Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Prevalence, Distribution, and Significance of Incidental Thoracic Ossification of the Ligamentum Flavum in Korean Patients with Back or Leg Pain : MR-Based Cross Sectional Study

  • Moon, Bong Ju (Department of Neurosurgery, Chonnam National University Hospital and Medical School) ;
  • Kuh, Sung Uk (Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine) ;
  • Kim, Sungjun (Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Kim, Keun Su (Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine) ;
  • Cho, Yong Eun (Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine) ;
  • Chin, Dong Kyu (Department of Neurosurgery, Gangnam Severance Hospital, The Spinal and Spinal Cord Institute, Yonsei University College of Medicine)
  • Received : 2015.04.05
  • Accepted : 2015.06.11
  • Published : 2015.08.28
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : Thoracic ossification of the ligamentum flavum (OLF) is a relatively rare disease. Because of ambiguous clinical symptom, it is difficult for early diagnosis of OLF and subsequent treatment can be delayed or missed. Therefore, the purpose of this study is to comprehensively assess the prevalence and distribution of thoracic OLF by magnetic resonance imaging (MRI) and coexisting spinal disease in Korean patients with back pain or leg pain. Methods : The sample included 2134 Korean patients who underwent MRI evaluation for back pain. The prevalence and distribution of thoracic OLF were assessed using lumbar MRI with whole spine sagittal images. Additionally, we examined the presence of coexisting lumbar and cervical diseases. The presence of thoracic OLF as well as clinical parameters such as age, sex, and surgery were retrospectively reviewed. Results : The prevalence of thoracic OLF in total patients was 16.9% (360/2134). The prevalence tended to increase with aging and was higher in women than in men. The lower thoracic segment of T10-11 was the most frequently affected segment. Of the 360 patients with OLF, 31.9% had coexisting herniated thoracic discs at the same level. Approximately 74% of the patients with OLF had coexisting lumbar and cervical disease. Nine (2.5%) of 360 OLF patients underwent surgery for thoracic lesion. Conclusion : The prevalenceof thoracic OLF was relatively higher than those of previous reports. And coexisting lumbar and cervical disease were very frequent. Therefore, we should check coexisting spinal diseases and the exact diagnostic localization of ossification besides lumbar disease.

Keywords

References

  1. Aizawa T, Sato T, Sasaki H, Kusakabe T, Morozumi N, Kokubun S : Thoracic myelopathy caused by ossification of the ligamentum flavum : clinical features and surgical results in the Japanese population. J Neurosurg Spine 5 : 514-519, 2006 https://doi.org/10.3171/spi.2006.5.6.514
  2. Aizawa T, Sato T, Tanaka Y, Ozawa H, Hoshikawa T, Ishii Y, et al. : Thoracic myelopathy in Japan : epidemiological retrospective study in Miyagi Prefecture during 15 years. Tohoku J Exp Med 210 : 199-208, 2006 https://doi.org/10.1620/tjem.210.199
  3. al-Orainy IA, Kolawole T : Ossification of the ligament flavum. Eur J Radiol 29 : 76-82, 1998 https://doi.org/10.1016/S0720-048X(98)00030-8
  4. Baur ST, Mai JJ, Dymecki SM : Combinatorial signaling through BMP receptor IB and GDF5 : shaping of the distal mouse limb and the genetics of distal limb diversity. Development 127 : 605-619, 2000
