Massive Ossification Research Articles

The surgical strategy for multilevel massive ossification of the posterior longitudinal ligaments.

Creating enough decompression, favorable outcome, less complication, and maintain adequate lordosis and stability in the patients with cervical myelopathy due to multilevel massive ossification of the posterior longitudinal ligament (OPLL) still poses a challenge for surgeons. The aim of our study is to retrospectively evaluate our patients and try to seek a better surgical strategy. Between 2015 and 2019, 55 consecutive patients with multilevel massive OPLL underwent surgical treatment. Among these, 40 patients were treated with cervical laminectomy and then anterior decompression, fusion, and fixation (ADF), which was defined as group 1, and 15 patients were treated with cervical laminectomy and fixation simultaneously, which was defined as group 2. The patient's radiographic characteristics and postoperative outcomes were evaluated. Better postoperative cervical sagittal lordosis and less long-term axial pain was achieved in group 1 (p < 0.001), though the functional outcome had no significant difference. In the multivariable analysis, anterior fixation accounts for independent factors for better cervical sagittal alignment (p < 0.001). No complications directly associated with cervical laminectomy were observed. In patients with cervical multilevel massive OPLL, laminectomy at compression level and then ADF depended on the severity and range of compression, but corpectomy of not more than two vertebral bodies is suggested, except K-line (+) and long-segment massive OPLL majorly involving the C2 and posterior laminectomy above and below the OPLL-affected levels with posterior fixation simultaneously.

Risk Factors and Prevention of C5 Palsy After Anterior Cervical Decompression and Fusion: Similarity of the Pathomechanism With That After a Posterior Approach.

This was a retrospective study. The objective of this study was to review clinical and imaging findings after anterior cervical decompression and fusion, as a basis for prevention of C5 palsy. C5 palsy is a common postoperative complication in spine surgery, but the mechanistic basis for this condition is unknown. The subjects were 239 patients with cervical myelopathy who underwent anterior cervical decompression and fusion including at C4-C5 disk level at our hospital from 2001 to 2018. Twelve of these patients (5.0%) had C5 palsy postoperatively. Clinical features and imaging findings were compared in patients with and without C5 palsy. In patients with C5 palsy, the sagittal alignment of the cervical spine was kyphotic, the width of the C5 intervertebral foramen was narrower, and the lateral decompressed line was wider beyond the medial part of the Luschka joint. Age, sex, disease, the number of fused segments, decompression width, and anterior shift of the spinal cord did not differ significantly between patients with and without C5 palsy. These results indicate that the pathomechanism of C5 palsy may be dependent on the location of the lateral decompression line, especially in patients with cervical kyphosis and a narrow C5 intervertebral foramen. Excessive lateral decompression beyond the Luchka joint might lead to C5 root kinking between the intervertebral foramen and posterior edge of vertebra. This pathomechanism may be similar in anterior and posterior approaches. To prevent C5 palsy, the medial line of the Luschka joint should be confirmed intraoperatively and decompression should be performed within the Luschka joints. Alternatively, medial foraminotomy should be used in cases needing wide decompression, such as those with massive ossification of the posterior longitudinal ligament, lateral osteophytes, and symptomatic foraminal stenosis. Level III.

Circumferential Operations of the Cervical Spine.

Generally, a combined anterior and posterior cervical approach is associated with significant morbidity since it requires an extended operative time, greater intraoperative blood loss, and both anterior- and posterior-related surgical complications. However, there are some instances where a circumferential cervical fusion can be advantageous. Our objective is to discuss the indications for circumferential cervical spine procedures. A narrative review of the literature was performed. We include the indications for circumferential cervical approaches of the senior author (KDR). Indications for circumferential approaches include: (1) high-risk patients for pseudoarthrosis, (2) cervical deformity (e.g., degenerative, posttraumatic, cervicothoracic kyphosis), (3) cervical spine metastases (especially those with multilevel involvement), (4) cervical spine infection, (5) unstable cervical trauma, (6) movement disorders and cerebral palsy, (7) Multiply operated patient (especially postlaminectomy kyphosis and patients with massive ossification of the posterior longitudinal ligament), and when (8) early fusion is desirable. Circumferential procedures may be useful in many different cervical spine conditions requiring surgery. Despite its advantages, particularly with reducing the risk for pseudarthrosis, the benefits of a combined approach must be weighed against the risks associated with a dual approach. With appropriate preoperative planning, intraoperative decision-making, and surgical techniques, excellent clinical outcomes can be achieved.

