
==== Front
Clin Spine Surg
Clin Spine Surg
BSD
Clinical Spine Surgery
2380-0186
2380-0194
Lippincott Williams & Wilkins Hagerstown, MD

38637918
CSS-23-339
10.1097/BSD.0000000000001606
00014
3
Primary Research
Improvement of Postoperative Quality of Life in Patients Over 80 Years Old With Thoracic Spinal Stenosis
Chen Guozhao MD *†zjgchenguozhao@163.com

Shi Jinhui MD shijinhui502@126.com
*
* Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou
† Department of Orthopaedics, The First People’s Hospital of Zhangjiagang, Zhangjiagang, Jiangsu, China
Reprints: Jinhui Shi, MD, Department of Orthopedics, The First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, Suzhou, Jiangsu 215006, China (e-mail: shijinhui502@126.com).
10 2024
18 4 2024
37 8 E383E388
14 9 2023
22 1 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Study Design:

A retrospective comparative study was conducted to analyze the outcome of surgical and conservative treatment for patients over 80 years old with thoracic spinal stenosis (TSS).

Objective:

To evaluate the safety and efficiency of posterior spinal cord decompression surgery for over 80-year-old patients with TSS.

Summary of Background Data:

Concerned about the risk of surgery, over 80-year-old patients with TSS are usually treated conservatively, which often leads to a decline in quality of life. So far as we know, no study demonstrates the risk and benefit of spine surgery for these patients.

Methods:

Over 80 years of age who underwent dorsal decompression surgery or conservative treatment due to TSS between January 2010 and November 2020 were analyzed. Sixty-four patients who completed follow-up PROM (patient-reported outcome measure) data were collected, including the mJOA (modified Japanese Orthopedic Association score) scoring system, VAS (visual analogue scale), questionnaire-based assessment of the ODI (Oswestry disability index), BI (Barthel index), and SF-36v2 (Short Form-36v2) Health Survey. The clinical characteristics, preoperative and postoperative imaging findings, operative records, complications, and individual outcomes were analyzed.

Results:

Of the 64 patients, 38 underwent posterior decompression, pedicle screw fixation, and posterolateral fusion; another 26 chose conservative treatment. The baseline characteristics of the TSS patients in 2 groups show no significant differences. The clinical symptoms and imaging outcomes showed a significant improvement in the surgical group compared with the nonsurgical group, according to mJOA, VAS, ODI, BI, and SF-36v2. Cerebrospinal fluid leakage occurred in 6 patients, and transient neurological impairment occurred in 2 patients.

Conclusions:

Posterior decompression surgery for over 80-year-old patients with TSS is a safe and effective treatment, it has a good clinical outcome as well as an acceptable complication rate. However, there were no obvious improvements in quality of life or pain with conservative treatment.

Key Words:

thoracic spinal stenosis
thoracic myelopathy
quality of life
follow up
over eighty years old
spinal surgery
OPEN-ACCESSTRUE
STATUSONLINE-ONLY
==== Body
pmcThe incidence of thoracic spinal stenosis (TSS) is lower than that of cervical and lumbar spinal stenosis,1 often leading to delayed diagnosis and resulting in serious physical disability. A large number of clinical studies have shown that decompression surgery is the only effective treatment in patients with symptomatic TSS,2–4 while conservative treatment tends to have a poor prognosis.5

The mean age of patients with thoracic myelopathy was ∼50 years, mostly between 34.7 and 70.5 years, in these studies.6 The prevalence is increasing in elderly people, especially Asian individuals. Population ageing is a worldwide social concern. By 2050, 1 in 4 people living in Europe and North America is expected to be 65 years of age or over. There were 167 million people over the age of 65 years and 249 million people over the age of 60 years in China according to statistics from the Chinese government in 2019.

The surgical safety of very old (80+) patients7 with spinal diseases is of great concern because they have a higher risk of postoperative complications than young patients. However, to our knowledge, there are no relevant studies on the improvement of postoperative quality of life in patients over 80 years old with thoracic spinal stenosis. To that end, we conducted a retrospective study to compare the short-term outcomes and quality of life of patients over 80 years of age between decompression surgery and conservative treatment for thoracic stenosis to help surgeons make clinical decisions.

