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01-10-2017 | Original Article

Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament

Authors: Chris Yuk Kwan Tang, Jason Pui Yin Cheung, Dino Samartzis, Ka Hei Leung, Yat Wa Wong, Keith Dip Kei Luk, Kenneth Man Chee Cheung

Published in: European Spine Journal | Issue 10/2017

Abstract

Purpose

To investigate the rate and predictive factors of post-operative neurological deterioration in ossified yellow ligament (OYL) surgery.

Methods

A retrospective review was conducted for all patients with thoracic OYL causing myelopathy requiring surgical decompression from January 1998 to December 2012. Clinical parameters under study included clinical presentation, distribution of OYL, pre-operative walking score, pre- and post-operative neurological status, status of intra-operative neurophysiological monitoring, and modified Japanese Orthopaedic Association (mJOA) score. Any complications were also recorded. All outcomes were measured at post-operative 1 week and at 2 years.

Results

A total of 26 patients were included in this study. Most patients (92.3%) had Frankel grade D pre-operatively. The rate of neurological deterioration was 15.4% and was correlated with the presence of dural tear, extra-dural hematoma and spinal cord injury. Pre-operative walking score was prognostic of patients’ walking ability in the post-operative period. Intra-operative monitoring of Somatosensory Evoked Potentials (SSEP) was found to be useful for monitoring spinal cord injury in OYL surgery, with a positive predictive value of 100% and a negative predictive value of 92.3%. The false negative rate of a SSEP signal drop was only 7.7%

Conclusions

This is the first study exploring risk factors for post-operative neurological deterioration after surgery for thoracic OYL. The rate of neurological deficit is not small and prognostic factors for poor outcome include poor pre-operative walking score, presence of intra-operative dural tear, extra-dural hematoma and spinal cord injury, and intra-operative drop of SSEP signal.

Mohindra S, Chhabra R, Mukherjee KK, Gupta SK, Vaiphei K, Khosla VK (2006) Spinal compression due to ossified yellow ligament: a short series of 5 patients and literature review. Surgical neurology 65:377–384. doi:10.1016/j.surneu.2005.10.026 (discussion 384)

Mohindra S, Gupta R, Chhabra R, Gupta SK (2011) Compressive myelopathy due to ossified yellow ligament among South Asians: analysis of surgical outcome. Acta Neurochir 153:581–587. doi:10.1007/s00701-010-0904-2 CrossRefPubMed

Aizawa T, Sato T, Sasaki H, Matsumoto F, Morozumi N, Kusakabe T, Itoi E, Kokubun S (2007) Results of surgical treatment for thoracic myelopathy: minimum 2-year follow-up study in 132 patients. J Neurosurg Spine 7:13–20. doi:10.3171/spi-07/07/013 CrossRefPubMed

Payer M, Bruder E, Fischer JA, Benini A (2000) Thoracic myelopathy due to enlarged ossified yellow ligaments. Case report and review of the literature. J Neurosurg 92:105–108PubMed

Yoshida M (2006) Pathology of Ossification of the Ligamentum Flavum

Hayashi K, Ishidou Y, Yonemori K, Nagamine T, Origuchi N, Maeda S, Imamura T, Kato M, Yoshida H, Sampath TK, ten Dijke P, Sakou T (1997) Expression and localization of bone morphogenetic proteins (BMPs) and BMP receptors in ossification of the ligamentum flavum. Bone 21:23–30CrossRefPubMed

Takeuchi Y, Matsumoto T, Takuwa Y, Hoshino Y, Kurokawa T, Shibuya N, Ogata E (1989) High incidence of obesity and elevated serum immunoreactive insulin level in patients with paravertebral ligamentous ossification: A relationship to the development of ectopic ossification. J Bone Miner Metab 7:17–21CrossRef

Aizawa T, Sato T, Sasaki H, Kusakabe T, Morozumi N, Kokubun S (2006) Thoracic myelopathy caused by ossification of the ligamentum flavum: clinical features and surgical results in the Japanese population. J Neurosurg Spine 5:514–519. doi:10.3171/spi.2006.5.6.514 CrossRefPubMed

Khan MH, Smith PN, Balzer JR, Crammond D, Welch WC, Gerszten P, Sclabassi RJ, Kang JD, Donaldson WF (2006) Intraoperative somatosensory evoked potential monitoring during cervical spine corpectomy surgery: experience with 508 cases. Spine 31:E105–E113. doi:10.1097/01.brs.0000200163.71909.1f CrossRefPubMed

10.

