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Journal of Peking University (Health Sciences) ›› 2022, Vol. 54 ›› Issue (5): 1021-1027. doi: 10.19723/j.issn.1671-167X.2022.05.032

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Intraoperative ultrasound assisted circumferential decompression for multilevel ossification of the posterior longitudinal ligament in thoracic vertebrae

Shu-heng ZHAI,Pan-pan HU,Xiao-guang LIU*()   

  1. Department of Orthopaedics, Peking University Third Hospital; Engineering Research Center of Bone and Joint Precision Medicine; Beijing Key Laboratory of Spinal Disease Research, Beijing 100191, China
  • Received:2022-06-22 Online:2022-10-18 Published:2022-10-14
  • Contact: Xiao-guang LIU E-mail:xgliudoctor@163.com
  • Supported by:
    the National Natural Science Foundation of China(81972103)

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Abstract:

Objective: To analyze the effect of short-segment circumferential decompression and the nerve function improvement in 30 cases of multilevel thoracic OPLL assisted by intraoperative ultrasound. Methods: A total of 30 patients with multilevel thoracic OPLL from January 2016 to January 2021 were enrolled, all of whom were located by intraoperative ultrasound and underwent circumferential decompression. There were 14 males and 16 females, with an average age of (49.3±11.4) years. The initial symptoms were mainly numbness and weakness of lower limbs (83.3%), and the mean duration of symptoms was (33.9±42.9) months (1-168 months). Neurological function was assessed by the Modified Japanese Orthopedic Association (mJOA) score (0-11) preoperative and at the last follow-up, in which the rate of neurological improvement was calculated by the Harabayashi method. The patients were divided into excellent improved group and poor improved group according to the improvement of neurological function. The age, body mass index (BMI), duration of symptoms, operation time, blood loss, mJOA score, surgical level, and cerebrospinal fluid leakage of the two groups were collected and analyzed for statistical differences. The factors influencing the improvement of neurological function were analyzed by univariate and multivariate Logisitic regression analysis. Results: The mean operation time was 137.4±33.8 (56-190) min, and the mean blood loss was (653.7±534.2) mL (200－3 000 mL). The preoperative mJOA score was 6.0±2.1 (2－9), and the last follow-up mJOA score was 7.6±1.9 (4－11), which was significantly improved in all the patients (P < 0.001). The average improvement rate of neurological function was 38.1%±24.4% (14.3%－100%), including 75%－100% in 4 cases, 50%－74% in 3 cases, 25%－49% improved in 14 cases, and 0%－24% in 9 cases. There was significant difference in intraoperative blood loss between the excellent improved group and the poor improved group (P=0.047). Intraoperative blood loss was also an independent risk factor in regression analysis of neurological improvement. Conclusion: Thoracic circumferential decompression assisted with intraoperative ultrasound can significantly improve the neurological function of patients with multilevel OPLL and achieve good efficacy. The improvement rate of nerve function can be improved effectively by controlling intraoperative blood loss.

Key words: Ossification of the posterior longitudinal ligament, Thoracic vertebra, Circumferential decompression, Intraoperative ultrasound, Thoracic spinal stenosis

CLC Number: 

  • R61

Table 1

General data of 30 patients"

