Advances in surgical strategies for ossification of posterior longitudinal ligament involving the C<sub>2</sub> segment_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Teng ¹ , GU Guoning ¹ , ZHAN Chenguang ¹ , LI Haishan ¹ , GUO Huizhi ² , LI Yongxian ² , MO Guoye ² , YUAN Kai ² , ZHANG Shuncong ² , YANG Zhidong ² ,  TANG Yongchao ²

1. The First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou Guangdong, 510405, P. R. China;
2. Department of Spinal Orthopedics, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou Guangdong, 510407, P. R. China;

Corresponding author：

TANG Yongchao, Email: zmdrntyc@163.com

Keywords：

Ossification of the posterior longitudinal ligament; cervical spondylotic myelopathy; C₂; surgical strategy

DOI：

10.7507/1002-1892.202302039

Video：

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Objective To evaluate the application of surgical strategies for the treatment of cervical ossification of the posterior longitudinal ligament (OPLL) involving the C₂ segment. Methods The literature about the surgery for cervical OPLL involving C₂ segment was reviewed, and the indications, advantages, and disadvantages of surgery were summarized. Results For cervical OPLL involving the C₂ segments, laminectomy is suitable for patients with OPLL involving multiple segments, often combined with screw fixation, and has the advantages of adequate decompression and restoration of cervical curvature, with the disadvantages of loss of cervical fixed segmental mobility. Canal-expansive laminoplasty is suitable for patients with positive K-line and has the advantages of simple operation and preservation of cervical segmental mobility, and the disadvantages include progression of ossification, axial symptoms, and fracture of the portal axis. Dome-like laminoplasty is suitable for patients without kyphosis/cervical instability and with negative R-line, and can reduce the occurrence of axial symptoms, with the disadvantage of limited decompression. The Shelter technique is suitable for patients with single/double segments and canal encroachment >50% and allows for direct decompression, but is technically demanding and involves risk of dural tear and nerve injury. Double-dome laminoplasty is suitable for patients without kyphosis/cervical instability. Its advantages are the reduction of damage to the cervical semispinal muscles and attachment points and maintenance of cervical curvature, but there is progress in postoperative ossification. Conclusion OPLL involving the C₂ segment is a complex subtype of cervical OPLL, which is mainly treated through posterior surgery. However, the degree of spinal cord floatation is limited, and with the progress of ossification, the long-term effectiveness is poor. More research is needed to address the etiology of OPLL and to establish a systematic treatment strategy for cervical OPLL involving the C₂ segment.

Citation： LIU Teng, GU Guoning, ZHAN Chenguang, LI Haishan, GUO Huizhi, LI Yongxian, MO Guoye, YUAN Kai, ZHANG Shuncong, YANG Zhidong, TANG Yongchao. Advances in surgical strategies for ossification of posterior longitudinal ligament involving the C₂ segment. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(6): 742-747. doi: 10.7507/1002-1892.202302039 Copy

