Thoracic Myelopathy Research Articles

Thoracic myelopathy caused by calcification of the ligamentum flavum.

Calcification of the ligamentum flavum (CLF), which is a rare disorder that can potentially cause myelopathy, occurs uncommonly in the thoracic spine. Here, we report a rare case of thoracic myelopathy caused by CLF in a 78-year-old man. Magnetic resonance imaging (MRI) showed posterior spinal cord compression by a hypo-signal intense mass, and computed tomography (CT) revealed CLF and vacuum disc phenomenon at T10/11. After undergoing posterior decompression and instrumented fusion (T9–T12), the patient’s gait difficulties improved. The pathogenesis of CLF is largely unknown; however, it involves accumulation of calcium pyrophosphate dehydrate crystals (CPPD), and CLF from CPPD deposition tends to occur within a thickened and hypertrophic ligament. CLF occurs predominantly in the cervical spine and less frequently in the lumbar spine, with few cases involving the thoraco-lumbar spine. The thoracic spine is characterized by hypomobility; however, the thoraco-lumbar spine has a mobile segment which may potentiate CLF formation. Decompression with fusion surgery can be useful for treating patients with thoraco-lumbar CLF.

Technological advancements that can be adopted for performing a safe vertebral column resection

Recent technological advancements have reduced the risks involved in vertebral column resection (VCR) with a wide range of tools that can be adopted. We intend to highlight the importance of these tools for performing a safe VCR. The patient, a 35-year-old man, presented with hyperkyphotic thoracic spine and symptomatic thoracic myelopathy. Radiological evaluation showed anterior wedging and fused T6-T7 vertebra, resulting in a gibbus deformity causing significant canal stenosis. Hence, T3-T10 posterior stabilization, T5-T8 decompression, and T6-T7 VCR and anterior column reconstruction were planned. We used recent technological advancements such as: (1) three-dimensional printed spine model for preoperative planning, (2) multimodal intraoperative neuromonitoring, (3) ultrasonic bone debulking, and (4) computed tomography–based image-guided spinal navigation. These advancements have made spine surgery relatively safer, predictable, and precise. Moreover, the field is constantly evolving. Hence, adapting to these advancements and utilizing it in complex scenarios are highly beneficial.

Surgery-related predictable risk factors influencing postoperative clinical outcomes for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: a multicenter retrospective study.

Compression of the spinal cord by thoracic ossification of the posterior longitudinal ligament (T-OPLL) often causes severe thoracic myelopathy. Although surgery is the most effective treatment for T-OPLL, problems associated with surgical intervention require resolution because surgical outcomes are not always favorable, and a small number of patients experience deterioration of their neurological status after surgery. The aim of the present study was to examine the surgery-related risk factors contributing to poor clinical outcomes for myelopathy caused by T-OPLL. Data were extracted from the records of 55 patients with thoracic myelopathy due to T-OPLL at institutions in the Fukuoka Spine Group. The mean follow-up period was 5.3 years. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale. To investigate the definitive factors associated with surgical outcomes, univariate and multivariate regression analyses were performed with several patient-related and surgery-related factors, including preoperative comorbidities, radiological findings, JOA score, surgical methods, surgical outcomes, and complications. Neurological status improved in 33 patients (60.0%) and deteriorated in 10 patients (18.2%) after surgery. The use of instrumentation was significantly associated with an improved outcome. In the comparison of surgical approaches, posterior decompression and fusion resulted in a significantly higher neurological recovery rate than did anterior decompression via a posterior approach and fusion or decompression alone. It was also found that postoperative neurological status was significantly poorer when there were fewer instrumented spinal levels than decompression levels. CSF leakage was a predictable risk factor for deterioration following surgery. It is important to identify preventable risk factors for poor surgical outcomes for T-OPLL. The findings of the present study suggest that intraoperative CSF leakage and a lower number of instrumented spinal fusion levels than decompression levels were exacerbating factors for the neurological improvement in T-OPLL surgery.