Kang KC, Lee CS, Shin SK, Park SJ, Chung CH, Chung SS (2011) Ossification of the ligamentum flavum of the thoracic spine in the Korean population. J Neurosurg Spine 14:513–519. doi:10.3171/2010.11.spine10405 CrossRefPubMed

11.

Guo JJ, Luk KD, Karppinen J, Yang H, Cheung KM (2010) 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 35:51–56. doi:10.1097/BRS.0b013e3181b3f779 CrossRefPubMed

12.

Miyakoshi N, Shimada Y, Suzuki T, Hongo M, Kasukawa Y, Okada K, Itoi E (2003) Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg 99:251–256PubMed

13.

Kawaguchi Y, Yasuda T, Seki S, Nakano M, Kanamori M, Sumi S, Kimura T (2013) Variables affecting postsurgical prognosis of thoracic myelopathy caused by ossification of the ligamentum flavum. Spine J Off J North Am Spine Soc 13:1095–1107. doi:10.1016/j.spinee.2013.03.001 CrossRef

14.

Sun X, Sun C, Liu X, Liu Z, Qi Q, Guo Z, Leng H, Chen Z (2012) The frequency and treatment of dural tears and cerebrospinal fluid leakage in 266 patients with thoracic myelopathy caused by ossification of the ligamentum flavum. Spine 37:E702–E707. doi:10.1097/BRS.0b013e31824586a8 CrossRefPubMed

15.

Epstein NE (2007) The frequency and etiology of intraoperative dural tears in 110 predominantly geriatric patients undergoing multilevel laminectomy with noninstrumented fusions. J Spinal Disord Techn 20:380–386. doi:10.1097/BSD.0b013e31802dabd2 CrossRef

16.

Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD, Walsh JJ (1969) The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 7:179–192. doi:10.1038/sc.1969.30 CrossRefPubMed

17.

Forbes HJ, Allen PW, Waller CS, Jones SJ, Edgar MA, Webb PJ, Ransford AO (1991) Spinal cord monitoring in scoliosis surgery. Experience with 1168 cases. J Bone Joint Surg Br 73:487–491PubMed

18.

Jones SJ, Edgar MA, Ransford AO, Thomas NP (1983) A system for the electrophysiological monitoring of the spinal cord during operations for scoliosis. J Bone Joint Surg Br 65:134–139PubMed

19.

Ney JP, van der Goes DN (2012) Evidence-based guideline update: Intraoperative spinal monitoring with somatosensory and transcranial electrical motor evoked potentials. Report of the therapeutics and technology assessment subcommittee of the american academy of neurology and the american clinical neurophysiology society. Neurology 79:292. doi:10.1212/WNL.0b013e3182637c24 (author replies 292–294)

20.

Council MR (1976) Aids to examination of the peripheral nervous system. Memorandum no 45 London: Her Majesty’s Stationary Office

21.

Baker GA, Cizik AM, Bransford RJ, Bellabarba C, Konodi MA, Chapman JR, Lee MJ (2012) Risk factors for unintended durotomy during spine surgery: a multivariate analysis. Spine J Off J North Am Spine Soc 12:121–126. doi:10.1016/j.spinee.2012.01.012 CrossRef

22.

Muthukumar N (2009) Dural ossification in ossification of the ligamentum flavum: a preliminary report. Spine 34:2654–2661. doi:10.1097/BRS.0b013e3181b541c9 CrossRefPubMed

23.

