Early Recurrence of Thoracic Ossification of the Ligamentum Flavum After Posterior Decompression Surgery: A Case Report.

Abstract

Thoracic ossification of the ligamentum flavum (OLF) is known to result in spinal canal stenosis and myelopathy. It is typically treated through decompressive laminectomy and resection of the ossified ligament, which is known to improve neurological deficits. However, the recurrence of OLF post-surgery remains a relatively undocumented and complex issue. The present report describes the case of a 58-year-old male patient who had obesity (BMI 34), diabetes mellitus, and Basedow's disease. The patient presented with bilateral lower limb paresthesia and associated gait impairment, resulting in an urgent hospital admission. Imaging diagnostics identified extensive thoracic ossification of the posterior longitudinal ligament and OLF, both of which resulted in significant spinal cord compression. He underwent posterior decompression with instrumented fusion from T1 to T9 and additional laminectomy and OLF resection at T10/11. Despite an initial improvement in the postoperative period, the patient developed an epidural hematoma one week following surgery, causing significant paralysis of the lower limbs. This complication was promptly addressed with hematoma removal surgery. Six months after the initial procedure, his walking function improved significantly, but eight months after surgery, he experienced a sudden regression in motor functions due to the recurrence of OLF at T10/11, necessitating an additional posterior instrumented fusion surgery. Subsequent to the additional surgical procedure, the patient experienced an amelioration in paralysis, enabling him to ambulate with the aid of a cane. The recurrence of thoracic OLF after decompression surgery is a significant concern, especially in cases where decompression without instrumented fusion is performed. When determining the surgical procedure for thoracic OLF in cases with extensive ossification of the spinal ligaments, it is crucial to consider the degree of spontaneous fusion and mobility of the spinal segments, as demonstrated in the present case. The concentration of mechanical stress due to fusion at adjacent segments and intervertebral mobility at the thoracolumbar junction may increase the risk of OLF recurrence and should be carefully assessed preoperatively, even though posterior decompression surgery is typically considered a sufficient option for thoracic OLF.