  5. Fukuyama S, Nakamura T, Ikeda T, Takagi K : The effect of mechanical stress on hypertrophy of the lumbar ligamentum flavum. J Spinal Disord 8 : 126-130, 1995
  6. Furusawa N, Baba H, Maezawa Y, Uchida K, Wada M, Imura S, et al. : Calcium crystal deposition in the ligamentum flavum of the lumbar spine. Clin Exp Rheumatol 15 : 641-647, 1997
  7. Guo JJ, Luk KD, Karppinen J, Yang H, Cheung KM : Prevalence, distribution, and morphology of ossification of the ligamentum flavum : a population study of one thousand seven hundred thirty-six magnetic resonance imaging scans. Spine (Phila Pa 1976) 35 : 51-56, 2010 https://doi.org/10.1097/BRS.0b013e3181b3f779
  8. Guo JJ, Yang HL, Cheung KM, Tang TS, Luk KD : Classification and management of the tandem ossification of the posterior longitudinal ligament and flaval ligament. Chin Med J (Engl) 122 : 219-224, 2009
  9. Han IH, Suh SH, Kuh SU, Chin DK, Kim KS : Types and prevalence of coexisting spine lesions on whole spine sagittal MR images in surgical degenerative spinal diseases. Yonsei Med J 51 : 414-420, 2010 https://doi.org/10.3349/ymj.2010.51.3.414
  10. Hayashi K, Ishidou Y, Yonemori K, Nagamine T, Origuchi N, Maeda S, et al. : Expression and localization of bone morphogenetic proteins (BMPs) and BMP receptors in ossification of the ligamentum flavum. Bone 21 : 23-30, 1997 https://doi.org/10.1016/S8756-3282(97)00080-X
  11. He S, Hussain N, Li S, Hou T : Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population. J Neurosurg Spine 3 : 348-354, 2005 https://doi.org/10.3171/spi.2005.3.5.0348
  12. Inaba K, Matsunaga S, Ishidou Y, Imamura T, Yoshida H : Effect of transforming growth factor-beta on fibroblasts in ossification of the posterior longitudinal ligament. In Vivo 10 : 445-449, 1996
  13. Kang KC, Lee CS, Shin SK, Park SJ, Chung CH, Chung SS : Ossification of the ligamentum flavum of the thoracic spine in the Korean population. J Neurosurg Spine 14 : 513-519, 2011 https://doi.org/10.3171/2010.11.SPINE10405
  14. Kawaguchi H, Kurokawa T, Hoshino Y, Kawahara H, Ogata E, Matsumoto T : Immunohistochemical demonstration of bone morphogenetic protein-2 and transforming growth factor-beta in the ossification of the posterior longitudinal ligament of the cervical spine. Spine (Phila Pa 1976) 17 (3 Suppl) : S33-S36, 1992 https://doi.org/10.1097/00007632-199203001-00007
  15. Kuh SU, Kim YS, Cho YE, Jin BH, Kim KS, Yoon YS, et al. : Contributing factors affecting the prognosis surgical outcome for thoracic OLF. Eur Spine J 15 : 485-491, 2006 https://doi.org/10.1007/s00586-005-0903-9
  16. Kurihara A, Tanaka Y, Tsumura N, Iwasaki Y : Hyperostotic lumbar spinal stenosis. A review of 12 surgically treated cases with roentgenographic survey of ossification of the yellow ligament at the lumbar spine. Spine (Phila Pa 1976) 13 : 1308-1316, 1988 https://doi.org/10.1097/00007632-198811000-00018
  17. Lang N, Yuan HS, Wang HL, Liao J, Li M, Guo FX, et al. : Epidemiological survey of ossification of the ligamentum flavum in thoracic spine : CT imaging observation of 993 cases. Eur Spine J 22 : 857-862, 2013 https://doi.org/10.1007/s00586-012-2492-8
  18. Liao CC, Chen TY, Jung SM, Chen LR : Surgical experience with symptomatic thoracic ossification of the ligamentum flavum. J Neurosurg Spine 2 : 34-39, 2005 https://doi.org/10.3171/spi.2005.2.1.0034
