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Abstract
Ossification of ligamentum flavum (OLF) is calcification of the ligamentum flavum, which might narrow the spinal canal and causes myeloradiculopathy. This condition mainly affects the lower thoracal segment. Published reports on OLF are mostly from East Asia. There was only one Indonesian OLF case that had been published. The majority of OLF involves a single level only. This is the first Indonesian case-report on multilevel OLF. Through this case report, we aim to describe the natural history of the patient and our treatment strategy in managing the multilevel OLF case.
Delayed time to surgery is the key contributory factor in unfavorable surgical outcome in thoracic OLF. Choosing an appropriate surgical procedure is important. The neurological symptoms of the patient may not improve or worsen when an inadequate surgical procedure is used.
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References
- Aizawa T, Sato T, Sasaki H, et al. Thoracic myelopathy caused by ossification of the ligamentum flavum: clinical features and surgical results in the Japanese population. SPI. 2006;5(6):514-519. DOI:10.3171/spi.2006.5.6.514
- Moon BJ, Kuh SU, Kim S, et al. Prevalence, Distribution, and Significance of Incidental Thoracic Ossification of the Ligamentum Flavum in Korean Patients with Back or Leg Pain : MR-Based Cross Sectional Study. J Korean Neurosurg Soc. 2015;58(2):112. DOI:10.3340/jkns.2015.58.2.112
- Kang KC, Lee CS, Shin SK, et al. Ossification of the ligamentum flavum of the thoracic spine in the Korean population: Clinical article. Journal of Neurosurgery: Spine. 2011;14(4):513-519. DOI:10.3171/2010.11.SPINE10405
- Ahn DK, Lee S, Moon SH, et al. Ossification of the Ligamentum Flavum. Asian Spine Journal. 2014;8(1):89. DOI:10.4184/asj.2014.8.1.89
- Ikuta K, Tarukado K, Senba H, et al. Decompression Procedure using a Microendoscopic Technique for Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum. Minim Invasive Neurosurg. 2011;54(05/06):271-273. DOI:10.1055/s-0031-1297986
- Wang VY, Kanter AS, Mummaneni PV. Removal of ossified ligamentum flavum via a minimally invasive surgical approach: Case report. Neurosurgical Focus. 2008;25(2):E7. DOI:10.3171/FOC/2008/25/8/E7
- Liang H, Liu G, Lu S, et al. Epidemiology of ossification of the spinal ligaments and associated factors in the Chinese population: a cross-sectional study of 2000 consecutive individuals. BMC Musculoskelet Disord. 2019;20. DOI:10.1186/s12891-019-2569-1
- Li Z, Ren D, Zhao Y, et al. Clinical characteristics and surgical outcome of thoracic myelopathy caused by ossification of the ligamentum flavum: a retrospective analysis of 85 cases. Spinal Cord. 2016;54(3):188-196. DOI:10.1038/sc.2015.139
- Pascal-Mousselard H, Smadja D, Cabre P, et al. Ossification of the ligamenta flava with severe myelopathy in a black patient. A case report. Spine. 1998;23(14):1607-1608. DOI:10.1097/00007632-199807150-00019
- Pascal-Moussellard H, Cabre P, Smadja D, et al. Symptomatic ossification of the ligamentum flavum: a clinical series from the French Antilles. Spine (Phila Pa 1976). 2005;30(14):E400-5. DOI:10.1097/01.brs.0000169450.49181.91
- Lang N, Yuan HS, Wang HL, et al. Epidemiological survey of ossification of the ligamentum flavum in thoracic spine: CT imaging observation of 993 cases. Eur Spine J. 2013;22(4):857-862. DOI:10.1007/s00586-012-2492-8
- Yudoyono F, Dahlan RH, Ompusunggu SE, et al. Myelopathy caused by Ossification of Thoracic Ligamentum Flavum. Indonesian Journal of Rheumatology. 2016;8(1). DOI:10.37275/ijr.v8i1.11
- Tetreault L, Kopjar B, Nouri A, et al. The modified Japanese Orthopaedic Association scale: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy. Eur Spine J. 2017;26(1):78-84. DOI:10.1007/s00586-016-4660-8
- Hirabayashi K, Miyakawa J, Satomi K, et al. Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine. 1981;6(4):354-364. DOI:10.1097/00007632-198107000-00005
- Guo JJ, Luk KDK, Karppinen J, et al. Prevalence, distribution, and morphology of ossification of the ligamentum flavum: a population study of one thousand seven hundred thirty-six magnetic resonance imaging scans. Spine. 2010;35(1):51-56. DOI:10.1097/BRS.0b013e3181b3f779
- Feng F, Sun C, Chen Z. Progress on Clinical Characteristics and Identification of Location of Thoracic Ossification of the Ligamentum Flavum. Orthop Surg. 2015;7(2):87-96. DOI:10.1111/os.12165
- Yamada T, Torigoe I, Sakai K, et al. Contiguous Multilevel Thoracic Ossification of Ligamentum Flavum in a Young Adult Spine. Case Reports in Orthopedics. DOI: 10.1155/2019/1640485
- Toledo JA, Isseldyk FV, Re M, et al. Ossification of the ligamentum flavum as cause of thoracic cord compression: Case report of a Latin American man and review of the literature. Surg Neurol Int. 2013;4. DOI:10.4103/2152-7806.118489
- Lee BJ, Park JH, Jeon SR, et al. Clinically significant radiographic parameter for thoracic myelopathy caused by ossification of the ligamentum flavum. Eur Spine J. 2019;28(8):1846-1854. DOI:10.1007/s00586-018-5750-6
- Miyazawa N, Akiyama I. Ossification of the ligamentum flavum of the cervical spine. J Neurosurg Sci. 2007;51(3):139-144.
