Indirect posterior decompression with corrective fusion for ossification of the posterior longitudinal ligament of the thoracic spine: is it possible to predict the surgical results?

To investigation of the outcomes of indirect posterior decompression with corrective fusion for myelopathy associated with thoracic ossification of the longitudinal ligament, and prognostic factors. Conservative treatment for myelopathy associated with thoracic ossification of the longitudinal ligament (OPLL) is mostly ineffective, and treatment is necessary. However, many authors have reported poor surgical outcomes, and no standard surgical procedure has been established. We have been performing indirect spinal cord decompression by posterior laminectomy and simultaneous corrective fusion of the thoracic kyphosis. Twenty patients underwent indirect posterior decompression with corrective fusion, and were included in this study. The follow-up period was minimum 2 years and averaged 2 years and 9 months (2-5 years 6 months). Operative results were examined using JOA scoring system (full marks: 11 points) and Hirabayashi's recovery rate, as excellent (100-75%), good (74-50%), fair (49-25%), unchanged (24-0%) and deteriorated (i.e., decrease in score less than 0%). Cases in which the spinal cord is floating from OPLL on intraoperative ultrasonography were defined as the floating (+) group, and those without floating as the floating (-) group. In addition, we used compound muscle action potentials (CMAP) as intraoperative spinal cord monitoring and the cases were divided into three groups: Group A, no change in potential; Group B, potential decreased, and Group C, potential improved. The mean pre- and postoperative JOA scores were 6.2 and 8.9 points, respectively, and the recovery rate was 56%. The outcome was rated excellent in three, good in eight, fair in six, unchanged in two, and deteriorated in one. The mean preoperative thoracic kyphosis measured 58 degrees , and was corrected to 51 degrees after surgery. On intraoperative ultrasonography, 12 cases were included in the floating (+) and 8 in the floating (-) groups; the recovery rates were 58 and 52%, respectively, showing no significant difference between the recovery rates of the two groups. Regarding intraoperative CMAP, the outcome was excellent in one, good in seven, fair in four, and unchanged in one in Group A; fair in one, unchanged in one, and deteriorated in one in Group B, and excellent in two and good in one in Group C. The recovery rates were 50, 48 and 68.3% in Groups A, B and C, respectively, showing that the postoperative outcome was significantly poorer in Group B. Although indirect posterior decompression with corrective fusion using instruments obtained satisfactory outcomes, not all cases achieved good outcomes using this procedure. We consider that additional application of anterior decompressive fusion is preferable when improvement of symptoms occurs not satisfactory after indirect posterior decompression with corrective fusion using instruments. Intraoperative spinal cord monitoring of CMAP demonstrated that the spinal cord was already impaired during the laminectomy via the posterior approach. Concomitant intraoperative monitoring of CMAP to avoid impairment of the vulnerable spinal cord and corrective posterior spinal fusion with indirect spinal cord decompression is recommendable as a method capable of preventing postoperative neurological aggravation.