Thoracic Spinal Stenosis: Surgical Approaches and Outcomes

Year 2021, Volume: 7 Issue: 2, 212 - 220, 31.08.2021

Aykut Gökbel , Mehmet Seçer , Tugba Gokbel

https://doi.org/10.19127/mbsjohs.956344

Abstract

Objective: Thoracic spinal stenosis (TSS) develops as a result of decreased spinal canal volume in the thoracic spine. The prevalence of TSS is low as when compared with cervical or lumbar spinal stenosis, and conservative treatment is not effective. The present study aimed to present all surgical methods employed and their outcomes in patients diagnosed with TSS in our clinic.

Methods: In this study, the data of 14 patients including three patients with single-level, nine patients with two-level, one patient with three-level, and one patient with multilevel TSS and hypophosphatemic rickets who underwent surgery due to TSS, were retrospectively evaluated using the discharge summary, surgical reports, and preoperative and postoperative radiological images.

Results: The age of the patients ranged from 53 to 68 years. Of the patients included in the study, one underwent hemilaminectomy, two underwent total laminectomy, six underwent laminoplasty, and five underwent total laminectomy with fusion and posterior instrumentation. A dramatic improvement was observed in the neurological deficits existing in the preoperative period in patients who were diagnosed in the early period and underwent surgery with adequate decompression before the development of severe neurological deficits and who continued postoperative rehabilitation added to the treatment.

Conclusion: Patients with TSS have an insidious clinical course manifested by upper motor neuron symptoms. Although the prevalence of TSS is low, early diagnosis and treatment are important. The results of surgery are satisfactory when adequate decompression is achieved before the clinical condition worsens.