METHODS

The study was approved by the ethics committee of our university. This study was performed in accordance with the Declaration of Helsinki. This was a retrospective analysis of all patients over 80 years of age who underwent dorsal decompression surgery and conservative treatment due to thoracic spinal stenosis between January 2010 and November 2020. The inclusion criteria consisted of the following: (1) single-level or multilevel OPLL (ossification of the posterior longitudinal ligament), posterior vertebral osteophytes, or OLF (ossification of the thoracic ligamentum flavum), leading to spinal cord compression on magnetic resonance imaging (MRI) and/or computed tomography (CT); (2) clinical symptoms matching radiographic imaging and MRI findings; and (3) exclusion of other pathologic conditions, such as spine deformity, tumor, tuberculosis, infection, or metabolic bone disorders. Exclusion criteria (1) clinical symptoms did not match the radiographic imaging and MRI findings; (2) spine deformity, tumor, tuberculosis, infection, or metabolic bone disorders.

Patients over 80 years of age diagnosed with thoracic spinal stenosis were divided into 2 groups: the surgical group (group 1) and the nonsurgical group (group 2). In the surgical group, posterior decompression, fixation, and fusion procedures were performed. Nonsurgical treatments included NSAIDs (nonsteroidal anti-inflammatory drugs), Neurontin (Mecobalamine), and physical therapy to reduce irritation and pressure from the nerves to relieve pain. After the identification of all matching patients, informed consent was obtained, and their clinical characteristics, preoperative and postoperative imaging findings, operative records, complications, and individual outcomes were analyzed.

Clinical Evaluation

The Japanese Orthopaedic Association (JOA) scoring system modified by Benzel (mJOA)8 was used for neurological assessment with regard to myelopathic symptoms. The visual analog scale (VAS)9 was used for evaluating TSS-related pain, and the Oswestry disability index (ODI)10 was used for evaluating related disability. The assessment of quality-of-life aspects was performed with the Short Form (SF)-36v2 Health Survey,11 while general performance in daily life was assessed using the Barthel index (BI).12

The mean follow-up was 24.5 months, and patients were assessed with a standardized telephone interview and a questionnaire evaluation. If patients reported any change in motor function or neurological status compared with the last outpatient visit in our hospital, a reconfirming outpatient examination was performed. The mean last outpatient visit in our hospital was 12.6 months.

Patient-reported outcome measures (PROMs) were collected by 2 senior spine surgeons specifically trained in patient assessment.

Imaging Evaluation

The characteristic features of OPLL, posterior vertebral osteophytes, and OLF were evaluated by MRI and CT. The Naganawa 4-point scale13 was used to evaluate stenosis severity with the following grades: grade 0—no stenosis, normal width of the spinal canal, no signs of anterior/posterior CSF space narrowing; grade 1—mild stenosis, partial compression of the dural sac, and slight stenosis of the canal; grade 2—moderate stenosis, obliteration of the anterior/posterior CSF space with no or slight deformity of the spinal cord; grade 3—severe stenosis, anterior/posterior cord impingement, and severe cord deformity.

Surgical Procedures

After general anesthesia patients were positioned in prone. Target levels and the extent of the skin incision were identified by fluoroscopic control. All surgeries were performed under neurological supervision. Patients in the surgery group got pedicle screw fixation and posterolateral fusion when posterior decompression was performed. For patients with thin pedicles, O-arm navigation was used for pedicle screw internal fixation to ensure accurate screw implantation. The ultrasonic bone curette or high-speed burr was used in the laminae decompression process. A midline incision was made along the spinous processes of the target levels, and the paraspinous muscles were stripped off the exposed laminae bilaterally. After the completion of pedicle screw implantation, the laminae were thinned by the use of an ultrasonic drill or high-speed burr, the laminae and ligamenta flava were cut and removed by rongeurs. The posterior spinal canal was completely decompressed, laterally to the medial edge of the pedicle, and longitudinally to complete relaxation of the spinal cord with evident epidural adipose tissue. The bone obtained by posterior laminae decompression was used for posterolateral fusion.

Statistical Analysis

All the collected data were analyzed using SPSS 22.0 software (IBM Corp.). The patient population was described with summary statistics. For comparison of groups for differences, the Student t test and paired-samples t test were used for numeric values, the Mann-Whitney rank-sum test was used for ordinal variables, and the χ2 test was used for nominal variables. The criterion of a minimum clinically important difference (MCID) was considered to be fulfilled if the mean improvement was greater than the SE of measurement (SEM) for the respective numeric outcome variable;14 for the mJOA score, an improvement of ≥2 points was estimated as the cutoff for an MCID as described previously.15 P<0.05 was considered to indicate a statistically significant difference, while P<0.01 was considered indicative of a high level of significance.