Three-Dimensional Analysis of the Radiological Risk Factors for Progression of the Thoracic Ossification of the Posterior Longitudinal Ligament After Posterior Decompression and Stabilization

Although research shows that the ossified masses of ossification of the posterior longitudinal ligament (OPLL) continue to grow postoperatively, information regarding thoracic OPLL (T-OPLL) is lacking. To date, no study has investigated the progression of T-OPLL within each motion segment. The purpose of this study was to analyze the progression of T-OPLL in each motion segment using a 3-dimensional measurement and evaluate whether the type of T-OPLL and surgical methods affect its progression postoperatively. Clinical data from 20 patients (101 segments) with thoracic myelopathy secondary to OPLL were evaluated retrospectively. All patients underwent posterior decompression (laminectomy and stabilization or circumferential decompression [CD] and stabilization) at a single center. The 3-dimensional measurement of OPLL volume was performed using computed tomography scans. The ossified masses were classified into 2 types based on the fusion of each segment at the intervertebral space: type 1= complete bridging (fused); type 2= not fused. Statistical analyses were performed to determine the degree of T-OPLL progression according to the types and surgical methods. Mean OPLL progression was significantly higher in type 2. The mean annual growth rates of OPLL (AGRO) for groups 1 and 2 were 6.21% ± 6.11% per year and 23.50% ± 11.34% per year, respectively (P < 0.01). Further, no statistically significant differences were seen between the fixed and non-fixed groups (P= 0.23), and CD and non-CD segments (P= 0.56). The mean AGRO does not decrease even after stabilization and CD. Type 2 intervertebral space was a risk factor for T-OPLL progression. Cases of type 2 without CD need close follow-up.

Clinical Features of Thoracic Myelopathy: A Single-Center Study.

Introduction:Thoracic myelopathy is relatively uncommon because few degenerative changes occur as a result of the restricted range of motion surrounding the rib cage.Methods:A retrospective study was performed in 300 consecutive surgical cases of thoracic disorders with myelopathy treated in our department from 2000 to 2015. Girdle pain, back pain, low back pain, leg numbness, leg pain, gait disturbance, leg paresis, and bowel bladder disturbance as initial and preoperative symptoms; patellar tendon reflex, ankle tendon reflex, and ankle clonus as preoperative neurologic findings; MRI and CT findings; and surgical procedure, intraoperative findings, and postoperative recovery were investigated.Results:The disease distribution included ossification of the ligamentum flavum (OLF) (n = 48), ossification of the posterior longitudinal ligament (OPLL) (n = 30), OPLL with OLF (n = 27), intradural extramedullary tumor (n = 98), intramedullary spinal cord tumor (n = 64), vertebral tumor (n = 17), spinal cord herniation (n = 7), vertebral fracture (n = 4), and thoracic disk herniation (n = 5). There were notable associations of gait disturbance with OPLL and OPLL + OLF; back pain at initial diagnosis with disease at upper levels; and low back pain with disease at a lower level.Conclusion:These findings suggest that patients with gait disturbance, back pain, and low back pain on physical examination may have thoracic disease that results in myelopathy.

Repair of Thoracic Spinal Cord Herniation: 2-Dimensional Operative Video.

Spinal cord herniation is an uncommon surgically treatable cause of thoracic myelopathy and progressive paraplegia. The thoracic spinal cord focally protrudes through a defect in the dura, resulting in progressive weakness, numbness, and spasticity affecting the lower extremities, in addition to possible urinary symptoms. In this video, we present the case of a 69-yr-old female who presented with 3 yr of progressive thoracic myelopathy due to a thoracic spinal cord herniation at T4-T5. We demonstrate the surgical steps to lyse arachnoid webs, mobilize the spinal cord, reduce the spinal cord herniation, and repair the dural defect. Appropriate patient consent was obtained.

Microsurgical resection of ossification of the posterior longitudinal ligament in the thoracic spine via the transthoracic approach without spinal fusion: case series and technical note.