Anterior selective stabilization combined with laminoplasty for cervical myelopathy due to massive ossification of the posterior longitudinal ligament: report of early outcomes in 14 patients.

Surgical management of massive ossification of the posterior longitudinal ligament (OPLL) is challenging. To reduce surgical complications, the authors have performed anterior selective stabilization combined with laminoplasty (antSS+LP) for massive OPLL since 2012. This study aimed to elucidate the short-term outcome of the antSS+LP procedure. The authors' analysis was based on data from 14 patients who underwent antSS+LP for cervical myelopathy caused by massive OPLL and were followed up for at least 2 years after surgery (mean follow-up duration 3.3 years). Clinical outcome was evaluated preoperatively, at 6 months and 1 year postoperatively, and at the final follow-up using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy and the recovery rate of the JOA score. The following radiographic parameters were measured preoperatively, immediately after surgery, at 1 year after surgery, and at the final follow-up: the C2-7 angle, measured on lateral plain radiographs, and the segmental lordosis angle (SLA), measured on sagittal CT scans. The correlation between radiographic parameters and clinical outcomes was evaluated. The mean JOA score increased from 10.4 before surgery to 13.6 and 13.8 at 6 months and 1 year after surgery, respectively; at the final follow-up the mean score was 13.4. This postoperative recovery was significant (p = 0.004) and was maintained until the final follow-up. No patient required revision surgery due to postoperative neurological deterioration. However, the C2-7 angle gradually deteriorated postoperatively. Similarly, the SLA was significantly increased immediately after surgery, but the improvement was not maintained. The recovery rate at the final follow-up correlated positively with the change in C2-7 angle (r = 0.60, p = 0.03) and the change in SLA (r = 0.72, p < 0.01). AntSS+LP is safe and effective and may be an alternative to anterior decompression and fusion for the treatment of patients with massive OPLL. No postoperative neurological complications or significant postoperative exacerbation of neck pain were observed in our case series. Not only reducing intervertebral motion and decompressing the canal at the maximal compression level but also acquiring segmental lordosis at the maximal compression level are crucial factors for achieving successful outcomes of antSS+LP.

Low-grade Myofibroblastic sarcoma: clinical and imaging findings

BackgroundLow-grade myofibroblastic sarcoma (LGMS) is a rare type of tumor. Previous research has paid much attention to reporting pathological analyses of LGMS. However, only few systematic clinical and/or radiological studies have been conducted.MethodsThis study recruited 14 cases (8 males and 6 females) of LGMS. X-ray or computer tomography (CT) scan were performed on 11 cases. MRI was performed on 5 cases.ResultsX-Ray and CT scan: Five cases developed LGMS in bones, including 3 cases in the distal femur, 1 in the right shoulder blade, and another 1 in the right inferior ramus. Massive infiltrative and vermiform bone destruction with poorly-circumscribed lesion margins and partial soft tissue masses were observed. The other 9 cases were developed in soft tissues. Out of them, 4 cases presented slightly irregular hyper- or lower-density masses with poorly-circumscribed margins. 2 cases presented massive calcification and ossification. Significant enhancement was observed in 1 case, while no obvious enhancement was seen in the other 2 cases.MRI: MR images of 5 cases revealed homogeneous iso- or hyper-signal intensity on T1WI and homogeneous or heterogeneous hyper-signal intensity on T2WI. Enhanced MRI revealed homogeneous enhancement in 2 cases and rim enhancement in 1 case.ConclusionsOur findings show that LGMS is characterized by invasiveness, metastases and calcification. Different radiological tools should be employed to make an accurate diagnosis.

Massive traumatic myositis ossificans

Introduction. Traumatic myositis ossificans (TMO) is a rare condition, which can jeopardize athletic careers, especially in cases when a large ossification is formed. The aim of this paper is to present the results of treating a large TMO mass by application of physical procedures. Case outline. A TMO mass of large dimensions was detected in a 13-year-old competitive athlete two months after the patient sustained a direct blow to the quadriceps. Physical treatment lasted three months. The patient was able to carry out normal daily activities and recreational sports activities without limitation eight months after the initial injury. The imaging over a five-year follow-up detected a decrease in height and width of the ossification, but also a discrete increase in its length. Conclusion. Physical therapy resulted in full functional recovery, regardless of the massive ossification. The height and width of the ossification was reduced, but its length increased.