RESULTS

Epidemiological and Clinical Characteristics

A total of 81 patients over 80 years of age were diagnosed with TSS. Due to loss of follow-up and incomplete information, a total of 64 patients with complete follow-up were finally included, 38 of whom (including 37 patients with primary thoracic stenosis and 1 patient with secondary thoracic stenosis due to cement leakage after vertebroplasty) underwent posterior decompression, pedicle screw fixation, and posterolateral fusion, while the remaining 26 patients with primary thoracic stenosis chose conservative treatment. The baseline characteristics of the TSS patients in groups 1 and 2 are displayed in Table 1, which shows no significant statistical differences between the groups (P>0.05).

TABLE 1 Baseline Characteristics of the 2 Groups*

	Patients (TSS)		
Characteristic	Group 1 (n=38)	Group 2 (n=26)	P	
Sex, male/female	25/13	17/9	0.973	
Median age	82.3±1.54	82.1±1.45	0.603	
Preoperative symptoms, n (%)	
 Ataxia	23 (60.5)	16 (61.5)	0.935	
 Sensory disturbances	20 (52.6)	12 (46.2)	0.611	
 Paresis	21 (55.3)	13 (50.0)	0.679	
 Pain	14 (36.8)	8 (30.8)	0.615	
 Vegetative disorders	4 (10.5)	2 (7.7)	0.702	
Comorbidities, n (%)	
 Cardiovascular diseases	10 (26.3)	6 (23.1)	0.769	
 Diabetes mellitus	9 (23.7)	7 (26.9)	0.769	
 Obesity	8 (21.1)	7 (26.9)	0.586	
 History of smoking	15 (39.5)	9 (34.6)	0.693	
* Mean values are presented mean±SD.

Imaging and Surgical Characteristics

Sixty patients experienced single-level stenosis, 2 patients experienced 2-level stenosis (1 in group 1 and 1 in group 2), 1 patient experienced 3-level stenosis (group 1), and 1 patient experienced 4-level stenosis (group 2). The median Naganawa grade of the stenoses was 2 (range: 1–3).

Seventy-five percent (45/60) of all stenoses were located in the distal third of the thoracic spine. In all cases, the main compressive component of the spinal cord was dorsal, and the stenosis was mostly caused by ossification of the ligamentum flavum (OLF, 46 patients). Other causes included ossification of the posterior longitudinal ligament (OPLL, 5 patients), intervertebral disc herniation (2 cases), hyperplasia of the facet joints (5 patients), osteophytes of the posterior edges of vertebral bodies (4 patients), a combination of OLF and OPLL (1 patient), and bone cement leakage (1 patient). The details of the location, narrow segments, and pathology of the stenoses are displayed in Table 2, which shows no significant statistical differences (P>0.05) between the groups as well. Therefore, the authors believed the baseline characteristic of patients in 2 groups were comparable, according to Tables 1 and 2. An illustration of surgical assignment is given in Figures 1 and 2

TABLE 2 Location, Narrow Segments, and Pathology of Thoracic Spinal Stenosis

	Patients (TSS)		
Characteristic	Group 1 (n=38)	Group 2 (n=26)	P	
Spinal level, n	
 Th 4	1	0	0.518	
 Th 5	1	1		
 Th 6	2	1		
 Th 7	5	2		
 Th 8	7	6		
 Th 9	9	6		
 Th 10	8	8		
 Th 11	8	6		
Narrow segments, n (%)	
 One segment	36 (94.7)	24 (92.3)	0.684	
 Two segments	1 (2.6)	1 (3.8)		
 Three segments	1 (2.6)	0		
 Four segments	0	1 (3.8)		
Pathology, n	
 Ossification of the ligamentum flavum (OLF)	28	18	0.856	
 Ossification of the posterior longitudinal ligament (OPLL)	2	3		
 Intervertebral disc herniation	1	1		
 Hhyperplasia of the facet joints	3	2		
 Osteophytes of the posterior edges of vertebral bodies	2	2		
 Combination of OLF and OPLL	1	0		
 Bone cement leakage	1	0		

FIGURE 1 Male, 87 years old. A, Preoperative sagittal and transverse CT images indicate thoracic spinal stenosis at the T7 level caused by a combination of OLF and OPLL. B, Preoperative sagittal and axial T2-weighted MR images show thoracic spinal stenosis. C, The postoperative sagittal and transverse CT images display the patient’s status after posterior thoracic laminectomy. D, The corresponding postoperative MR images display the patient’s status after posterior thoracic laminectomy.