Surgical management of thoracic ossification of the posterior longitudinal ligament (OPLL) remains challenging because of the anatomical complexity of the thoracic spine and the fragility of the thoracic spinal cord. Several surgical approaches have been described, but it remains unclear which of these is the most effective. The present study describes the microsurgical removal of OPLL in the middle thoracic level via the transthoracic anterolateral approach without spinal fusion, including the surgical outcome and operative tips. Between 2002 and 2017, a total of 8 patients with thoracic myelopathy due to OPLL were surgically treated via the transthoracic anterolateral approach without spinal fusion. The surgical techniques are described in detail. Clinical outcome, surgical complications, and the pre- and postoperative thoracic kyphotic angle were assessed. The mean patient age at the time of surgery was 55 years (range 47-77 years). There were 5 women and 3 men. The surgically treated levels were within T3-9. The clinical symptoms and Japanese Orthopaedic Association (JOA) score improved postoperatively in 7 cases, but did not change in 1 case. The mean JOA score increased from 6.4 preoperatively to 7.5 postoperatively (recovery rate 26%). Intraoperative CSF leakage occurred in 4 cases, and was successfully treated with fibrin glue sealing and spinal drainage. The mean follow-up period was 82.6 months (range 15.3-169 months). None of the patients had deterioration of the thoracic kyphotic angle. Anterior decompression is the logical and ideal procedure to treat thoracic myelopathy caused by OPLL on the concave side of the spinal cord; however, this procedure is technically demanding. Microsurgery via the transthoracic anterolateral approach enables direct visualization of the thoracic ventral ossified lesion. The use of microscopic procedures might negate the need for bone grafting or spinal instrumentation.

A Crescent-Shaped Juxtafacet Cyst as a Rare Cause of High Thoracic Myelopathy with Partial Brown-Séquard's Syndrome

A Crescent-Shaped Juxtafacet Cyst as a Rare Cause of High Thoracic Myelopathy with Partial Brown-Séquard's Syndrome

Clinical and neuroimaging findings of spinal dural arteriovenous fistulas: How to avoid misdiagnosis of this disease

ObjectiveSpinal dural arteriovenous fistulas (DAVFs) are rare but can cause serious gait and micturition disturbances. Delays in diagnosis and treatment result in poor clinical outcomes; however, the process of misdiagnosis is unknown. MethodsForty consecutive patients were retrospectively analyzed. ResultsThirty-one patients (78%) were initially misdiagnosed with lumbar spinal stenosis or other diseases, mostly by orthopedic surgeons, even though most patients (85%) had specific symptoms or characteristic neuroimaging findings of spinal DAVFs: they often presented with spastic gait (thoracic myelopathy), progressive ascending numbness that begins in the distal lower extremities (epicous syndrome), and urinary tract symptoms (conus medullaris syndrome); initial lumbar MRI showed T2 signal change in the conus medullaris and vascular flow voids around the cord. The median time from onset to treatment was longer in patients with a misdiagnosis than in those with the correct diagnosis (11 vs 4 months). In all patients, the fistula was completely obliterated by the direct microsurgical procedure; however, patients with a misdiagnosis had developed additional disabilities by the time a correct diagnosis was made (Aminoff-Logue gait grade of 3.6 ± 1.4 vs 2.1 ± 1.5 p = 0.013), and achieved markedly smaller improvements after the treatment (Aminoff-Logue gait grade of 3.0 ± 1.6 vs 1.1 ± 1.5, p = 0.006) than those with the correct diagnosis of spinal DAVFs. ConclusionsWhen common spinal stenosis fail to explain the symptoms such as thoracic myelopathy, epiconus syndrome, and conus medullaris syndrome, the possibility of spinal DAVFs should be considered. If lumbar MRI shows conus medullaris lesions, thoracic MRI should be performed to confirm the diagnosis.

Clinical characteristics of patients with thoracic myelopathy caused by ossification of the posterior longitudinal ligament.

