An intraoperatively guided posterior decompression with fusion-first strategy for nonambulatory patients with beak-type thoracic ossification of the posterior longitudinal ligament.

Abstract

Surgical management of nonambulatory patients with beak-type thoracic ossification of the posterior longitudinal ligament (T-OPLL) remains challenging, and the optimal extent of decompression is unexplored. This study aimed to evaluate neurological outcomes and perioperative characteristics of a selective posterior decompression with fusion (PDF)-first strategy, with circumferential decompression (CD) performed only when indirect decompression was deemed insufficient based on intraoperative assessment. Nonambulatory patients with beak-type T-OPLL who underwent thoracic spine surgery between September 2012 and July 2022 were retrospectively reviewed. All patients initially underwent PDF. Conversion to CD via a posterior approach was performed intraoperatively when persistent ventral spinal cord compression was identified based on dural sac refilling, spinal cord pulsation, and findings on intraoperative ultrasonography and neurophysiological monitoring. Neurological outcomes were assessed using the modified Japanese Orthopaedic Association (mJOA) score, recovery rate, ambulation status, and health-related quality of life (EQ-5D-5L score). Perioperative parameters and complications were recorded. A total of 31 patients met the inclusion criteria, including 19 treated with PDF alone and 12 who required additional CD. At final follow-up, significant neurological improvement was observed in the overall cohort, with 93.6% of patients regaining ambulatory ability. Both groups demonstrated significant postoperative improvements in mJOA and EQ-5D-5L scores compared with baseline. Patients who underwent CD had significantly longer operative times and greater estimated blood loss. The incidence of cerebrospinal fluid leakage was high but was successfully managed without permanent neurological sequelae. In nonambulatory patients with beak-type T-OPLL, a selective PDF-first surgical strategy resulted in favorable neurological recovery in the majority of patients. CD served as an effective adjunct when intraoperative findings indicated inadequate indirect decompression. These findings support an individualized, intraoperatively guided approach rather than the routine use of CD in this high-risk population.