Microsurgical Resection of Ossification of the Posterior Longitudinal Ligament in the Thoracic Spine via the Transthoracic Approach Without Spinal Fusion: 2-Dimensional Operative Video

Abstract

Surgical management of thoracic ossification of the posterior longitudinal ligament (OPLL) remains challenging because of the fragility of the thoracic spinal cord. Posterior approach with long instrumentation has been predominantly performed. However, this procedure includes the risk of neurologic deterioration caused by the progression of OPLL during long-term follow-up and the need for long instrumentation to achieve dekyphosis, even for so-called beaked-type OPLL between 1 vertebra. The present Video shows the microsurgical removal of OPLL in the middle thoracic level without spinal fusion, including the operative tips. The surgical techniques were demonstrated in detail handling patients with single OPLL. The patient is a 54-year-old woman with T5-6 OPLL. She presented with gradually worsening myelopathy and underwent the operation via the transthoracic anterolateral approach. Although intraoperative cerebrospinal fluid leakage occurred, it was successfully treated with fibrin glue sealing and spinal drainage. The modified Japanese Orthopaedic Association score improved from 5.5 preoperatively to 8.0 postoperatively. Postoperative deterioration of the thoracic kyphotic angle has not been noticed during the follow-up period of 149.7 months. Anterior decompression is the logical and ideal procedure to treat thoracic myelopathy caused by OPLL; however, this procedure is technically demanding. Microsurgery via the transthoracic anterolateral approach enables direct visualization of the thoracic ventral ossified lesion. Relatively narrow and little resection of the vertebral body under the presently demonstrated microsurgical procedures might negate the need for bone grafting or spinal instrumentation. The patient gave informed consent for surgery and video recording (Video 1).