1.	Le HV, Wick JB, Van BW, et al. Ossification of the posterior longitudinal ligament: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg, 2022, 30(17): 820-830.
2.	Cao B, Chen J, Yuan B, et al. Comparison of the outcome after anterior cervical ossified posterior longitudinal ligament en bloc resection versus posterior total laminectomy and fusion in patients with ossification of the cervical posterior longitudinal ligament: a prospective randomized controlled trial. Bone Joint J, 2023, 105-B(4): 412-421.
3.	Sun J, Sun K, Wang S, et al. “Shelter technique” in the treatment of ossification of the posterior longitudinal ligament involving the C₂ segment. World Neurosurg, 2019, 125: e456-e464.
4.	曲哲, 马胜, 高啸, 等. 颈椎后纵韧带骨化累及C₂椎体对颈椎矢状面参数影响的影像学研究. 中华解剖与临床杂志, 2022, 27(10): 684-690.
5.	Yoshii T, Sakai K, Machino M, et al. Choice of surgical procedure for cervical ossification of the posterior longitudinal ligament. J Clin Med, 2022, 11(18): 5396. doi: 10.3390/jcm11185396.
6.	Li W, Wang B, Feng X, et al. Preoperative management and postoperative complications associated with transoral decompression for the upper cervical spine. BMC Musculoskelet Disord, 2022, 23(1): 128. doi: 10.1186/s12891-022-05081-7.
7.	Lee DH, Dadufalza GKP, Baik JM, et al. Double dome laminoplasty: A novel technique for C₂ decompression. Neurospine, 2021, 18(4): 882-888.
8.	Zhu C, Deng X, Pan H, et al. Unilateral biportal endoscopic laminectomy with lateral mass screw fixation for treating cervical spinal stenosis. Acta Neurochir (Wien), 2022, 164(6): 1529-1533.
9.	祁磊, 史桂东. 双通道脊柱内镜在颈椎胸椎疾病手术中的应用. 临床外科杂志, 2022, 30(4): 306-308.
10.	Beyer RS, Nguyen A, Brown NJ, et al. Spinal robotics in cervical spine surgery: a systematic review with key concepts and technical considerations. J Neurosurg Spine, 2022, 38(1): 66-74.
11.	许春阳, 杨晋才, 尹鹏, 等. 颈椎后路手术治疗脊髓型颈椎病的应用进展. 中华骨与关节外科杂志, 2022, 15(4): 296-301.
12.	Zhang JN, Hao DJ. Seesaw-like cervical ossification of posterior longitudinal ligament. World Neurosurg, 2021, 150: 127-131.
13.	Yamazaki A, Homma T, Uchiyama S, et al. Morphologic limitations of posterior decompression by midsagittal splitting method for myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Spine (Phila Pa 1976), 1999, 24(1): 32-34.
14.	Moon EJ, Lee BJ, Lee S, et al. The R-line: A new imaging index for decision making regarding C₂ lamina decompression in cervical ossification of the posterior longitudinal ligament. Korean J Neurotrauma, 2020, 16(1): 60-66.
15.	Lee BJ, Lee S, Jeon SR, et al. A new indicator predicting the degree of cord shift after posterior decompression of cervical ossification of the posterior longitudinal ligament extended to the C₂ level and its clinical usefulness. Turk Neurosurg, 2021, 31(6): 866-872.
16.	Manzano GR, Casella G, Wang MY, et al. A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery, 2012, 70(2): 264-277.
17.	McDonald CL, Hershman SH, Hogan W, et al. Cervical laminoplasty versus posterior laminectomy and fusion: trends in utilization and evaluation of complication and revision surgery rates. J Am Acad Orthop Surg, 2022, 30(17): 858-866.
18.	Ramos MRD, Liu G, Tan JH, et al. Risk factors for surgical complications in the management of ossification of the posterior longitudinal ligament. Spine J, 2021, 21(7): 1176-1184.
19.	Chiapparelli E, Okano I, Salzmann SN, et al. C₂ pedicle sclerosis grading, more than diameter, predicts surgeons’ preoperative assessment of safe screw placement: A novel classification system. World Neurosurg, 2021, 149: e576-e581.
20.	Kim GU, Lee GW. The C₂ cortical screw, an alternative fixation technique for the C₂ segment during high cervical spine surgery: Technical note. World Neurosurg, 2020, 142: 24-28.
21.	Azimi P, Yazdanian T, Benzel EC, et al. Accuracy and safety of C₂ pedicle or pars screw placement: a systematic review and meta-analysis. J Orthop Surg Res, 2020, 15(1): 272. doi: 10.1186/s13018-020-01798-0.