Sun J, Zhang C, Ning G, Li Y, Li Y, Wang P, Feng S (2014) Surgical strategies for ossified ligamentum flavum associated with dural ossification in thoracic spinal stenosis. J Clin Neurosci Off J Neurosurg Soc Australasia 21:2102–2106. doi:10.1016/j.jocn.2014.02.027

24.

Xu N, Yu M, Liu X, Sun C, Chen Z, Liu Z (2015) A systematic review of complications in thoracic spine surgery for ossification of the posterior longitudinal ligament. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. doi:10.1007/s00586-015-4097-5

25.

Wang H, Ma L, Xue R, Yang D, Wang T, Wang Y, Yang S, Ding W (2016) The incidence and risk factors of postoperative neurological deterioration after posterior decompression with or without instrumented fusion for thoracic myelopathy. Medicine 95:e5519. doi:10.1097/md.0000000000005519 CrossRefPubMedPubMedCentral

26.

Baba S, Oshima Y, Iwahori T, Takano Y, Inanami H, Koga H (2016) Microendoscopic posterior decompression for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum: a technical report. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 25:1912–1919. doi:10.1007/s00586-015-4158-9 CrossRef

27.

Wang T, Yin C, Wang D, Li S, Chen X (2017) Surgical technique for decompression of severe thoracic myelopathy due to tuberous ossification of ligamentum flavum. Clin Spine Surg 30:E7-e12. doi:10.1097/bsd.0000000000000213 PubMed

28.

Deutsch H, Arginteanu M, Manhart K, Perin N, Camins M, Moore F, Steinberger AA, Weisz DJ (2000) Somatosensory evoked potential monitoring in anterior thoracic vertebrectomy. J Neurosurg 92:155–161PubMed

29.

Papastefanou SL, Henderson LM, Smith NJ, Hamilton A, Webb JK (2000) Surface electrode somatosensory-evoked potentials in spinal surgery: implications for indications and practice. Spine 25:2467–2472CrossRefPubMed

30.

Stechison MT, Panagis SG, Reinhart SS (1995) Somatosensory evoked potential. Monitoring during spinal surgery. Acta Neurochirurgica 135:56–61CrossRefPubMed

31.

Leung YL, Grevitt M, Henderson L, Smith J (2005) Cord monitoring changes and segmental vessel ligation in the “at risk” cord during anterior spinal deformity surgery. Spine 30:1870–1874CrossRefPubMed

32.

May DM, Jones SJ, Crockard HA (1996) Somatosensory evoked potential monitoring in cervical surgery: identification of pre- and intraoperative risk factors associated with neurological deterioration. J Neurosurg 85:566–573. doi:10.3171/jns.1996.85.4.0566 CrossRefPubMed

33.

Manninen PH (1998) Monitoring evoked potentials during spinal surgery in one institution. Canadian J Anaesthesia = J canadien d’anesthesie 45:460–465. doi:10.1007/bf03012582 CrossRef

34.

Ito Z, Matsuyama Y, Ando M, Kawabata S, Kanchiku T, Kida K, Fujiwara Y, Yamada K, Yamamoto N, Kobayashi S, Saito T, Wada K, Satomi K, Shinomiya K, Tani T (2016) What is the best multimodality combination for intraoperative spinal cord monitoring of motor function? A Multicenter study by the monitoring committee of the Japanese Society for spine surgery and related research. Global Spine J 6:234–241. doi:10.1055/s-0035-1559582 CrossRefPubMed

35.

He S, Hussain N, Li S, Hou T (2005) Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population. J Neurosurg Spine 3:348–354. doi:10.3171/spi.2005.3.5.0348 CrossRefPubMed

Title: Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament
Authors: Chris Yuk Kwan Tang
Jason Pui Yin Cheung
Dino Samartzis
Ka Hei Leung
Yat Wa Wong
Keith Dip Kei Luk
Kenneth Man Chee Cheung
Publication date: 01-10-2017
Publisher: Springer Berlin Heidelberg
Published in: European Spine Journal / Issue 10/2017
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-017-5078-7

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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