Massive heterotopic ossification after distal femur fracture

Introduction Heterotopic ossification is the formation of lamellar bone in periarticular soft tissue that can be seen in paralysed patients or following trauma. It can cause significant burden to already debilitated patients. Case presentation A 12-year-old boy with paraplegia due to neuromyelitis optica presented with progressive right knee pain and swelling. There was no history of trauma to the knee. Anteroposterior radiograph of femur at the initial presentation showed a supracondylar femur fracture for which casting was performed. Six weeks later, when casting was removed, swelling along with increased rubor in distal thigh region was noted. Radiography of the right femur revealed an unhealed distal femur fracture along with massive ossification extending from lesser trochanter to fracture line along the soft tissue around the femoral shaft. Conclusion This case presented the clinical and imaging findings of a giant heterotopic ossification in the thigh region following an extra-articular fracture.

Clinical and radiological features of Forestier's disease presenting with dysphagia.

Background:Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is a rheumatologic condition characterized by ossification of the spinal ligaments and tendons. Large anterior osteophytes are typically present in the lower cervical levels, while upper cervical ossification resulting in dysphagia is very rare.Methods:Here, we presented a patient with Forestier's disease involving massive ossification of the anterior longitudinal ligament extending from C3 to C4 downward contributing to severe dysphagia.Results:A 65-year-old male presented with cervical pain and dysphagia. The computed tomography of the cervical spine demonstrated massive anterior longitudinal ligament ossification (DISH) extending from C3 to C7. There was an additional large osteophyte at the C3-C4 level, and also a high-grade intracanalicular C6-C7 cervical stenosis due to ossification of the posterior longitudinal ligament. The patient was offered surgical intervention (e.g., resection of the C3-C7 anterior DISH and anterior cervical discectomy/fusion at the C6-C7 level), but he declined.Conclusions:When conservative management fails to resolve severe dysphagia for cervical DISH/Forestier's disease, anterior surgical resection is typically performed. In this case, the patient refused surgery and opted for conservative management strategies.

A silent massive ossification of Achilles tendon as a suspected rare late effect of surgery for club foot

We report the case of a 66-year-old male patient with massive ossification of the distal portion of the Achilles tendon, as a late consequence of a surgical release for club foot conducted in his childhood. The singularity of the case report derives from its clinical features: the bone mass was of abnormal dimensions, almost substituting the entire tendon; the condition had always been asymptomatic, without deficits in range of motion, in absence of either pain or biomechanical defects with age. In fact, the condition was diagnosed just recently as a consequence of a tear. Despite an ultrasound diagnosis after the injury, only during the surgical treatment, a proper evaluation of the entity of the pathology was possible. Although the ossification of Achilles tendon is a rare clinical condition with a complex multifactorial etiology, in our case report, some of the elements in the patient’s medical history could be useful for the pathogenesis and early diagnosis of the disease. The aim of this case report is to emphasize the importance both of a correct evaluation of clinical history and of an accurate diagnosis, in order to conduct a proper management of this pathology.

Hiperostose esquelética idiopática difusa canina – relato de caso

Diffuse idiopathic skeletal hyperostosis is a rare disease characterized by massive and progressive ossification of soft tissues that surround the axial and appendicular skeletons, affecting more frequently the ventral longitudinal ligament. The etiological and therapeutic aspects of the disease have not yet been completely clarified and there is little information available on the occurrence of the disease in the canine species. This work reports the first case of this disease in the national literature and aims to describe the clinical and radiographic aspects of the condition in a seven-year-old bitch presenting gait abnormalities and thoracolumbar postural alterations associated with lower back pain. Diagnosis was made by conventional radiography and initial treatment with a selective COX-2 anti-inflammatory drug has shown good results in pain relief and short-term control of clinical signs.

Massive Patellar Tendon Ossification: Excision and Simultaneous Total Knee Replacement

Tendon ossification has a multifactorial aetiology. We present a case of a massive ossification within the substance of patellar tendon. A 79-years-old male who had a previous history of patellar tendon rupture and its surgical repair. He gradually developed a large bony mass within the patellar tendon and progressive symptoms of arthritis in the knee joint. The patient underwent a total knee replacement along with simultaneous excision of the entire bony lump and primary repair of the patellar tendon. The knee was mobilised gradually after surgery and achieved satisfactory range of motion, function and alleviation of symptoms without any complication.