22.	Zhang JN, Fan Y, Hao DJ. Risk factors for robot-assisted spinal pedicle screw malposition. Sci Rep, 2019, 9(1): 3025. doi: 10.1038/s41598-019-40057-z.
23.	刘昆, 史建刚, 贾连顺, 等. 选择性半椎板切除治疗颈椎后纵韧带骨化症. 脊柱外科杂志, 2013, 11(2): 75-80.
24.	Yang Y, Wang Y, Cao J, et al. Laminoplasty and simultaneous C₂ semi-laminectomy with internal fixation in treating ossification of the posterior longitudinal ligament in cervical discs at C₂ segment. Am J Transl Res, 2022, 14(4): 2419-2427.
25.	MacDowall A, Löfgren H, Edström E, et al. Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial. Trials, 2023, 24(1): 106. doi: 10.1186/s13063-023-07123-4.
26.	Kang KC, Im SK, Lee JH, et al. Impact of lamina-open side on unilateral open door laminoplasty in patients with degenerative cervical myelopathy. Sci Rep, 2023, 13(1): 2062. doi: 10.1038/s41598-023-28490-7.
27.	刘大千, 刘京松, 王晓宇, 等. 颈椎后纵韧带骨化症治疗策略研究进展. 中国脊柱脊髓杂志, 2020, 30(3): 270-277.
28.	Liu X, Li T, Shi L, et al. Extended laminoplasty for ossification of posterior longitudinal ligament involving the C₂ segment. World Neurosurg, 2019, 130: 317-323.
29.	赵晓峰, 陆向东, 赵轶波, 等. 对延伸至上颈椎单开门椎管扩大成形术治疗上颈椎后纵韧带骨化症的长期随访. 骨科临床与研究杂志, 2022, 7(5): 267-273, 280.
30.	Yu C, Wu Y, Zhang Z, et al. Comparative effectiveness and functional outcome of C₂ dome-like expansive versus C₂ expansive open-door laminoplasty for upper cervical ossification of the posterior longitudinal ligament: A retrospective cohort study. Spine (Phila Pa 1976), 2022, 47(10): E448-E455.
31.	詹乙, 王彪. 颈椎后方韧带复合体作为多节段颈椎病后路手术新思路的可行性探讨. 骨科, 2022, 13(6): 568-572.
32.	Yang HY, Zhang YG, Zhao D, et al. A new posterior extensor attachment-point reconstruction technique for cervical spondylotic myelopathy involving C₂ segment: Clinical outcome and safety. J Neurol Surg A Cent Eur Neurosurg, 2021, 82(2): 169-175.
33.	马立泰, 刘浩, 黄康康, 等. 延伸至上颈椎的颈椎后纵韧带骨化的治疗策略. 生物骨科材料与临床研究, 2018, 15(3): 18-22, 28, 83.
34.	Sugrue PA, McClendon J, Halpin RJ, et al. Surgical management of cervical ossification of the posterior longitudinal ligament: natural history and the role of surgical decompression and stabilization. Neurosurg Focus, 2011, 30(3): E3. doi: 10.3171/2010.12.FOCUS10283.
35.	Park S, Lee DH, Ahn J, et al. How does ossification of posterior longitudinal ligament progress in conservatively managed patients? Spine (Phila Pa 1976), 2020, 45(4): 234-243.
36.	Wu W, Zhang S, Yan T. Initial clinical experiences of the muscle-preserving double door cervical laminoplasty with adjustable mini plates. Front Surg, 2023, 9: 1049937. doi: 10.3389/fsurg.2022.1049937.
37.	Hirabayashi S, Yamada H, Motosuneya T, et al. Comparison of enlargement of the spinal canal after cervical laminoplasty: open-door type and double-door type. Eur Spine J, 2010, 19(10): 1690-1694.
38.	Yuan SM. Which is better for C₂ involved ossification of posterior longitudinal ligament (OPLL): dome-like laminoplasty or double-door laminoplasty? The Spine Journal, 2018, 18(8): S121.
39.	Matsuzaki H, Hoshino M, Kiuchi T, et al. Dome-like expansive laminoplasty for the second cervical vertebra. Spine (Phila Pa 1976), 1989, 14(11): 1198-1203.
40.	石磊, 陈德玉, 许国华, 等. 涉及C₂水平的长节段颈椎后纵韧带骨化症的手术疗效观察. 中华解剖与临床杂志, 2016, 21(4): 297-300.
41.	Wang W, Xue C, Ma X, et al. Extension of decompression to C₂ doesn’t affect the spinal sagittal parameters compared with standard open-door laminoplasty. Medicine (Baltimore), 2022, 101(51): e32532. doi: 10.1097/MD.0000000000032532.
42.	吴凡, 李红, 万盛钰, 等. 枢椎椎弓根与枢椎段椎动脉对C₂椎弓根螺钉植入的影响. 中国修复重建外科杂志, 2022, 36(7): 866-872.
43.	Riew KD. Double dome laminoplasty: Works well but there are exceptions. Neurospine, 2021, 18(4): 889-890.
44.	Tang Y, Sun Y, Zeng J, et al. Exosomal miR-140-5p inhibits osteogenesis by targeting IGF1R and regulating the mTOR pathway in ossification of the posterior longitudinal ligament. J Nanobiotechnology, 2022, 20(1): 452. doi: 10.1186/s12951-022-01655-8.