Although ossification of the posterior longitudinal ligament (OPLL) commonly develops in the cervical spine, it also occurs, albeit less commonly, in the thoracic spine. However, data are scarce regarding the characteristics of patients with thoracic OPLL. In the current study, we performed a cross-sectional study on a total of 133 patients with OPLL to clarify the clinical characteristics of patients with thoracic OPLL compared with those of patients with cervical OPLL. The subjects were divided into four groups according to the main region of OPLL and treatment type: C-OPLL-C, cervical OPLL treated conservatively; C-OPLL-S, cervical OPLL treated via surgery; T-OPLL-C, thoracic OPLL treated conservatively; and T-OPLL-S, thoracic OPLL treated via surgery. Symptoms developed at an earlier age in the T-OPLL-S group than in the C-OPLL groups. Current body mass index (BMI), maximum lifetime BMI, and BMI at the age of 20years were significantly higher in the T-OPLL-S group than in the C-OPLL groups. Yearly weight gain from the age of 20years to the age at which maximum body weight was attained was significantly greater in the T-OPLL-S group than in the C-OPLL groups. The T-OPLL group showed a higher rate of co-existence of OPLL at other regions or ossification of the ligamentum flavum compared to the C-OPLL groups. Our findings demonstrate that severe obesity, early-onset of symptoms, and diffuse ossification of spinal ligaments are distinct features of patients with myelopathy caused by thoracic OPLL.

Surgical Results of Patients with Myelopathy due to Ossification of the Ligamentum Flavum with Ossification of the Posterior Longitudinal Ligament or a Vertebral Fracture at the Same Level of the Thoracic Spine: A Retrospective Comparative Study.

Study DesignRetrospective and comparative study.PurposeWe assessed surgical treatment outcomes in patients with thoracic myelopathy due to ossification of the ligamentum flavum (OLF), and OLF combined with ossification of the posterior longitudinal ligament (OPLL) or vertebral fracture (VF) at the same level.Overview of LiteratureOLF and OPLL cause severe thoracic myelopathy. Osteoporotic VF commonly occurs at the thoracolumbar junction. There have been no investigations of thoracic myelopathy due to OLF and VF.MethodsForty patients were divided among three groups: the OLF group (n=23): myelopathy due to OLF, the OLF+OPLL group (n=12): myelopathy due to OLF and OPLL, and the OLF+VF group (n=5): myelopathy due to OLF and VF. We recorded OLF, OPLL, and VF sites and operative procedures. Each patient’s neurological status, according to the Japanese Orthopaedic Association (JOA) score, and walking ability were evaluated pre- and postoperatively.ResultsPatients in the OLF+OPLL group were significantly younger than those in the other two groups. The preoperative JOA score was significantly lower in the OLF+VF than OLF group. The final JOA score was significantly lower in the OLF+VF than OLF and OLF+OPLL groups. The JOA score recovery rate was significantly lower in the OLF+VF than OLF group. Final walking ability was significantly worse in the OLF+OPLL and OLF+VF groups than in the OLF group and significantly worse in the OLF+VF than OLF+OPLL group.ConclusionsThoracic myelopathy due to OLF+VF occurs primarily in older females, who also exhibit worse preoperative and postoperative neurological status, and worse walking ability, than patients with thoracic myelopathy due to OLF or OLF+OPLL.

Microsurgical Management of a Spinal Dural Arteriovenous Fistula With Shared Blood Supply to the Artery of Adamkiewicz: 3-Dimensional Operative Video.