Intramuscular hemangioma with extensive ossification: Unique radiographic and histologic features

Intramuscular hemangioma is a benign tumor representing 0.8% of all hemangiomas. Rarely intramuscular hemangioma presents with massive ossification in the mass that can be misleading and cause misdiagnoses, and unnecessary workups. We describe a case of intramuscular hemangioma with massive ossification in the left thigh of a 54-year-old man presented with pressure symptoms while exercising.

Cervical Disc Arthroplasty Combined with Interbody Fusion for the Treatment of Cervical Myelopathy with Diffuse Idiopathic Skeletal Hyperostosis

Cervical Disc Arthroplasty Combined with Interbody Fusion for the Treatment of Cervical Myelopathy with Diffuse Idiopathic Skeletal Hyperostosis

Bronchial carcinoid with massive ossification: A case report and review of literature

We report a case of a 47-year-old male with unexplained fatigue, shortness of breath, fever, chronic cough, and weight loss of over 12 pounds over a 3 months period. Chest x-ray revealed complete opacification of the right hemithorax with collapse of the right middle and lower lung lobes and midline shift towards the right. A CT scan with contrast showed a 6 cm mass arising from the right mainstem bronchus that was completely occluding the lumen, causing right lung atelectasis. Histopathologic examination of the tumor revealed an atypical carcinoid tumor with massive ossification. This is a case report and review of the literature of the rare bronchial carcinoid demonstrating bone formation.

Successful treatment of a fracture of a huge Achilles tendon ossification with autologous hamstring tendon graft and gastrocnemius fascia flap: a case report

BackgroundFracture of an ossified Achilles tendon is a rare entity, and no standard treatment has been established. This is the first report to describe the use of a hamstring tendon graft and gastrocnemius fascia flap for Achilles tendon reconstruction.Case presentationWe present the case of a 50-year-old woman with fracture of an ossified Achilles tendon. She presented to our clinic with acute right hindfoot pain, which started suddenly while going up the stairs. Plain radiography and magnetic resonance imaging revealed a massive ossification on the right Achilles tendon extending over 14 cm in length; the ossification was fractured at 5 cm proximal to the calcaneus insertion. Surgical treatment included removal of the ossified tendon and reconstruction with an autologous hamstring tendon graft and gastrocnemius fascia flap. One year after surgery, she was able to walk with little pain or discomfort and to stand on her right tiptoe.ConclusionOur novel surgical procedure may be useful in the treatment of fractured ossified Achilles tendons and large Achilles tendon defects.

Massive Ossification of the Patellar Fat Pad: An Unusual Cause of Knee Stiffness

While stiffness following an injury is usually secondary to soft tissue scarring, a variety of different benign and malignant lesions may restrict range of motion about the knee. We report the unusual case of a patient who presented with a chronic knee extension contracture secondary to a large ossified mass in the anterior aspect of the knee. Radiographs, magnetic resonance imaging, and subsequent histopathology were consistent with a diagnosis of myositis ossificans of the fat pad. Subsequent resection resulted in full motion recovery and resolution of symptoms at 30-month follow-up.

Anterior corpectomy and fusion to C2 for cervical myelopathy: clinical results and complications

Anterior cervical corpectomy and fusion (ACCF) to C2 (ACCF-C2) for multilevel lesions is a challenging procedure that is indicated for massive ossification of the posterior longitudinal ligament (OPLL) extending to C2 or stenosis at the upper cervical region accompanied by kyphosis. However, there is little information on the effectiveness of and complications related to ACCF-C2. The purpose of this study was to investigate the overall surgical results and postoperative complications of ACCF-C2 for cervical myelopathy. Sixteen patients who underwent ACCF-C2 for OPLL and cervical spondylotic myelopathy were evaluated. An iliac bone or a fibular strut was grafted using a cervical plate. The mean fusion level was 3.8, and the mean follow-up period was 36 months. Patients' charts, clinical results assessed using the Japanese Orthopedic Association (JOA) scale, and radiographs were retrospectively reviewed. The average preoperative JOA score was 11.5 ± 3.5, and improved significantly to 13.1 ± 3.2 at 24 months after surgery (P < 0.01). The postoperative cervical alignment was significantly improved at the last follow-up (P < 0.05). Seven patients experienced complications, including neurological complications in three, graft-related complications in three, cerebrospinal fluid leakage in two, late retropharyngeal perforation in one, and dysphasia in one. Three of 16 patients experienced upper airway obstruction in this series, and 2 of 473 patients who underwent anterior cervical decompression and fusion at lower levels in the same period (P < 0.001). ACCF-C2 is effective for massive OPLL and stenosis accompanied by kyphosis. To avoid complications, skilled decompression and bone grafting technique are necessary, and delayed extubation for upper airway obstruction is preferable.