FIGURE 2 Male, 88 years old. The patient did not undergo an MRI examination because he was implanted with a pacemaker. A, Preoperative sagittal and transverse CT images indicate thoracic spinal stenosis at the T6 level caused by bone cement leakage. B, The postoperative sagittal and transverse CT images display the patient’s status after posterior thoracic laminectomy. C, Postoperative lateral X-ray and intraoperative O-arm navigation. D, The lower limb muscle strength recovered from preoperative level I to postoperative level IV.

Long-Term Evaluation

In all patients, complete follow-up PROM data were available with regard to the mJOA scoring system, VAS, questionnaire-based assessment of ODI, BI, and SF-36v2 Health Survey. Clinical and imaging outcomes for the 2 groups are displayed in Table 3. There were no significant differences between the 2 groups with regard to the preoperative or first PROM scores.

TABLE 3 Outcome Parameters During Short-Term Follow-Up*

	Patients		
	Group 1	Group 2	Change in PROM between groups	
Characteristic	Preoperation	Postoperation	P	First follow-up	Last follow-up	P	P	
Median Naganawa grade	2.10±0.69	0.10±0.31	0.000	2.08±0.63	2.23±0.65	0.390	0.000	
Median VAS	5.05±0.98	1.66±0.71	0.000	4.96±0.82	4.58±0.76	0.086	0.000	
Median mJOA	12.39±1.00	15.26±0.69	0.000	12.77±0.99	11.81±0.94	0.001	0.000	
Mean ODI	52.18±4.56	25.13±3.87	0.000	51.58±5.23	58.69±6.67	0.000	0.000	
Mean SF-36-MCS	28.76±2.55	42.37±2.66	0.000	29.58±3.66	22.54±1.56	0.000	0.000	
Median BI	66.47±4.48	93.92±5.19	0.000	64.62±5.46	57.50±4.30	0.000	0.000	
* Mean values are presented mean±SD.

The clinical symptoms and imaging outcomes showed a more significant improvement in the surgical group than in the nonsurgical group. Postoperative MR or CT imaging showed sufficient decompression of the spinal canal (median Naganawa grade 0.10 vs. 2.10, P=0.000), while the nonsurgical group showed persistent stenosis (median Naganawa grade 2.23 vs. 2.08, P=0.390). In the surgical group, the mJOA (median mJOA score increase of 2.87 points at last follow-up, meeting the criterion of an effect above the MCID) and VAS (median VAS score dropped from 5.05 to 1.66, P=0.000) at short-term follow-up were significantly improved (P<0.05), while in the nonsurgical group, there was no significant difference in the VAS score (median dropped from 4.96 to 4.58, P=0.086>0.05), and the median mJOA score dropped from 12.77 to 11.81 over the short-term follow-up (P=0.001). Moreover, the mean ODI, SF-36-MCS score and BI at long-term follow-up were improved over the preoperative values in the surgical group (ODI: 25.13 vs. 52.18, P=0.000; SF-36-MCS: 42.37 vs. 28.76, P=0.000; BI: 93.92 vs. 66.47, P=0.000), which met the criteria of an effect above the MCID. However, the ODI, SF-36-MCS score and BI were worse (ODI: 58.69 vs. 51.58, P=0.000; SF-36-MCS: 42.37 vs. 28.76, P=0.000; BI: 57.50 vs. 64.62, P=0.000) over short-term follow-up in the nonsurgical group. At the last follow-up, all the follow-up data (Naganawa grade, VAS, mJOA, ODI, SF-36-MCS, and BI) in the surgical group showed a significant improvement over those of the nonsurgical group (P=0.000). None of the patients in the surgical group needed a second surgery during the long-term follow-up.

In the surgical group, 6 patients experienced cerebrospinal fluid leakage after surgery; as the deep fascia was tightly sutured during surgery, no obvious discomfort or complications occurred. Two patients showed a transient decrease in sensory and motor strength relative to preoperation and received symptomatic treatment including methylprednisolone, mecobalamin, and mannitol. At the last follow-up, the patients’ symptoms were significantly improved, and their sensory and motor strength improved compared with preoperation. During the short-term follow-up, no infection, internal fixation loosening, or fracture occurred.

DISCUSSION

Thoracic spinal stenosis (TSS) is most frequently seen in people aged 45–65 years. Age is by far the most common cause of TSS. As the global population ages, the number of very old patients (80+) with thoracic spinal stenosis is increasing, especially in East Asia. Treating very old patients is still controversial. Unfortunately, conservative treatment for TSS often leads to a poor prognosis.

