Ossification of the Posterior Longitudinal Ligament

Pathogenesis, Management, and Current Surgical Approaches: A Review

Zachary A. Smith, M.D.; Colin C. Buchanan, M.D.; Dan Raphael, P.A.-C.; and Larry T. Khoo, M.D.


Neurosurg Focus. 2011;30(3):e10 

In This Article

Abstract and Introduction


Ossification of the posterior longitudinal ligament (OPLL) is an important cause of cervical myelopathy that results from bony ossification of the cervical or thoracic posterior longitudinal ligament (PLL). It has been estimated that nearly 25% of patients with cervical myelopathy will have features of OPLL. Patients commonly present in their mid-40s or 50s with clinical evidence of myelopathy. On MR and CT imaging, this can be seen as areas of ossification that commonly coalesce behind the cervical vertebral bodies, leading to direct ventral compression of the cord. While MR imaging will commonly demonstrate associated changes in the soft tissue, CT scanning will better define areas of ossification. This can also provide the clinician with evidence of possible dural ossification. The surgical management of OPLL remains a challenge to spine surgeons. Surgical alternatives include anterior, posterior, or circumferential decompression and/or stabilization. Anterior cervical stabilization options include cervical corpectomy or multilevel anterior cervical corpectomy and fusion, while posterior stabilization approaches include instrumented or noninstrumented fusion or laminoplasty. Each of these approaches has distinct advantages and disadvantages. While anterior approaches may provide more direct decompression and best improve myelopathy scores, there is soft-tissue morbidity associated with the anterior approach. Posterior approaches, including laminectomy and fusion and laminoplasty, may be well tolerated in older patients. However, there often is associated axial neck pain and less improvement in myelopathy scores. In this review, the authors discuss the epidemiology, imaging findings, and clinical presentation of OPLL. The authors additionally discuss the merits of the different surgical techniques in the management of this challenging disease.


Ossification of the posterior longitudinal ligament is an important cause of cervical myelopathy that results from heterotopic ossification of the cervical or thoracic PLL. It has been estimated that up to 25% of patients presenting with cervical myelopathy have features of OPLL.[12] Furthermore, OPLL has been associated with several diseases, most importantly DISH.[52] While multiple surgical approaches have been used in the treatment of myeloradiculopathy due to OPLL,[2,4,8,12–20,23,29,31,48,53,60,70] the individual merits of these techniques remain controversial. In this review, we discuss the epidemiology, natural history, and common radiographic findings associated with OPLL. The advantages and disadvantages of current treatment options, including anterior corpectomy, laminectomy, and laminoplasty are reviewed.


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