Extensive ossification of an intramuscular venous malformation in the submental region

We describe a 62-year-old male patient with an extensively ossified venous malformation within the mylohyoid muscle. Phleboliths and calcifications are characteristic of venous malformations, while massive ossification is rare. To our knowledge, no extensive ossified venous malformation within the mylohyoid muscle has been reported. Intramuscular vascular lesions occur with an incidence of 0.8 in 10, occurring in the head and neck region in 15% of cases. Most are venous malformations. The diagnosis is rarely made before surgery and requires a definitive histological analysis, as there are no pathognomonic clinical or radiographic findings, especially with extensive ossification. Spontaneous regression does not occur, and treatment must be based on aesthetic and functional disturbances. We reviewed the classification of vascular anomalies, focusing on differentiating between venous malformations and haemangiomas, which are frequently confused in the literature.

Osseous Metaplastic Meningioma in the Thoracic Spine Mimicking Osteosarcoma

Case report. We describe a case of osseous metaplastic meningioma in the thoracic spine that pathologically mimicked osteosarcoma. As meningioma presents in many pathological forms, it is sometimes difficult to diagnose it pathologically. The patient's medical records, imaging results, and pathological findings were reviewed, as was the relevant literature. A 20-year-old woman with a 6-month history of lumbago and right sciatica was referred to our hospital because magnetic resonance imaging (MRI) showed a tumor compressing her spinal cord at the T11 vertebra level. Computed tomography (CT) showed calcification of the tumor, and the preoperative diagnosis was meningioma. Surgery was performed and the tumor was entirely removed. The tumor was very hard, and pathological findings suggested atypical meningioma with massive ossification. Some parts of the tumor seemed malignant, as spindle cells with a high nucleocytoplasmic ratio were highly concentrated, which led to the possibility of osteosarcoma. The tumor was conclusively diagnosed as osseous metaplastic meningioma based not only on the pathology, but also on CT and MRI findings and the postoperative course. As meningioma presents in many pathological forms, it is sometimes difficult to diagnose it pathologically. Results of imaging studies including CT and MRI, as well as patients' postoperative course, should be considered when making a final diagnosis of meningioma. N/A.

Anterior surgery in selective patients with massive ossification of posterior longitudinal ligament of cervical spine: technical note

The study includes case series, technical note and review of literature. The objective of this study was to assess the validity of the radiographic indicator and the result of anterior operation for massive ossification of posterior longitudinal ligament (MOPLL, ossification of posterior longitudinal ligament with an occupying ratio exceeding 50%). Anterior decompression yielded a better outcome than posterior approach in patients with MOPLL of cervical spine. But anterior surgery has the problem of technically demanding and was associated with a high incidence of surgery-related complications. Many ways for reducing the risk of anterior surgery have been reported, including floating method, employing microscopes or burrs, and laser-assisted corpectomy. A case series of selective patients with MOPLL of cervical spine undergoing anterior surgery is reported. All patients were strictly selected based on CT images with the appearance of open-base. 29 cases with more than 12 months follow-up (average, 31.0 ± 10.0 m) were reviewed. Average age at operation was 59.3 ± 8.2 years (43-73 years). Anterior decompression was done only for one or two vertebrae. One corpectomy was done in 13 cases, two corpectomies in 3 cases, and one corpectomy and one discectomy in 13 cases. Three levels were fused in 16 cases and two levels in 13 cases. No permanent neurological deterioration was observed. Neurological improvement was observed in every patients with an average improvement rate of 64 ± 23%. Mesh migration was observed in one case. A fusion rate of 100% was achieved. Anterior surgery using our technique may be a relatively simple and safe procedure in selective patients with massive ossification of posterior longitudinal ligament of cervical spine.