Keywords

Thoracic spinal stenosis, dural ossification, ossified ligamentum flavum

References

• 1. Palumbo MA, Hilibrand AS, Hart RA, Bohlman HH. Surgical Treatment of Thoracic Spinal Stenosis. Spine (Phila Pa 1976). 2001; 26(5): 558-66.
• 2. Hou X, Sun C, Liu XY, Liu Z, Qi O, Guo Z, et al. Clinical Features of Thoracic Spinal Stenosis-associated Myelopathy; A Retrospective Analysis of 427 Cases. Clin Spine Surg. 2016; 29(2): 86-9. 3. Li B, Qiu G, Guo S, Li W, Li Y, Peng H, et al. Dural ossification associated with ossification of ligamentum flavum in the thoracic spine: a retrospective analysis. BMJ Open. 2016; 6(12): e013887.
• 4. Barath AS, Wu OC, Patel M, Kasliwal MK. Repeated recurrence of thoracic spine stenosis following decompression alone for ossification of the ligamentum flavum: case report. J Neurosurg Spine. 2019; 30: 332-6.
• 5. Okada K, Oka S, Tohge K, Ono K, Yonenobu K, Hosoya T. Thoracic myelopathy caused by ossification of the ligamentum flavum. Clinicopathologic study and surgical treatment. Spine (Phila Pa 1976). 1991; 16: 280-7.
• 6. 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. 1987; 66: 511-8.
• 7. Yu S, Wu D, Li F, Hou T. Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentum flavum: posterior surgery by laminectomy. Acta Neurochir. 2013; 155: 1169-77.
• 8. Dützmann S, Fernandez R, Rosenthal D. Spinalkanalstenose im Thorakalbereich. Ätiologie, Pathogenese, Diagnostik und Therapie. Der Orthopäde. 2019; 48: 844-8.
• 9. Barnett GH, Hardy Jr RW, Little JR, Bay JW, Sypert GW. Thoracic spinal canal stenosis. J Neurosurg. 1987; 66: 338-44.
• 10. Epstein NE. Patients with “Lumbar Stenosis” and unrecognized distal thoracic cord compression. Spinal Surg. 2007; 21: 101-4.
• 11. Ahn DK, Lee S, Moon SH, Boo KH, Chang BK, Lee JI. Ossification of the ligamentum flavum. Asian Spine J. 2014; 8:89-96.
• 12. Amato V, Giannachi L, Irace C, Corona C. Thoracic spinal stenosis and myelopathy: report of two rare cases and review of the literature. J Neurosurg Sci. 2012; 56: 373-8.
• 13. Sun J, Zhang C, Ning G, Li Y, Li Y, Wang P, et al. Surgical strategies for ossified ligamentum flavum associated with dural ossification in thoracic spinal stenosis. J Clin Neurosci. 2014; 21: 2102-6.
• 14. Inamasu J, Guiot BH. A review of factors predictive of surgical outcome for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg Spine. 2006; 5: 133-9. 15. 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). 2010; 35: 51-6.
• 16. Yang Z, Xue Y, Zhang C, Dai Q, Zhou H. Surgical treatment of ossification of the ligamentum flavum associated with dural ossification in the thoracic spine. J Clin Neurosci. 2013; 20: 212-6.
• 17. Prasad GL. Thoracic spine ossified ligamentum flavum: single surgeon experience of fifteen cases and a new MRI finding for preoperative diagnosis of dural ossification. Br J Neurosurgery. 2020; 34(6): 638-46.
• 18. 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 2001; 94: 221-6.
• 19. Miyakoshi N, Shimada Y, Suzuki T, Hongo M, Kasukawa Y, Okada K, et al. Factors related to long-term outcome after decompressive surgery for ossification of the ligamen- tum flavum of the thoracic spine. J Neurosurg. 2003; 99: 251-6.
• 20. Yayama T, Uchida K, Kobayashi S, Kokubo Y, Sato R, Nakajima H, et al. Thoracic ossification of the human ligamentum flavum:histopathological and immunohistochemical findings around the ossified lesion. J Neurosurg Spine. 2007; 7(2): 184-93.
• 21. Miyasaka K, Kaneda K, Ito T, Takei H, Sugimoto S, Tsuru N. Ossification of spinal ligaments causing thoracic radiculomyelopathy. Radiology. 1982; 143: 463-8.
• 22. Shiraishi T, Crock HV, Lewis P. Thoracic myelopathy due to isolated ossification of ligamentum flavum. J Bone Joint Surg Br. 1995; 77:131-3.
• 23. Ando K, Imagama S, Ito Z, Hirano K, Mramoto A, Kato F, et al. Predictive factors for a poor surgical outcome with thoracic ossification of the ligamentum flavum by multi- variate analysis. Spine (Phila Pa 1976). 2013; 38(12): 748-54.
• 24. Li F, Chen Q, Xu K. Surgical treatment of 40 patients with thoracic ossification of the ligamentum flavum. J Neurosurg Spine. 2006; 4: 191-7.
• 25. Aizawa T, Sato T, Sasaki H, 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. 2006; 5(6): 514-9.
• 26. Muthukumar N. Dural ossification in ossification of the ligamentum flavum: a preliminary report. Spine (Phila Pa 1976). 2009; 34 (24): 2654-61.
• 27. Gaucher C, Walrant-Debray O, Nguyen TM, Esterle L, Garabedian M, Jehan F. PHEX analysis in 118 pedigrees reveals new genetic clues in hypophosphatemic rickets. Hum Genet. 2009; 125(4): 401-11.
• 28. Liang G, Katz LD, Insogna KL, Carpenter TO, Macica CM. Survey of the enthesopathy of X-linked hypophosphatemia and its characterization in Hyp mice. Calcif Tissue Int. 2009; 85: 235-46.
• 29. Ballantyne ES, Findlay GFG. Thoracic spinal stenosis in two brothers due to vitamin D-resistant rickets. Eur Spine J. 1996; 5(2): 125-7.
• 30. Riccio AR, Entezami P, Giuffrida A, Dowling J, Forrest G, German JW. Minimally Invasive Surgical Management of Thoracic Ossification of the Ligamentum Flavum Associated with X-linked Hypophosphatemia. World Neurosurg. 2016; 94: 580.
• 31. Miyakoshi N, Shimada Y, Suzuki T, Hongo M, Kasukawa Y, Okada K, et al. Factors related to long-term outcome after decompressive surgery for ossification of the ligamentum flavum of the thoracic spine. J Neurosurg. 2003; 99(3): 251-6.
• 32. Liao CC, Chen TY, Jung SM, Chen LR. Surgical experience with symptomatic thoracic ossification of the ligamentum flavum. J Neurosurg Spine. 2005; 2(1): 34-9.
• 33. Mohindra S, Gupta R, Chhabra R, Gupta SK. Compressive myelopathy due to ossified yellow ligament among South Asians: analysis of surgical outcome. Acta Neurochir. 2011; 153 (3): 581-7.
• 34. Wang VY, Kanter AS, Mummaneni PV. Removal of ossified ligamentum flavum via a minimally invasive surgical approach. Neurosurg Focus. 2008; 25(2): 7.
• 35. Baba S, Oshima Y, Iwahori T, Takano Y, Inanami H, Koga H. Microendoscopic posterior decompression for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum: a technical report. Eur Spine J. 2016; 25(6): 1912-9.
• 36. Wen BT, Chen ZQ, Sun CG, Jin KJ, Zhong J, Liu X, et al. Three-dimensional navigation (O-arm) versus fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone cürette. Medicine (Baltimore). 2019; 98(20):e15647. 37. Luther N, Iorgulescu JB, Geannette C, Gebhard H, Saleh T, Tsiouris AJ, et al. Comparison of navigated versus non-navigated pedicle screw placement in 260 patients and 1434 screws: screw accuracy, screw size, and the complexity of surgery. J Spinal Disord Tech. 2015; 28(5): 298-303.
• 38. 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. 2006;15(4): 485-91.
• 39. Ranee S, Thao D, Kerry B, Loretta G. Ossification of the Ligamentum Flavum Causing Thoracic Myelopathy. Am J Phys Med Rehabil. 1997; 76(1): 68-72.
• 40. Kubota S, Abe T, Kadone H, Shimizu Y, Funayama T, Watanabe H, et al. Hybrid assistive limb (HAL) treatment for patients with severe thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL) in the postoperative acute/ subacute phase: A clinical trial. J Spinal Cord Med. 2019; 42(4): 517-25.