  19. Miyasaka K, Kaneda K, Ito T, Takei H, Sugimoto S, Tsuru M : Ossification of spinal ligaments causing thoracic radiculomyelopathy. Radiology 143 : 463-468, 1982 https://doi.org/10.1148/radiology.143.2.7071348
  20. Miyasaka K, Kaneda K, Sato S, Iwasaki Y, Abe S, Takei H, et al. : Myelopathy due to ossification or calcification of the ligamentum flavum : radiologic and histologic evaluations. AJNR Am J Neuroradiol 4 : 629-632, 1983
  21. Mori K, Kasahara T, Mimura T, Nishizawa K, Murakami Y, Matsusue Y, et al. : Prevalence, distribution, and morphology of thoracic ossification of the yellow ligament in Japanese : results of CT-based cross-sectional study. Spine (Phila Pa 1976) 38 : E1216-E1222, 2013 https://doi.org/10.1097/BRS.0b013e31829e018b
  22. Nishiura I, Isozumi T, Nishihara K, Handa H, Koyama T : Surgical approach to ossification of the thoracic yellow ligament. Surg Neurol 51 : 368-372, 1999 https://doi.org/10.1016/S0090-3019(98)00051-2
  23. Ono M, Russell WJ, Kudo S, Kuroiwa Y, Takamori M, Motomura S, et al. : Ossification of the thoracic posterior longitudinal ligament in a fixed population. Radiological and neurological manifestations. Radiology 143 : 469-474, 1982 https://doi.org/10.1148/radiology.143.2.7071349
  24. Pantazis G, Tsitsopoulos P, Bibis A, Mihas C, Chatzistamou I, Kouzelis C : Symptomatic ossification of the ligamentum flavum at the lumbar spine : a retrospective study. Spine (Phila Pa 1976) 33 : 306-311, 2008 https://doi.org/10.1097/BRS.0b013e3181624535
  25. Park JY, Chin DK, Kim KS, Cho YE : Thoracic ligament ossification in patients with cervical ossification of the posterior longitudinal ligaments : tandem ossification in the cervical and thoracic spine. Spine (Phila Pa 1976) 33 : E407-E410, 2008 https://doi.org/10.1097/BRS.0b013e318175c276
  26. Polgar F : Uber interakuelle wirbelverkalkung. Fortschr Geb Rontgenstrahlen Nuklearmed Erganzungsbd 40 : 292-298, 1920
  27. Postacchini F, Gumina S, Cinotti G, Perugia D, DeMartino C : Ligamenta flava in lumbar disc herniation and spinal stenosis. Light and electron microscopic morphology. Spine (Phila Pa 1976) 19 : 917-922, 1994 https://doi.org/10.1097/00007632-199404150-00009
  28. Resnick D, Guerra J Jr, Robinson CA, Vint VC : Association of diffuse idiopathic skeletal hyperostosis (DISH) and calcification and ossification of the posterior longitudinal ligament. AJR Am J Roentgenol 131 : 1049-1053, 1978 https://doi.org/10.2214/ajr.131.6.1049
  29. Saiki K, Hattori A, Kawai S, Miyamoto T, Tsue K, Kotani H : The ossification of the yellow ligament in the thoracic spine : incidence, classification, neurological finding and narrow spinal canal. Orthop Surg Traumatol (Jpn) 24 : 191-199, 1981
  30. Shiokawa K, Hanakita J, Suwa H, Saiki M, Oda M, Kajiwara M : Clinical analysis and prognostic study of ossified ligamentum flavum of the thoracic spine. J Neurosurg 94 (2 Suppl) : 221-226, 2001 https://doi.org/10.3171/spi.2001.94.2.0221
  31. Sugimura H, Kakitsubata Y, Suzuki Y, Kakitsubata S, Tamura S, Uwada O, et al. : MRI of ossification of ligamentum flavum. J Comput Assist Tomogr 16 : 73-76, 1992 https://doi.org/10.1097/00004728-199201000-00013
  32. Takeuchi A, Miyamoto K, Hosoe H, Shimizu K : Thoracic paraplegia due to missed thoracic compressive lesions after lumbar spinal decompression surgery. Report of three cases. J Neurosurg 100 (1 Suppl Spine) : 71-74, 2004 https://doi.org/10.3171/spi.2004.100.1.0071