In China, due to traditional thinking, elderly patients are often opposed to surgical treatment. The common thought of elderly patients is that surgery is not conducive to improving symptoms but will accelerate the deterioration of the disease. They are more willing to choose conservative treatment. In the control group, 26 patients with thoracic spinal stenosis were recommended for surgical treatment, while they chose conservative treatment due to their elderly age and the concern of a high risk of surgery, but the follow-up showed poor clinical outcomes. Surgery is the only effective treatment for TSS. At present, a variety of methods are used for the surgical treatment of TSS, but there is no consensus on the choice of surgical method for TSS patients with different pathologic manifestations.6 Posterior decompression is the most common treatment, while the anterior thoracic approach and the extrapleural or lateral posterior approach are also widely used for ventral spinal cord compression. For patients with severe anterior and posterior spinal cord compression, a combination of anterior and posterior decompression can be chosen.16–19 In our study, 38 patients underwent surgical treatment, including 37 with primary thoracic spinal stenosis and 1 with secondary thoracic spinal stenosis caused by bone cement leakage. All patients underwent posterior laminectomy decompression surgery to reduce surgical trauma (in one patient with bone cement leakage, in addition to posterior lamina decompression, the leaked bone cement in the spinal canal was removed through a posterior-lateral approach). The quality of life of the patients was improved, and the clinical outcome was satisfactory.

The incidence of complications after TSS is still higher than that after other spine surgeries, such as dural sac injury, cerebrospinal fluid leakage, spinal cord injury, and nerve root injury.20,21 In our study, cerebrospinal fluid leakage occurred in 6 patients, among whom 4 had dural sac rupture and cerebrospinal fluid leakage during the operation. As the ruptures were smaller than 0.5 cm, we did not repair them during the operation. There was no obvious cerebrospinal fluid leakage during the operation in 2 patients, but cerebrospinal fluid leakage occurred postoperatively. The sharp tympanic surface after decompression punctured the dural sac, which could be the cause of delayed CSF leakage. The deep fascia was tightly sutured in all surgical patients. All 6 patients recovered well without subcutaneous effusion, infection, or other serious complications. Two patients showed a transient decrease in sensory and motor strength relative to preoperation (level 3–level 2). The functional decrease in these 2 patients might be related to ischemia-reperfusion injury of the spinal cord.22,23 During the short-term follow-up, no infection, internal fixation loosening, or fracture occurred.

Both the pain (VAS) and the functional outcome with regard to the mJOA were significantly improved postoperatively and remained steadily improved during the short-term follow-up in our cohort, with an effect above the MCID cutoff, which was previously determined by Tetreault et al15 in a large cohort of patients with degenerative cervical myelopathy. Most patients in our surgical group exhibited improvement or at least stability in their neurological status at the last follow-up. Our results showed that significant improvements in various QOL aspects were present during short-term follow-up in the surgical group: the pain-related disability (measured by the ODI), the activities of daily life (measured by the BI), and the mental burden of the disease (measured by the SF-36 MCS) were significantly improved and met the criteria of an effect above the MCID,14 while in the nonsurgical group, all the follow-up data, including Naganawa grade, VAS, mJOA, ODI, SF-36-MCS, and BI, were worse, which indicated a significant decline in function and a serious decline in the quality of life in patients over 80 years old with TSS. At the last follow-up, all the follow-up data (Naganawa grade, VAS, mJOA, ODI, SF-36-MCS, and BI) in the surgery group were significantly improved compared with those of the conservative group, which indicated that the quality of life of patients over 80 years old with TSS improved significantly after the operation.

CONCLUSION

Posterior decompression surgery for elderly patients over 80 years of age with thoracic spinal stenosis is a safe and effective treatment, and it has a good clinical outcome as well as an acceptable complication rate. However, there were no obvious improvements in quality of life or pain with conservative treatment.

Funded by the Medical Research Project of the Jiangsu Commission of Health (M2021097).