The presented case is of a 65-yr-old gentleman referred for thoracic myelopathy. He developed bilateral, nondermatomal foot dysesthesia 14 mo prior to presentation, which progressed to numbness below the L3 level. He reported progressive gait instability, bilateral lower extremity weakness, and required a cane for ambulation. He subsequently developed urinary incontinence, while bowel function was spared. The neurological examination upon presentation revealed lower extremity strength was reduced to 4/5 in all major muscle groups bilaterally, while sensation and proprioception were reduced below the L3 level. Patellar and Achilles reflexes were not elicited and clonus was absent. Gait was unsteady and slow. The patient was not able to perform heel, toe and tandem gait. MRI revealed abnormal T2 hyper-intense signal and spinal cord expansion from T6 through the conus medullaris. Angiography revealed a dural arteriovenous fistula (dAVF) originating from the left T9 radicomedullary pedicle, which also supplied the Artery of Adamkiewicz (AoA). The patient underwent T8-10 laminectomies. Prior to disconnection of the fistula, an aneurysm clip was applied to the fistulous point and an indocyanine green video angiogram was completed to show that the fistula no longer opacified, but that the AoA remained patent, which was later confirmed with angiography. As of discharge, the patient's motor exam had improved substantially, though his sensory deficits persisted. This case demonstrates that surgical disconnection is requisite in the treatment of spinal dAVF that have a shared blood supply with the AoA, as embolization risks spinal cord infarction. The patient consented to presentation of this case in a de-identified fashion.

Near complete block of spinal canal and thoracic myelopathy due to tuberous ossification of ligamentum flavum in a 32 year old female

Near complete block of spinal canal and thoracic myelopathy due to tuberous ossification of ligamentum flavum in a 32 year old female

Operative Management of Idiopathic Spinal Cord Herniation: Case Series and Novel Technique for Repair of Recurrent Herniation

Idiopathic spinal cord herniation (ISCH) is a rare pathology of the spine defined by herniation of the spinal cord through a dural defect. To highlight the operative management of ISCH and the surgical nuances of ISCH repairs conducted at our institution. This retrospective review examines consecutive patients with ISCH who were treated surgically between January 1, 2010, and July 31, 2017, at Barrow Neurological Institute, Phoenix, Arizona. Four patients with ISCH presented with thoracic myelopathy and lower extremity weakness during the study period. Treatment consisted of reduction of the herniated spinal cord and filling of the dural defect with a collagen-based dural regeneration matrix. In 3 patients the dural edges were covered with a collagen-matrix intradural sling, and in 1 patient they were repaired primarily with interrupted sutures. Three of the 4 patients experienced improvement in myelopathic symptoms; the fourth patient suffered neurological decline in the immediate postoperative period. ISCH is a complex pathological condition likely to result in progressive myelopathy. Surgery offers patients the possibility of stabilizing the progression of the spinal cord dysfunction and perhaps restoring neurological function. However, extreme care must be taken during surgery to minimize manipulation of the fragile herniated cord.

Percutaneous full endoscopic posterior decompression of thoracic myelopathy caused by ossification of the ligamentum flavum.

Ossification of ligamentum flavum (OLF) is the leading cause of progressive thoracic myelopathy (TM) in East Asian countries. Surgical decompression is the general treatment for TM. This study investigated the application of percutaneous full endoscopic posterior decompression (PEPD) for the treatment of thoracic OLF. Eighteen patients with TM were treated by PEPD under local anaesthesia. Patients had an average age of 59.1years and single-level lesions mostly at the lower thoracic vertebrae. Computed tomography and magnetic resonance imaging were used to classify the OLF. The pre- and postoperative neurological statuses were evaluated using the American Spinal Injury Association (ASIA) sensory and motor score, modified Japanese Orthopaedic Association (mJOA) score and Frankel grade. OLF for all patients was classed as lateral, extended, and enlarged types without comma and tram track signs. Decompression was completed, and a dome-shaped laminotomy was performed through limited laminectomy and flavectomy. Dural tears in 2patients were the only observed complication. The average score of ASIA sensory and motor, mJOA, as well as the Frankel grade improved significantly after surgery at an average follow-up time of 17.4months. The average recovery rate (RR) was 47.5% as calculated from the mJOA scores. According to RR, 10 cases were classified as good, 4 cases fair, and 4 cases unchanged. For patients with thoracic OLF at a single level and lateral, extended, and enlarged types without comma and tram track signs, it is safe and reliable to perform PEPD, which has satisfactory clinical results. These slides can be retrieved under Electronic Supplementary Material.

Anterolateral Approach for Central Thoracic Disc Prolapse-Surgical Strategies Used to Tackle Differing Operative Findings: 3-Dimensional Operative Video.

