeral. The quest for a diagnosis led me to Dubai, UAE, where the preliminary medical tests pointed toward a lumbar spine issue that warranted surgical intervention. Given the dearth of familial support in a foreign land, I decided to seek treatment in my home country, the Philippines. The same diagnosis was reiterated at a reputed hospital in the Philippines after extensive tests – MRI and CT scan with contrast. My weight, higher than average since childhood, was considered a potential contributory factor. Following three weeks of rigorous physical therapy, I returned to work in Iraq, only to experience a recurrence of the pain within a month. I embarked on a whirlwind journey of exploring every available treatment option – traditional healers, massage therapists, acupuncturists – only to encounter persistent symptoms. It was only at the Philippine Orthopedic Center that a consultant on spine surgery proposed a deviation from the established diagnosis – he suspected the problem was with my thoracic spine rather than the lumbar.

Subsequent MRI and EMG confirmed his suspicion in September 2009 – my ossified ligament from T3-T9 was compressing my spinal cord, inducing myelopathy, spasticity, and neuropathic pain. An intervening natural disaster delayed further consultation and potential surgery. By the time I saw the doctor again in November 2009, my condition had exacerbated – significant swelling in the legs, inability to walk, severe spasticity leading to breathing difficulties, and heightened sensitivity to touch. The subsequent surgery, a memory etched in my mind, was marked by periods of discomfort and stress. My recovery, although slow, was aided by an extended hospital stay involving rigorous physical therapy. Eventually, I was able to regain my ability to stand, urinate, and have bowel movements independently. While I was able to return to work overseas and continue with my daily activities post-surgery, the symptoms resurfaced periodically, leading to multiple rounds of posterior laminectomy surgeries between 2011 and 2016.

Each surgical intervention was necessitated by the unfortunate regeneration of the spinal bone, compressing my spinal cord from various levels, T3-T9 to T9-T11. In 2016, my fifth among my thoracic spine surgery, my surgeon performed an extensive laminectomy from the T3-T12 level, which seems to have curbed the recurrence of symptoms since then. My persistent curiosity about the nature of OPLL led me to delve into various studies and research on the subject. The ensuing journey of knowledge exploration has shed light on many aspects of this condition, although many aspects remain enigmatic, such as the exact reason for the regeneration of the spine causing spinal cord compression. The hope remains for the development of effective medication and a broader understanding of this disease, its prevalence among different demographics, particularly the Japanese descent (Sasaki, et al. [1]), and its complex nature.

The complicated and clinically relevant syndrome known as ossification of the posterior longitudinal ligament (OPLL), which appears as ectopic new bone development in the spinal ligament, has been thoroughly investigated in several research. A summary and analysis of the surgical therapy of OPLL, biology, epidemiology, natural history, radiographic predictors, tandem ossification, and other related surgical problems are included in this review of the literature. (Epstein [2]) pioneered research in the surgical management of OPLL, studying a cohort of 51 patients. This research underscored the significance of tailoring surgical approaches to individual patients based on variables such as OPLL severity and overall health condition. Epstein’s work set a strong foundation for further surgical studies, emphasizing the necessity of meticulous preoperative planning and surgical precision. (Inamasu, et al. [3]) provided a comprehensive review of the biology, epidemiology, and natural history of OPLL. The researchers explicated the systemic nature of OPLL, linking it to metabolic abnormalities. Furthermore, they clarified the demographic patterns of OPLL, primarily its prevalence in Asian populations, and its natural, slowly progressive course (Inamasu, et al. [3]).

A similar exploration of OPLL was conducted by (Matsunaga, et al. [4]), focusing on the radiographic predictors for the onset of myelopathy in patients with OPLL. They underscored the role of the occupying ratio of OPLL and the range of motion at the segment of the canal stenosis as crucial predictive factors. The findings emphasized the importance of radiographic evaluation in clinical practice. Tandem ossification in the cervical and thoracic spine was investigated by (Park, et al. [5]) They noted a significant association between cervical OPLL and thoracic ligament ossification, pointing towards a systemic propensity for ossification. Their findings have important implications for patient evaluations and emphasize vigilance in treating cervical OPLL due to potential thoracic involvement. (Yamazaki, et al. [6,7]) presented two case studies about the potential postoperative neurological complications in patients undergoing laminectomy for thoracic myelopathy due to OPLL. These cases highlight the importance of surgical caution and robust postoperative care due to the risk of transient paraparesis following the procedure. In cohort research conducted by (Sasaki, et al. [1]), the prevalence of cervical OPLL symptoms in the general Japanese population was found to be 3.9 percent in symptomatic participants and 2.2 percent in asymptomatic individuals. Most OPLL patients exhibited symptoms between the neck and the arm. However, there were some untreated cases among the general Japanese population. According to this study, many people might be at risk for cervical cord injuries, and there may be a way to stop this serious harm. As was previously reported, this study found that the prevalence of OPLL was more significant in Japan than in other nations.