  33. Ugarriza LF, Cabezudo JM, Porras LF, Rodriguez-Sanchez JA : Cord compression secondary to cervical disc herniation associated with calcification of the ligamentum flavum : case report. Neurosurgery 48 : 673-676, 2001 https://doi.org/10.1097/00006123-200103000-00047
  34. Xiong L, Zeng QY, Jinkins JR : CT and MRI characteristics of ossification of the ligamenta flava in the thoracic spine. Eur Radiol 11 : 1798-1802, 2001 https://doi.org/10.1007/s003300000788
  35. Yamashita Y, Takahashi M, Matsuno Y, Sakamoto Y, Yoshizumi K, Oguni T, et al. : Spinal cord compression due to ossification of ligaments : MR imaging. Radiology 175 : 843-848, 1990 https://doi.org/10.1148/radiology.175.3.2111569
  36. Yonenobu K, Ebara S, Fujiwara K, Yamashita K, Ono K, Yamamoto T, et al. : Thoracic myelopathy secondary to ossification of the spinal ligament. J Neurosurg 66 : 511-518, 1987 https://doi.org/10.3171/jns.1987.66.4.0511

Cited by

  1. Ossification of the ligamentum flavum vol.1, pp.4, 2015, https://doi.org/10.22603/ssrr.1.2016-0031
  2. Two novel BMP-2 variants identified in patients with thoracic ossification of the ligamentum flavum vol.25, pp.5, 2015, https://doi.org/10.1038/ejhg.2017.2
  3. The bridge crane technique for the treatment of the severe thoracic ossification of the ligamentum flavum with myelopathy vol.27, pp.8, 2018, https://doi.org/10.1007/s00586-018-5683-0
  4. Thoracic Ossification of the Ligamentum Flavum―Neuroradiologic and Pathologic Findings Based on Our Operative Experience and a Literature Review― vol.32, pp.2, 2015, https://doi.org/10.2531/spinalsurg.32.167
  5. Calcification of the Ligamentum Flavum in the Cervical Spine―Our Experiences and a Review of the Literatures― vol.32, pp.1, 2015, https://doi.org/10.2531/spinalsurg.32.46
  6. Clinical Outcomes and Prognostic Factors in Patients With Myelopathy Caused by Thoracic Ossification of the Ligamentum Flavum vol.15, pp.3, 2015, https://doi.org/10.14245/ns.1836128.064
  7. Ossification of the Ligamentum Flavum in a Nineteenth-Century Skeletal Population Sample from Ireland: Using Bioarchaeology to Reveal a Neglected Spine Pathology vol.8, pp.None, 2015, https://doi.org/10.1038/s41598-018-27522-x
  8. Epidemiology of ossification of the spinal ligaments and associated factors in the Chinese population: a cross-sectional study of 2000 consecutive individuals vol.20, pp.None, 2019, https://doi.org/10.1186/s12891-019-2569-1
  9. Novel Simultaneous Decompression Through Single-stage Mini-thoracotomy for Concurrent Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum at the Same Thoracic vol.46, pp.3, 2015, https://doi.org/10.1097/brs.0000000000003748
  10. Sagittal Alignment in Patients with Thoracic Myelopathy Caused by the Ossification of the Ligamentum Flavum : A Retrospective Matched Case-Control Study vol.46, pp.5, 2021, https://doi.org/10.1097/brs.0000000000003791
  11. Clinical effect analysis of laminectomy alone and laminectomy with instrumentation in the treatment of TOLF vol.22, pp.1, 2015, https://doi.org/10.1186/s12891-021-04564-3
  12. The role of cerebrospinal fluid cross-section area ratio in the prediction of dural ossification and clinical outcomes in patients with thoracic ossification of ligamentum flavum vol.22, pp.1, 2015, https://doi.org/10.1186/s12891-021-04574-1