Elsevier

The Spine Journal

Volume 11, Issue 11, November 2011, Pages 1049-1057
The Spine Journal

Review Article
A systematic review of complications in cervical spine surgery for ossification of the posterior longitudinal ligament

https://doi.org/10.1016/j.spinee.2011.09.008Get rights and content

Abstract

Background context

Surgical management of ossification of the posterior longitudinal ligament (OPLL) is associated with complications. However, surgical complications for OPLL have not been clearly documented.

Purpose

To review and summarize the incidence of surgical complications of OPLL in the cervical spine and evaluate the impact of surgical approach (anterior or posterior), year of study publication, follow-up duration, and the surgical outcome on complication incidence.

Study design

Systematic review.

Methods

An English literature review was conducted especially on surgical complications of cervical OPLL. The incidence of complications was statistically summarized, with its correlation to surgical approaches, year of study publications, follow-up duration, and the surgical outcome was statistically evaluated.

Results

Twenty-seven retrospective studies, including a total of 1,558 patients, were reviewed. The overall incidence of surgical complications of cervical OPLL was 21.8%. Neurologic deficit (8.3%, overall rate), cerebrospinal fluid leakage (CFL) (5.1%), axial pain (3.5%), and implant complications (3.5%) were relatively common. The incidence of complications for posterior approach was not statistically different from those for anterior procedures. However, with regard to individual complication, C5 palsy and axial pain occurred more frequently in patients approached posteriorly, whereas CFL, implant complications, hoarseness, dysphagia, and dyspnea appeared more common in anterior cases.

Conclusions

There is a relatively high incidence of surgical complications for cervical OPLL compared with other cervical degeneration diseases. It is, therefore, necessary for surgeons to take into consideration the risk of surgical complications when communicating with patients for decision making and to alert complications during or after surgical procedures.

Introduction

Ossification of the posterior longitudinal ligament (OPLL) has been known as one of the main causes of cervical myelopathy [1]. In Asian countries, the prevalence of OPLL has been 1.9% to 4.3% among individuals older than 30 years, as shown by epidemiologic studies [2], [3], [4], [5]. In contrast, the prevalence of OPLL in other continents has not been well documented. In a large cohort research by Cervical Spine Research Society in 1997, surgery for cervical OPLL remained 5% of cervical spine surgery, with possibly higher actual rate because of recent awareness of the disease among spine surgeons [6]. Although surgery is usually necessary for patients with neurologic symptoms, different operative procedures can be adopted. Although both anterior and posterior approaches for cervical OPLL have been shown effective, adverse effects or complications are frequently reported.

The overview of perioperative complications for overall cervical degenerative disease has been well described in several large cohort studies, including recent articles discussing the approach-related complications for cervical OPLL; however, few studies focus specifically on the overview of surgical complications for cervical OPLL [6], [7], [8], [9], [10], [11], [12], [13]. Cervical OPLL has unique characteristics that are different from other cervical spine degenerative diseases, such as cervical spondylotic myelopathy or cervical disc herniation. Multilevel ossification may progress postoperatively unless the ossified foci are removed. The ossified foci are also often adherent to the dura mater, thus making direct anterior removal very difficult [1]. However, by now, the overall status of complications in surgery of cervical OPLL is not clear. The incidence of complications for various approaches (anterior or posterior) for OPLL has been reported but not compared.

A better understanding of complications in surgical treatment of cervical OPLL will aid when counseling patients, choosing an operative intervention, and improving surgical outcomes. Therefore, this systematic review was performed to examine the studies with special reference to surgical complications of cervical OPLL, summarize its incidence, and evaluate the impact of surgical approach (anterior or posterior), year of study publication, follow-up duration, and surgical outcome on complication incidence.

Section snippets

Inclusion criteria and search strategy

For this systematic review, the articles have been selected according to the following criterias: the article specially addressing the surgical complications (including incidence, treatment, or sequel) of patients with OPLL and consisting of 10 or more cases has been included; English literatures published between 1975 and June 2010 have been included; and the articles pertaining to thoracic or lumbar OPLL have been excluded. Those with mixed data of OPLL and cervical spondylotic myelopathy or

Study details

Our query retrieved 27 studies that met our inclusion criteria (Fig. 1). All the studies are retrospective case series. The patients’ demographics of each study are summarized in Table 1 [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40]. These studies included a total of 1,558 patients. The male:female ratio ranged from approximately 1.7:1 to 23:1. The mean age of patients ranged from

Incidence of complications

The total incidence of surgical complications of cervical OPLL in the systematic review (21.8%) is relatively higher than that reported in other previous reviews, including several large cohort studies on surgery for principal cervical diseases (5–19%) [6], [7], [8], [9], [10], [11]. It is similar with other reviews that the incidence of complications reported in the included studies varies widely, by which it is difficult to deduce which are best or worst studies. Previous studies reported

Conclusion

The overall incidence of surgical complications of cervical OPLL was 21.8%. Cerebrospinal fluid leakage, neurologic deficit, axial pain, and implant complications were relatively common complications after surgery of cervical OPLL. No surgery-related death was reported. The overall morbidity of complications was not statistically different between posterior and anterior procedures and not correlated with the year of study publication, mean age of patients, postoperative recovery rate, or

Acknowledgments

The authors thank Dr Gabriel Liu for his careful editing.

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