1. Le HV, Wick JB, Van BW, et al. Ossification of the posterior longitudinal ligament: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg, 2022, 30(17): 820-830.
2. Cao B, Chen J, Yuan B, et al. Comparison of the outcome after anterior cervical ossified posterior longitudinal ligament en bloc resection versus posterior total laminectomy and fusion in patients with ossification of the cervical posterior longitudinal ligament: a prospective randomized controlled trial. Bone Joint J, 2023, 105-B(4): 412-421.
3. Sun J, Sun K, Wang S, et al. “Shelter technique” in the treatment of ossification of the posterior longitudinal ligament involving the C₂ segment. World Neurosurg, 2019, 125: e456-e464.
4. 曲哲, 马胜, 高啸, 等. 颈椎后纵韧带骨化累及C₂椎体对颈椎矢状面参数影响的影像学研究. 中华解剖与临床杂志, 2022, 27(10): 684-690.
5. Yoshii T, Sakai K, Machino M, et al. Choice of surgical procedure for cervical ossification of the posterior longitudinal ligament. J Clin Med, 2022, 11(18): 5396. doi: 10.3390/jcm11185396.
6. Li W, Wang B, Feng X, et al. Preoperative management and postoperative complications associated with transoral decompression for the upper cervical spine. BMC Musculoskelet Disord, 2022, 23(1): 128. doi: 10.1186/s12891-022-05081-7.
7. Lee DH, Dadufalza GKP, Baik JM, et al. Double dome laminoplasty: A novel technique for C₂ decompression. Neurospine, 2021, 18(4): 882-888.
8. Zhu C, Deng X, Pan H, et al. Unilateral biportal endoscopic laminectomy with lateral mass screw fixation for treating cervical spinal stenosis. Acta Neurochir (Wien), 2022, 164(6): 1529-1533.
9. 祁磊, 史桂东. 双通道脊柱内镜在颈椎胸椎疾病手术中的应用. 临床外科杂志, 2022, 30(4): 306-308.
10. Beyer RS, Nguyen A, Brown NJ, et al. Spinal robotics in cervical spine surgery: a systematic review with key concepts and technical considerations. J Neurosurg Spine, 2022, 38(1): 66-74.
11. 许春阳, 杨晋才, 尹鹏, 等. 颈椎后路手术治疗脊髓型颈椎病的应用进展. 中华骨与关节外科杂志, 2022, 15(4): 296-301.
12. Zhang JN, Hao DJ. Seesaw-like cervical ossification of posterior longitudinal ligament. World Neurosurg, 2021, 150: 127-131.
13. Yamazaki A, Homma T, Uchiyama S, et al. Morphologic limitations of posterior decompression by midsagittal splitting method for myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine. Spine (Phila Pa 1976), 1999, 24(1): 32-34.
14. Moon EJ, Lee BJ, Lee S, et al. The R-line: A new imaging index for decision making regarding C₂ lamina decompression in cervical ossification of the posterior longitudinal ligament. Korean J Neurotrauma, 2020, 16(1): 60-66.
15. Lee BJ, Lee S, Jeon SR, et al. A new indicator predicting the degree of cord shift after posterior decompression of cervical ossification of the posterior longitudinal ligament extended to the C₂ level and its clinical usefulness. Turk Neurosurg, 2021, 31(6): 866-872.
