Accidental anterior longitudinal ligament rupture during lateral lumbar interbody fusion disclosed after posterior corrective fusion surgery resulting in local hyper-lordosis / Journal of Rural Medicine

Objective: To report a case of anterior longitudinal ligament (ALL) injury that was not noticeable during lateral lumbar interbody fusion and was disclosed after posterior corrective fusion surgery.Case presentation: After performing lateral lumbar interbody fusion followed by posterior corrective fusion surgery, we observed an anterior longitudinal ligament rupture that required additional surgery. Postoperative pain in the left lower limb and muscle weakness due to nerve traction appeared, but this was improved by stabilization between the vertebral bodies.Conclusion: Unidentified anterior longitudinal ligament rupture can result in unexpected local lordosis during posterior surgery, possibly related to lower extremity palsy. Therefore, checking for possible rupture during and after anterior surgery is important. If the ALL damage is disclosed before posterior surgery, the proper surgical strategy for the posterior surgery must be considered.

Factors Affecting Postoperative Sagittal Alignment after Lateral Lumbar Interbody Fusion in Adult Spinal Deformity: Posterior Osteotomy, Anterior Longitudinal Ligament Rupture, and Endplate Injury

STUDY DESIGN: Prospective cohort study. PURPOSE: To identify factors that affect sagittal alignment correction in lateral lumbar interbody fusion (LIF) surgery for adult spinal deformity (ASD) and to investigate the degree of correction in each condition. OVERVIEW OF LITERATURE: LIF is a useful procedure for ASD, but the degree of correction can be affected by posterior osteotomy, intraoperative endplate injury, or anterior longitudinal ligament (ALL) rupture. METHODS: Radiographical data for 30 patients who underwent LIF for ASD were examined prospectively. All underwent two-stage surgery (LIF followed by posterior fixation). Radiographical parameters were measured preoperatively, after LIF, and after posterior fixation; these included the segmental lordotic angle, lumbar lordosis (LL), and other sagittal alignment factors. RESULTS: LL was corrected from 16.5°±16.7° preoperatively to 33.4°±13.8° after LIF (p<0.001) and then to 52.1°±7.9° following posterior fixation (p<0.001). At levels where Schwab grade 2 osteotomy was performed, the acquired segmental lordotic angles from the preoperative value to after posterior fixation and from after LIF to after posterior fixation were 19.5°±9.2° and 9.9°±3.9°, respectively. On average, 12.4° more was added than in cases without osteotomy. Endplate injury was identified at 21 levels (19.4%) after LIF, with a mean loss of 3.4° in the acquired segmental lordotic angle (5.3°±8.4° and 1.9°±5.9° without and with endplate injury, respectively). ALL rupture was identified at seven levels (6.5%), and on average 19.3° more was added in these cases between the preoperative and postoperative values than in cases without ALL rupture. CONCLUSIONS: LIF provides adequate sagittal alignment restoration for ASD, but the degree of correction is affected by grade 2 osteotomy, intraoperative endplate injury, and ALL rupture.

Dysphagia Caused by Ossificaion of the Cervical Anterior Longitudial Ligament : Report of Two Cases

We report two cases with progressive dysphagia and foreign body sensation resulted from severe cervical ossification of the anterior longitudinal ligament (OALL). A 63-years-old male presented progressive dysphagia and foreign body sensation with neck pain. Cervical computed tomography (CT) and magnetic resonance images (MRI) revealed diffuseOALL from C2 to C7 with esophageal compression by most severe OALL of C5, C6, C7 and spondylotic stenosis of C5- 6, C6-7. OALL removal of C5, 6, 7 and discectomy with interbody fusion via anterior approach was performed. The other 56-years-old female presented progressive dysphagia with foreign body sensation. Cervical CT and MRI revealed severe OALL of C4, 5, 6, 7 with esophageal compression and surgical removal was performed. In both patients, dysphagia and foreign body sensation was immediately relieved after operation and the distance between trachea and each cervical body was increased than preoperative distance in cervical lateral view.

Lumbar Corpectomy by Using Anterior Midline Route

Direct anterior approach for lesions located anterior to the thecal sac is definitely superior to lateral or posterior approach in many respects. However, various anatomical obstacles and technical difficulties often hinder direct anterior approach. Thanks to ripe experience of retroperitoneal approach to the lumbar spine for anterior lumbar interbody fusion and total disc replacement, the authors could perform lumbar corpectomy and reconstruction by using midline retroperitoneal approach recently. During this approach, we repaired anterior longitudinal ligament also to reduce the risk of graft extrusion and to prevent erosion of vascular wall due to direct contact between metallic hardware, which was used for reconstruction of vertebral body, and major vessels.

Dysphagia Caused by Ossification of the Cervical Anterior Longitudinal Ligament

We report a case of cervical ossification of the anterior longitudinal ligament(OALL) that contributed to dysphagia with ossification of posterior longitudinal ligament. A 63-year-old man complained of progressive dysphagia for solid foods. Clinical and radiographical findings including barium esophagogram and computed tomography showed OALL in cervical vertebrae from C2 to C7. Magnetic resonance images demonstrated displacement of the trachea and esophagus by OALL. The patient underwent anterior ostectomy from C2 to C7 via anterior cervical approach with excellent relief of dysphagia.

Ossification of Spinal Ligaments

This authors reviewed the radiographs of 20,057 patients with spinl radiculomyelopathy from April 1983 August 1990. The incidence and distribtion of the ossification of the spinal ligaments were analized as following. 1) The overall incidence of spinal ligaments ossification was 3.6% among 20,057 patients. 2) The most frequently occurs at lumbar area(67.1%), and then cervical(27.5%) thoracic(0.4%) area as in orders. 3) The OPLL was most common type(2.19%) of these spinal ligaments ossification, and then OALL(0.7%), OLF(0.24%) as in orders. 4) OPLL (1) OPLL was most frequent at lumbar area(58.6%) and then cervical(37.0%), thoracic(0.4%) area as in orders. (2) The cervical OPLL was commonly found at C5 & C6 area and morphologically, the multiple segmented type was most common then continuous type, mixed type and single segmented type in orders. (3) The multiple segmented type was more frequently found at upper cervical area, but the continuous type was more frequent at lower cervical area. 5) OALL (1) OALL was most frequent at lumbar area(86.0%) but thoracic(1.4%) and cervecal area(5.3%) were relatively low in frequency. (2) Of the lumbar OALL, the L4/5 area was most frequent site(37.8%) but the L3/4(25.3%) and L5/S1 area(24.5%) also had relatively high occurance rate. 6) OLF (1) OLF was most frequent at lumbar area(92.7%), but the incidence of OLF was relativerly rare at cervical(2.1%) and thoracic area(5.2%). (2) Of the lumbar OLF, the L4/5 area was most common site(33.1), but L5/S1 area had also high occurance rate(27.2%).