Thoracic disc prolapses causing cord compression can be challenging. For compressive central disc protrusions, a posterior approach is not suitable due to an unacceptable level of cord manipulation. An anterolateral transthoracic approach provides direct access to the disc prolapse allowing for decompression without disturbing the spinal cord. In this video, we describe 2 cases of thoracic myelopathy from a compressive central thoracic disc prolapse. In both cases, informed consent was obtained. Despite similar radiological appearances of heavy calcification, intraoperatively significant differences can be encountered. We demonstrate different surgical strategies depending on the consistency of the disc and the adherence to the thecal sac. With adequate exposure and detachment from adjacent vertebral bodies, soft discs can be, in most instances, separated from the theca with minimal cord manipulation. On the other hand, largely calcified discs often present a significantly greater challenge and require thinning the disc capsule before removal. In cases with significant adherence to dura, in order to prevent cord injury or cerebrospinal fluid leak a thinned shell can be left, providing total detachment from adjacent vertebrae can be achieved. Postoperatively, the first patient, with a significantly calcified disc, developed a transient left leg weakness which recovered by 3-month follow-up. This video outlines the anatomical considerations and operative steps for a transthoracic approach to a central disc prolapse, whilst demonstrating that computed tomography appearances are not always indicative of potential operative difficulties.

Electrophysiological Assessment and Classification of Motor Pathway Function in Patients With Spinal Dural Arteriovenous Fistula.

The diagnosis of spinal dural arteriovenous fistula (SDAVF) is difficult and often delayed because clinical features are often nonspecific. We assessed the motor function electrophysiologically in patients with SDAVF. Motor-evoked potentials after transcranial magnetic stimulation and compound muscle action potentials and F-waves after electrical stimulation in the ulnar and tibial nerves were measured from the abductor hallucis (AH) muscles in 14 patients with SDAVF (SDAVF group), 12 patients with compressive thoracic myelopathy (CTM group), and 16 normal subjects (control group). The peripheral conduction time determined from abductor hallucis muscles (PCT-AH) and the central motor conduction time determined from abductor hallucis muscles (CMCT-AH) were calculated. According to the neurological findings, patients in the SDAVF group were classified to upper motor neuron (UMN) sign and lower motor neuron (LMN) sign categories. CMCT-AH in the SDAVF and CMT groups were significantly longer than those in the control group. PCT-AH in the SDAVF group was significantly longer than that in the control and CMT groups. Twelve patients in the SDAVF group showed abnormal CMCT-AH and/or PCT-AH. Abnormal CMCT-AH and PCT-AH were detected in five cases that exhibited UMN sign and/or LMN sign. Three cases with abnormal CMCT-AH and normal PCT-AH exhibited UMN sign. LMN sign without UMN sign was observed in four cases with abnormal PCT-AH and normal CMCT-AH. Our study revealed abnormalities in the corticospinal tract and/or lower motor neurons, and classified the patients with SDAVF into three types: the UMN type, LMN type, and mixed type.

Angiopoietin-2 promotes osteogenic differentiation of thoracic ligamentum flavum cells via modulating the Notch signaling pathway.

Thoracic ossification of the ligamentum flavum (TOLF) is heterotopic ossification of spinal ligaments, which may cause serious thoracic spinal canal stenosis and myelopathy. However, the underlying etiology remains inadequately understood. In this study, the ossification patterns of TOLF were analyzed by micro-computer tomography (micro-CT). The expression profile of genes associated with angiogenesis was analyzed in thoracic ligamentum flavum cells at sites of different patterns of ossification using RNA sequencing. Significant differences in the expression profile of several genes were identified from Gene Ontology (GO) analysis. Angiopoietin-2 (ANGPT2) was significantly up-regulated in primary thoracic ligamentum flavum cells during osteogenic differentiation. To address the effect of ANGPT2 on Notch signaling and osteogenesis, ANGPT2 stimulation increased the expression of Notch2 and osteogenic markers of primary thoracic ligamentum flavum cells of immature ossification, while inhibition of ANGPT2 exhibited opposite effect on Notch pathway and osteogenesis of cells of mature ossification. These findings provide the first evidence for positive regulation of ANGPT2 on osteogenic differentiation in human thoracic ligamentum flavum cells via modulating the Notch signaling pathway.