Items Value
Gender, n (%)
  Male 14 (46.7)
  Female 16 (53.3)
Age/years, $\bar x \pm s$ (range) 19.3±11.4 (26－72)
BMI /(kg/m2), $\bar x \pm s$ (range) 28.0±4.8 (17.0－41.0)
Disease duration/months, $\bar x \pm s$ (range) 33.9±42.9 (1－168)
Initial symptoms, n (%)
  Limbs numbness and weakness 25 (83.3)
  Chest and back pain 5 (16.7)
Ossification of the ligamentum flavum, n (%) 13(43.3)
Follow-up time/months, $\bar x \pm s$ (range) 42.8±18.7 (18.5－75.9)
Hospital stay/d, $\bar x \pm s$ (range) 8.0±1.5 (5－13)
Postoperative hospital stay/d, $\bar x \pm s$ (range) 5.3±1.0 (4－8)
OPLL segment (vertebrae), $\bar x \pm s$ (range) 3.5±0.9 (3－6)
Posterior thoracic wall resection segments (vertebrae), $\bar x \pm s$ (range) 3.5±0.9 (3－6)
Circumferential decompression segments (vertebrae) 1
Circumferential decompression site，n (%)
  Upper thoracic spine 6 (20)
  Middle thoracic spine 16 (53.3)
  Lower thoracic spine 8 (26.7)
Operation time/min, $\bar x \pm s$ (range) 137.4±33.8 (56－190)
Operation blood loss/mL, $\bar x \pm s$ (range) 653.7±534.2 (200－3000)
Preoperative mJOA score, $\bar x \pm s$ (range) 6.0±2.1 (2－9)
The last follow-up mJOA score, $\bar x \pm s$ (range) 7.6±1.9 (4－11)
Neurological improvement rate, $\bar x \pm s$ (range) 38.1±24.4 (14.3－100.0)
  75%－100% 4 (13.3)
  50%－74% 3 (10.0)
  25%－49% 14 (46.7)
  0%－24% 9 (30.0)
   < 0% 0 (0)
Postoperative cerebrospinal fluid leakage，n (%) 16 (53.3)
Postoperative transient loss of muscle strength, n (%) 8 (26.7)

Figure 1

Imaging data of a 60-year-old woman with mJOA score of 6 before surgery and 8 at the last follow-up, and neurological improvement rate was 40% A, preoperative lateral thoracic X-ray; B, preoperative sagittal CT of thoracic vertebra, ossification of the posterior longitudinal ligament (OPLL) of T2-T9 could be seen, in which OPLL at T4-T5 was beak-like protrusion; C, preoperative axial CT of thoracic vertebrae at T4-T5 showed OPLL mass protruding into the spinal canal, with irregular shape and compression on the spinal cord; D and E, MRI of thoracic vertebrae before surgery showed multiple segments of spinal cord compression, with severe compression at T4-T5; F, lateral thoracic X-ray at the last follow-up showed good internal fixation; G and H, at the last follow-up, thoracic CT showed that the ossification mass was completely removed after circumferential decompression at the T4-T5 level, OPLL ossification was smooth at other segments, and intraspinal compression was effectively relieved; I and J, at last follow-up, MRI of the thoracic vertebra showed complete decompression of spinal cord compression at the operative segment, and no significant compression at the T4-T5 circumferential decompression segment."

Table 2

Comparison of data between the excellent neurological improved group and the poor neurological improved group"

Items Excellent improved group Poor improved group P
Case number 21 9
Age/years, $\bar x \pm s$ 49.5±11.5 49.0±12.1 0.921
BMI/(kg/m2), $\bar x \pm s$ 28.6±4.2 26.6±6.1 0.394
Disease duration/months, $\bar x \pm s$ 31.3±40.1 39.8±51.2 0.667
Operation time/min, $\bar x \pm s$ 136.9±28.0 138.4±46.7 0.911
Operation blood loss/mL, $\bar x \pm s$ 467.1±203.9 1088.9±791.3 0.047*
Preoperative mJOA score, $\bar x \pm s$ 6.5±2.2 4.9±1.3 0.052
The last follow-up mJOA score, $\bar x \pm s$ 8.3±1.8 6.0±1.1 0.002*
Neurological improvement rate/%, $\bar x \pm s$ 46.6±24.6 18.2±28.4 < 0.001*
Operation segments, $\bar x \pm s$ 3.4±0.7 4.0±1.0 0.121
Cerebrospinal fluid leakage，n 11 5 0.873

Figure 2

Intraoperative ultrasound images of circumferential decompression segments A and B, intraoperative ultrasound before circumferential decompression showed severe anterior spinal cord compression with reduced and delayed blood perfusion; C and D, intraoperative ultrasound after circumferential decompression showed decompression of anterior spinal cord compression, spinal cord re-expansion, and blood perfusion recovery."

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