- Wang H, Wei F, Long H, et al. Surgical outcome of thoracic myelopathy caused by ossification of ligamentum flavum. Journal of Clinical Neuroscience. 2017;45:83-88. DOI:10.1016/j.jocn.2017.07.008
- Mori K, Kasahara T, Mimura T, et al. Prevalence, distribution, and morphology of thoracic ossification of the yellow ligament in Japanese: results of CT-based cross-sectional study. Spine. 2013;38(19):E1216-1222. DOI:10.1097/BRS.0b013e31829e018b
- Tanaka Y, Sato T, Aizawa T. Surgery for ossification of the ligamentum flavum. In: Yonenobu K, Nakamura K, Toyama Y, editors. OPLL. 2nd Ed. Japan: Springer; 2006:265-269.
- Osman NS, Cheung ZB, Hussain AK, et al. Outcomes and Complications Following Laminectomy Alone for Thoracic Myelopathy due to Ossified Ligamentum Flavum. Spine (Phila Pa 1976). 2018;43(14):E842-E848. DOI:10.1097/BRS.0000000000002563
- Okada K, Oka S, Tohge K, et al. Thoracic myelopathy caused by ossification of the ligamentum flavum. Clinicopathologic study and surgical treatment. Spine. 1991;16(3):280-287. DOI:10.1097/00007632-199103000-00005
- Onishi E, Yasuda T, Yamamoto H, et al. Outcomes of Surgical Treatment for Thoracic Myelopathy: A Single-institutional Study of 73 Patients. Spine. 2016;41(22):E1356-E1363. DOI:10.1097/BRS.0000000000001622
- Li W, Guo S, Sun Z, et al. Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis: staged surgical strategy and clinical outcomes. BMC Musculoskelet Disord. 2015;16(1):206. DOI:10.1186/s12891-015-0672-5
- Kanno H, Takahashi T, Aizawa T, et al. Recurrence of ossification of ligamentum flavum at the same intervertebral level in the thoracic spine: a report of two cases and review of the literature. Eur Spine J. 2018;27(Suppl 3):359-367. DOI:10.1007/s00586-017-5281-6
- Kim JK, Ryu HS, Moon BJ, et al. Clinical Outcomes and Prognostic Factors in Patients With Myelopathy Caused by Thoracic Ossification of the Ligamentum Flavum. Neurospine. 2018;15(3):269-276. DOI:10.14245/ns.1836128.064
- Aizawa T, Sato T, Sasaki H, et al. Results of surgical treatment for thoracic myelopathy: minimum 2-year follow-up study in 132 patients. SPI. 2007;7(1):13-20. DOI:10.3171/SPI-07/07/013
- Wang H, Ma L, Xue R, et al. The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy. Medicine (Baltimore). 2016;95(49). DOI:10.1097/MD.0000000000005519
- Zhang J, Wang L, Li J, et al. Predictors of surgical outcome in thoracic ossification of the ligamentum flavum: focusing on the quantitative signal intensity. Sci Rep. 2016;6:23019. DOI:10.1038/srep23019
- Iv JW, Brazdzionis J, Mohrdar C, et al. Spinal Cord Reperfusion Injury: Case Report, Review of the Literature, and Future Treatment Strategies. Cureus Journal of Medical Science. 2019;11(7). DOI:10.7759/cureus.5279
- Wiginton JG, Brazdzionis J, Mohrdar C, et al. Spinal Cord Reperfusion Injury: Case Report, Review of the Literature, and Future Treatment Strategies. Cureus. 11(7). DOI:10.7759/cureus.5279
- Vidal PM, Karadimas SK, Ulndreaj A, et al. Delayed decompression exacerbates ischemia-reperfusion injury in cervical compressive myelopathy. JCI Insight. 2(11). DOI:10.1172/jci.insight.92512
- Karadimas SK, Laliberte AM, Tetreault L, et al. Riluzole blocks perioperative ischemia-reperfusion injury and enhances postdecompression outcomes in cervical spondylotic myelopathy. Science Translational Medicine. 2015;7(316):316ra194-316ra194. DOI:10.1126/scitranslmed.aac6524
- Tetreault, Lindsay, Kopjar B, et al. A Clinical Prediction Rule for Functional Outcomes in Patients Undergoing Surgery for Degenerative Cervical Myelopathy: Analysis of an International Prospective Multicenter Data Set of 757 Subjects. The Journal of Bone and Joint Surgery. 2015;97(24):2038-2046. DOI: 10.1055/s-0036-1582782