Thoracic ossification of the ligamentum flavum in elite athletes: a case series with surgical outcomes and return-to-play profiles.

PURPOSE: We aimed to describe the clinical characteristics, diagnostic features, surgical management, and return-to-play outcomes of thoracic ossification of the ligamentum flavum (OLF) in elite athletes.

METHODS

Ten elite athletes (mean age 31.3 [range 19-47] years) with symptomatic thoracic OLF underwent posterior decompression without fusion between 2012 and 2024. Demographic data, neurological findings, imaging characteristics, surgical details, the modified Japanese Orthopedic Association (JOA) recovery rate, and return-to-play timelines were retrospectively analyzed. The sharpened Romberg test (SRT) was performed for all patients.

RESULTS

Myelopathy was the predominant presentation (n = 8), although symptoms were frequently unilateral and atypical. All patients showed positive Sharpened Romberg findings despite high athletic function. Lesions commonly involved the lower thoracic spine. Up to two-thirds (unilateral) or one-half (bilateral) facetectomy was required in several patients. No patients required fusion. The mean preoperative and postoperative modified JOA scores for thoracic myelopathy were 7.2 ± 1.8 and 10.2 ± 1.2, respectively (p = 0.015). The median recovery rate was 88.5% (interquartile range 78-100%). All athletes returned to sport, with baseball pitchers resuming mound activity at a mean of 10.8 weeks. Postoperative computed tomography at 1 year showed facet remodeling without OLF recurrence.

CONCLUSION

Thoracic OLF can affect elite athletes and present with atypical symptoms. The SRT may assist in early detection. In our cohort, fusion was not required; anatomically precise posterior decompression without fusion appeared sufficient to enable a safe return to high-level competition.