Ossification of the Ligamentum Flavum: Thoracic Myelopathy in Non-Oriental Patient. Case report

Ossification of the ligamentum flavum (OLF) of thoracic spine occurs along with a progressive spine lesion, and is a rare myelopathy in non-Oriental patients. Computed Tomography or Magnetic Resonance imaging of spine are used for diagnosis, and early decompressive laminectomy is the treatment of choice. We report a case of female patient, 73-year-old, who presented progressive and symmetrical paraparesis, and painful tactile hypoesthesia at T4 level with two months of evolution of the case. After OLF diagnosis, with myelopathy on T1-T2 segment, we performed spine decompression with significant functional better results. According to our research and knowledge, this is the third case to be reported on Brazilian medical literature of a patient with non-Oriental descent.

Thoracic myelopathy secondary to ossified ligamentum flavum and dural ossification – A series of 19 cases and review of literature

Objective: Thoracic myelopathy has gradually risen to be a prominent diagnosis in patients with persistent upper back pain, bladder symptoms and spastic paraparesis. Often encountered, these conditions pose a serious dilemma to neurosurgeons with respect to surgical planning, timing of surgery, prognosis and possible complications and outcome assessment. In view of these queries and to clarify the indications of when to intervene the following study has been undertaken. To analyze the clinical presentation, radiological features, clinical implications and surgical nuances and outcomes in patients with single and multiple level dorsal canal ossified ligamentum flavum (D-OLF) and associated dural ossification (DO). Patients and methods: Nineteen patients with the diagnosis of thoracic myelopathy (TM) were identified between January 2012 and March 2017. All patients were treated surgically, with decompressive laminectomies, in a single tertiary care center in Southern India. mJOA was calculated preoperatively and assessed postoperatively and a mean mJOA was calculated to assess the significance in neurological improvement. The data was collected from the medical records department and various factors were analyzed, using SPSS software, for correlation.Results: Mean age of our group was 50.84 years with a range of 29 to 71 years. It comprised of 11 males and 8 females. All patients had features of myelopathy. Surgery did have a positive effect on neurological improvement (p = 0.001) in all patients except one. Dural ossification had correlation with pre op and post op urinary disturbances with p value of 0.02. (Mann Whitney Test for 2 independent variables used). A total of ten patients had urinary symptoms pre operatively, out of which six patients showed postoperative improvement at the end of one year. Four of these patients continued to have symptoms, two patients were on Clean Intermittent Catheterisation (CIC), and one patient had features of hesitancy and frequency. Preoperative bladder dysfunction was a strong predictor for continued bladder dysfunction at the end of 1 year (p < 0.004). Conclusions: All patients with D-OLF and or DO presented with myelopathic features. MRI with concurrent CT spine helps to delineate dural ossification from D-OLF and helped to rule out other differentials. The classical “tram track” and “comma sign” is well noted in CT spine and helps to plan surgical approach and anticipate probable complications. Patients with concurrent D-OLF and DO and long segment pathology had increased risk of intraoperative dural tears and postoperative CSF leaks. These subset of patients had a peaked incidence of bladder involvement or non-improvement of existing bladder dysfunction, postoperatively. Patients with D-OLF and DO seemed to do better after surgical decompression. Surgery should be offered once diagnosis is confirmed on imaging, as all patients in out study, except one, showed postoperative neurological improvement.Our study concluded that patients with prolonged preoperative symptoms persisted to have them even after surgery. Patients with concurrent D-OLF and DO showed more significant improvement, postoperatively, in terms of mJOA – postop with a p = 0.002 as compared to patients with D-OLF alone.We recommend that each case be treated individually and treatment should be planned appropriately, based on the radiology and levels involved, keeping in mind the preoperative symptoms and their duration.