16. Manzano GR, Casella G, Wang MY, et al. A prospective, randomized trial comparing expansile cervical laminoplasty and cervical laminectomy and fusion for multilevel cervical myelopathy. Neurosurgery, 2012, 70(2): 264-277.
17. McDonald CL, Hershman SH, Hogan W, et al. Cervical laminoplasty versus posterior laminectomy and fusion: trends in utilization and evaluation of complication and revision surgery rates. J Am Acad Orthop Surg, 2022, 30(17): 858-866.
18. Ramos MRD, Liu G, Tan JH, et al. Risk factors for surgical complications in the management of ossification of the posterior longitudinal ligament. Spine J, 2021, 21(7): 1176-1184.
19. Chiapparelli E, Okano I, Salzmann SN, et al. C₂ pedicle sclerosis grading, more than diameter, predicts surgeons’ preoperative assessment of safe screw placement: A novel classification system. World Neurosurg, 2021, 149: e576-e581.
20. Kim GU, Lee GW. The C₂ cortical screw, an alternative fixation technique for the C₂ segment during high cervical spine surgery: Technical note. World Neurosurg, 2020, 142: 24-28.
21. Azimi P, Yazdanian T, Benzel EC, et al. Accuracy and safety of C₂ pedicle or pars screw placement: a systematic review and meta-analysis. J Orthop Surg Res, 2020, 15(1): 272. doi: 10.1186/s13018-020-01798-0.
22. Zhang JN, Fan Y, Hao DJ. Risk factors for robot-assisted spinal pedicle screw malposition. Sci Rep, 2019, 9(1): 3025. doi: 10.1038/s41598-019-40057-z.
23. 刘昆, 史建刚, 贾连顺, 等. 选择性半椎板切除治疗颈椎后纵韧带骨化症. 脊柱外科杂志, 2013, 11(2): 75-80.
24. Yang Y, Wang Y, Cao J, et al. Laminoplasty and simultaneous C₂ semi-laminectomy with internal fixation in treating ossification of the posterior longitudinal ligament in cervical discs at C₂ segment. Am J Transl Res, 2022, 14(4): 2419-2427.
25. MacDowall A, Löfgren H, Edström E, et al. Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial. Trials, 2023, 24(1): 106. doi: 10.1186/s13063-023-07123-4.
26. Kang KC, Im SK, Lee JH, et al. Impact of lamina-open side on unilateral open door laminoplasty in patients with degenerative cervical myelopathy. Sci Rep, 2023, 13(1): 2062. doi: 10.1038/s41598-023-28490-7.
27. 刘大千, 刘京松, 王晓宇, 等. 颈椎后纵韧带骨化症治疗策略研究进展. 中国脊柱脊髓杂志, 2020, 30(3): 270-277.
28. Liu X, Li T, Shi L, et al. Extended laminoplasty for ossification of posterior longitudinal ligament involving the C₂ segment. World Neurosurg, 2019, 130: 317-323.
29. 赵晓峰, 陆向东, 赵轶波, 等. 对延伸至上颈椎单开门椎管扩大成形术治疗上颈椎后纵韧带骨化症的长期随访. 骨科临床与研究杂志, 2022, 7(5): 267-273, 280.
30. Yu C, Wu Y, Zhang Z, et al. Comparative effectiveness and functional outcome of C₂ dome-like expansive versus C₂ expansive open-door laminoplasty for upper cervical ossification of the posterior longitudinal ligament: A retrospective cohort study. Spine (Phila Pa 1976), 2022, 47(10): E448-E455.