The authors declare no conflict of interest.
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REFERENCES

1 Dützmann S Fernandez R Rosenthal D . Thoracic spinal stenosis: etiology, pathogenesis, and treatment. Orthopade. 2019;48 :844–848.31041462
2 Siller S Pannenbaecker L Tonn JC . Surgery of degenerative thoracic spinal stenosis-long-term outcome with quality-of-life after posterior decompression via an uni- or bilateral approach. Acta Neurochir (Wien). 2020;162 :317–325.31873792
3 Wang L Wang H Chen Z . Surgical strategy for non-continuous thoracic spinal stenosis: one-or two-stage surgery? Int Orthop. 2021;45 :1871–1880; Surgical strategy for non-continuous thoracic spinal stenosis: one- or two-stage surgery?.33427901
4 Mittal S Ahuja K Sudhakar PV . Simultaneous decompression of all stenotic regions versus decompression of only the most symptomatic region in patients with tandem spinal stenosis: a systematic review and meta-analysis. Eur Spine J. 2022;31 :561–574.34988710
5 Chen ZQ Sun CG Spine Surgery Group of Chinese Orthopedic Association . Clinical Guideline for Treatment of Symptomatic Thoracic Spinal Stenosis. Orthop Surg. 2015;7 :208–212.26311094
6 Zhu S Wang Y Yin P . A systematic review of surgical procedures on thoracic myelopathy. J Orthop Surg Res. 2020;15 :595.33302988
7 Forman DE Berman AD McCabe CH . PTCA in the elderly: the “young-old” versus the “old-old”. J Am Geriatr Soc. 1992;40 :19–22.1727842
8 Benzel EC Lancon J Kesterson L . Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord. 1991;4 :286–295.1802159
9 Faiz KW . VAS—visuell analog skala (VAS—visual analog scale). Tidsskr Nor Laegeforen. 2014;134 :323.24518484
10 Fairbank JC Couper J Davies JB . The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66 :271–273.6450426
11 Martin M Kosinski M Bjorner JB . Item response theory methods can improve the measurement of physical function by combining the modified health assessment questionnaire and the SF-36 physical function scale. Qual Life Res. 2007;16 :647–660.17334829
12 Mahoney FI Barthel DW . Functional evaluation: the Barthel index. Md State Med J. 1965;14 :61–65.
13 Naganawa T Miyamoto K Ogura H . Comparison of magnetic resonance imaging and computed tomogram-myelography for evaluation of cross sections of cervical spinal morphology. Spine (Phila Pa 1976). 2011;36 :50–56.20581762
14 Draak THP de Greef BTA Faber CG . The minimum clinically important difference: which direction to take. Eur J Neurol. 2019;26 :850–855.30793428
15 Tetreault L Nouri A Kopjar B . The minimum clinically important difference of the modified Japanese Orthopaedic Association Scale in patients with degenerative cervical myelopathy. Spine (Phila Pa 1976). 2015;40 :1653–1659.26502097
16 Yamada T Shindo S Yoshii T . Surgical outcomes of the thoracic ossification of ligamentum flavum: a retrospective analysis of 61 cases. BMC Musculoskelet Disord. 2021;22 :7.33397347
17 Morishita S Yoshii T Inose H . Comparison of perioperative complications in anterior decompression with fusion and posterior decompression with fusion for thoracic ossification of the posterior longitudinal ligament—a retrospective cohort study using a nationwide inpatient database. J Orthop Sci. 2022;27 :600–605.33972149
18 Tomita K Baba H Takahashi K . Total (anterior and posterior) decompression of the spinal cord: surgical treatment for combined ossification of the posterior longitudinal ligament and yellow ligament of the thoracic spine. Nihon Seikeigeka Gakkai Zasshi. 1989;63 :501–506.2507716
19 Wang ZC Li SZ Qu XF . Transdural circumferential decompression for thoracic spinal stenosis caused by beak-type ossification of the posterior longitudinal ligament: a technical note. Br J Neurosurg. 2023;37 :1371–1374.32924632
20 He B Yan L Xu Z . Treatment strategies for the surgical complications of thoracic spinal stenosis: a retrospective analysis of two hundred and eighty-three cases. Int Orthop. 2014;38 :117–122.24057658
21 Ohara Y . Ossification of the ligaments in the cervical spine, including ossification of the anterior longitudinal ligament, ossification of the posterior longitudinal ligament, and ossification of the ligamentum flavum. Neurosurg Clin N Am. 2018;29 :63–68.29173437
22 Kahveci FO Kahveci R Gokce EC . Biochemical, pathological and ultrastructural investigation of whether lamotrigine has neuroprotective efficacy against spinal cord ischemia reperfusion injury. Injury. 2021;52 :2803–2812.34391576
23 Fan YD Zhu ML Geng D . The study on pathological mechanism and solution method for spinal cord ischemia reperfusion injury. Eur Rev Med Pharmacol Sci. 2018;22 :4063–4068.30024591