1291 general Japanese inhabitants served as the subjects. The lateral view of the cervical spine was used to identify radiographic OPLL, and participants were divided into OPLL and non-OPLL groups. We looked at visual analog scales for neck stiffness, neck pain, arm discomfort, and the Cervical Myelopathy Evaluation Questionnaire from the Japanese Orthopaedic Association. Statistics were used to compare neck and arm symptoms in OPLL and across subtypes (continuous, segmental, and mixed kinds). Another noteworthy case report by (Ricciardi, et al. [8]) focused on thoracic ligamentum flavum ossification, a rare cause of spinal cord injury in a Caucasian patient. This case study underlines the importance of recognizing the potential for ossification in multiple ligaments in the spine. (Sun, et al. [9]) explored the effect of laminectomy with instrumented fusion carried into the thoracic spine on the sagittal imbalance in patients with multilevel OPLL. Their work adds to the body of knowledge on how surgical techniques can influence postoperative outcomes and spinal biomechanics.

Finally, two studies reported the clinical results of surgery for thoracic myelopathy caused by OPLL, further elucidating the implications of ossification type and surgical options. Their work contributes to understanding the intricacies of surgical management and predicting postoperative outcomes in OPLL patients (Yamazaki, et al. [10,11]). Continuing from the previous literature review on ossification of the posterior longitudinal ligament (OPLL), this part focuses on the clinical features and surgical outcomes of thoracic myelopathy caused by multilevel ossification of the ligamentum flavum (OLF) as well as the utility of the posterior approach in the surgical treatment for OPLL at the thoracic spine. (Gao, et al. [12]) conducted a study to elucidate the clinical features and surgical outcomes of patients with thoracic myelopathy caused by multilevel OLF. They reported that the severity of thoracic OLF and the presence of other spinal disorders were key factors in determining the surgical outcome. The study highlighted the fact that multiple-level OLF tends to cause more severe myelopathy due to the expanded range of spinal cord compression. Early diagnosis and appropriate surgical intervention are vital to prevent severe disability and improve the quality of life in patients with multilevel OLF. Their findings underscored the need for meticulous preoperative evaluation and careful surgical planning for patients with this condition). In a different approach, one study explored the usefulness of the posterior approach in the surgical treatment of OPLL in the thoracic spine. They reported that the posterior approach provided sufficient spinal cord decompression and had relatively low surgical risk. Moreover, the posterior approach was found to be particularly effective in treating patients with a Hill-type of ossification, floating type of OPLL, or occupying ratio of OPLL of 60% or more. This study provides a strong argument for the application of the posterior approach in the surgical management of thoracic OPLL, particularly in certain subgroups of patients. It further emphasizes the importance of tailoring the surgical approach to individual patient characteristics (Hirabayashi, et al. [13]). In summary, the reviewed literature provides a comprehensive understanding of OPLL.

This body of work has made significant strides in understanding surgical management, underlying biological mechanisms, epidemiological trends, and clinical progression. The importance of radiographic evaluation and recognizing and addressing potential tandem ossification in the cervical and thoracic spine is also emphasized. Furthermore, case studies underscore the importance of cautious surgical procedures and robust postoperative care to mitigate the risk of complications such as transient paraparesis (Yamazaki, et al. [6,7]). Emerging research in surgical techniques also provides insight into how procedures can influence postoperative outcomes and spinal biomechanics (Sun, et al. [9]). It is clear that a patient-specific approach, considering the type of ossification and relevant systemic metabolic components, is paramount for achieving optimal patient outcomes (Matsuyama, et al. [10-13]) contribute important insights into OPLL and OLF clinical management. The findings emphasize the necessity of detailed preoperative evaluations and personalized surgical plans to optimize patient outcomes. Future research should continue to elucidate ossification mechanisms and improve therapeutic strategies for OPLL.

In conclusion, the journey through the Ossification of the Posterior Longitudinal Ligament (OPLL) and its associated spinal stenosis presents a complex and intricate medical narrative. The progression of this disease and the lack of a definitive cause and cure demonstrate the urgent need for continuous research and understanding in the field. Even though surgical interventions have provided temporary relief, the recurrent nature of this disease underpins the necessity for more durable and effective treatment strategies. It is vital to explore the molecular and genetic aspects of OPLL, which could offer deeper insights into the pathogenesis of this condition and subsequently lead to novel therapeutic approaches. The unanticipated regeneration of spinal bone causing spinal cord compression represents an intriguing aspect of this condition. To comprehend this phenomenon fully, extensive research and clinical studies need to be pursued, aiming at unraveling the underlying mechanisms of such pathological occurrences. Furthermore, the higher prevalence of OPLL among the Japanese population is an observation that calls for a detailed epidemiological study. Such investigations may lead to a better understanding of the etiology of OPLL, potentially shedding light on the genetic or environmental factors contributing to its development. This knowledge could be leveraged to craft preventive strategies or personalized treatment plans. In the face of these challenges and unknowns, patient experiences and narratives, such as the one recounted in this article, serve to reinforce the importance of patientcentric care. The strength and resilience demonstrated by patients living with OPLL are indeed commendable. These narratives add a human dimension to the clinical facet of this condition, reminding us that behind every disease is a person seeking answers and relief. As researchers, clinicians, and healthcare professionals, we must relentlessly pursue these answers, guided by the hope of a better future for all patients.

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