31. 詹乙, 王彪. 颈椎后方韧带复合体作为多节段颈椎病后路手术新思路的可行性探讨. 骨科, 2022, 13(6): 568-572.
32. Yang HY, Zhang YG, Zhao D, et al. A new posterior extensor attachment-point reconstruction technique for cervical spondylotic myelopathy involving C₂ segment: Clinical outcome and safety. J Neurol Surg A Cent Eur Neurosurg, 2021, 82(2): 169-175.
33. 马立泰, 刘浩, 黄康康, 等. 延伸至上颈椎的颈椎后纵韧带骨化的治疗策略. 生物骨科材料与临床研究, 2018, 15(3): 18-22, 28, 83.
34. Sugrue PA, McClendon J, Halpin RJ, et al. Surgical management of cervical ossification of the posterior longitudinal ligament: natural history and the role of surgical decompression and stabilization. Neurosurg Focus, 2011, 30(3): E3. doi: 10.3171/2010.12.FOCUS10283.
35. Park S, Lee DH, Ahn J, et al. How does ossification of posterior longitudinal ligament progress in conservatively managed patients? Spine (Phila Pa 1976), 2020, 45(4): 234-243.
36. Wu W, Zhang S, Yan T. Initial clinical experiences of the muscle-preserving double door cervical laminoplasty with adjustable mini plates. Front Surg, 2023, 9: 1049937. doi: 10.3389/fsurg.2022.1049937.
37. Hirabayashi S, Yamada H, Motosuneya T, et al. Comparison of enlargement of the spinal canal after cervical laminoplasty: open-door type and double-door type. Eur Spine J, 2010, 19(10): 1690-1694.
38. Yuan SM. Which is better for C₂ involved ossification of posterior longitudinal ligament (OPLL): dome-like laminoplasty or double-door laminoplasty? The Spine Journal, 2018, 18(8): S121.
39. Matsuzaki H, Hoshino M, Kiuchi T, et al. Dome-like expansive laminoplasty for the second cervical vertebra. Spine (Phila Pa 1976), 1989, 14(11): 1198-1203.
40. 石磊, 陈德玉, 许国华, 等. 涉及C₂水平的长节段颈椎后纵韧带骨化症的手术疗效观察. 中华解剖与临床杂志, 2016, 21(4): 297-300.
41. Wang W, Xue C, Ma X, et al. Extension of decompression to C₂ doesn’t affect the spinal sagittal parameters compared with standard open-door laminoplasty. Medicine (Baltimore), 2022, 101(51): e32532. doi: 10.1097/MD.0000000000032532.
42. 吴凡, 李红, 万盛钰, 等. 枢椎椎弓根与枢椎段椎动脉对C₂椎弓根螺钉植入的影响. 中国修复重建外科杂志, 2022, 36(7): 866-872.
43. Riew KD. Double dome laminoplasty: Works well but there are exceptions. Neurospine, 2021, 18(4): 889-890.
44. Tang Y, Sun Y, Zeng J, et al. Exosomal miR-140-5p inhibits osteogenesis by targeting IGF1R and regulating the mTOR pathway in ossification of the posterior longitudinal ligament. J Nanobiotechnology, 2022, 20(1): 452. doi: 10.1186/s12951-022-01655-8.

Chinese Journal of Reparative and Reconstructive Surgery

Advances in surgical strategies for ossification of posterior longitudinal ligament involving the C₂ segment

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Advances in surgical strategies for ossification of posterior longitudinal ligament involving the C₂ segment