Co esponding au ho M. ELKORNO
Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion License 4.0.
Ce ical ossi ica ion o he pos e io longi udinal ligamen : A case epo and
li e a u e e iew
Mohammed ELKORNO, Rayhane HAMDAOUI, Haja ELKORNO, Aymane IMALOUANE, Khalid SKOUNTI,
Mus apha HEMAMA, Niza EL FATEMI and Moulay Rachid EL MAAQILI
Depa men O Neu osu ge y, Hospi al Ibn Sina, Raba , Mohammed V Uni e si y o Raba , Mo occo.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
Publica ion his o y: Recei ed on 16 Ma ch 2025; e ised on 01 Ap il 2025; accep ed on 04 Ap il 2025
A icle DOI: h ps://doi.o g/10.30574/wja .2025.26.1.1448
Abs ac
Ossi ica ion o he pos e io longi udinal ligamen (OPLL) is a a e bu impo an cause o ce ical myelopa hy,
cha ac e ized by p og essi e ossi ica ion ha na ows he spinal canal and comp esses he spinal co d. Al hough mo e
p e alen in Eas Asian popula ions, cases a e inc easingly epo ed wo ldwide. We p esen he case o a 48-yea -old
Mo occan man wi h no no able medical his o y who de eloped p og essi e e apa esis and u ina y incon inence.
Imaging e ealed mul ile el ce ical OPLL om C2 o C5 wi h spinal co d comp ession and myelomalacia. The pa ien
unde wen pos e io decomp essi e laminec omy om C2 o C7. Pos ope a i e e olu ion showed mild igh -sided
mo o imp o emen , wi h pe sis en le -sided de ici s and u ina y dys unc ion. This case unde sco es he need o
conside OPLL in he di e en ial diagnosis o ce ical myelopa hy, e en in non-endemic egions. Ea ly ecogni ion and
app op ia e su gical in e en ion a e essen ial o p e en i e e sible neu ological damage and imp o e clinical
ou comes.
Keywo ds: Ce ical myelopa hy; Ossi ica ion o he pos e io longi udinal ligamen ; OPLL; Spinal co d comp ession;
Pos e io decomp ession; Ce ical spine; Case epo
1. In oduc ion
Ossi ica ion o he pos e io longi udinal ligamen (OPLL) is a degene a i e condi ion i s desc ibed in Japan in he
1960s [1]. Al hough ini ially hough o be mo e p e alen in Eas Asian popula ions, wi h epo ed a es o 2–4% in
men o e 40 yea s old [2], inc easing numbe s o cases a e being documen ed globally, including in No h A ica. Some
s udies ha e epo ed cases in A ican popula ions, albei wi h lowe es ima ed p e alence and limi ed epidemiological
da a [3].OPLL is cha ac e ized by p og essi e calci ica ion o he pos e io longi udinal ligamen , leading o spinal co d
comp ession and a spec um o neu ological mani es a ions anging om mild adiculopa hy o se e e e apa esis [4].
Diagnosis elies on compu ed omog aphy (CT) and magne ic esonance imaging (MRI), which a e essen ial o
assessing he ex en o ossi ica ion and i s impac on he spinal co d [5].We p esen he case o a 47-yea -old Mo occan
man who unde wen su gical decomp ession o p og essi ely wo sening e apa esis caused by ce ical OPLL
ex ending om C2 o C4.
2. Case P esen a ion
We epo he case o a 48-yea -old male wi h no signi ican medical his o y who p esen ed wi h a h ee-yea his o y
o bila e al ce icob achial neu algia and in e mi en pa es hesias in he uppe limbs. Ini ially, he pa ien managed
symp oms wi h o e - he-coun e medica ions and did no seek medical e alua ion.App oxima ely nine mon hs p io o
admission, his condi ion de e io a ed wi h he g adual onse o hea iness in all ou limbs and u ina y incon inence.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3952
This p og essed o comple e mo o de ici o he le hemibody, p omp ing hospi al admission.On clinical examina ion,
he pa ien exhibi ed spas ic e apa esis, mo e p onounced on he le (mo o s eng h: 3/5 on he igh , 1/5 on he
le ), wi h hype e lexia and gene alized polykine ic esponses. Rec al one was p ese ed. The Japanese O hopaedic
Associa ion (JOA) sco e o ce ical myelopa hy was 4, indica ing se e e neu ological impai men .
MRI o he ce ical spine (T1- and T2-weigh ed sagi al and axial sequences) showed a hypoin ense lesion along he
an e io spinal canal om C2 o C5, causing signi ican canal na owing—mos se e e om C2 o C4—and T2
hype in ensi y wi hin he co d sugges i e o myelomalacia. ( igu e.1) . CT scan con i med ex ensi e OPLL om C2 o
C5, Sagi al pa enchymal window images show ce ical canal na owing a C2–C4 and C5–C7 le els due o an
in acanalicula calci ied lesion. Mul ile el ce ical spondylosis wi h calci ica ion o he an e io longi udinal ligamen
is no ed, while he ce ical lo dosis is ela i ely p ese ed.
Axial images demons a e ex ensi e ossi ica ion o he pos e io longi udinal ligamen (OPLL), leading o signi ican
spinal canal s enosis and a lamina ed appea ance o he spinal co d.
Based on hese images, he occupancy a e o he ossi ied ligamen wi hin he spinal canal can be calcula ed using h ee
pa ame e s:
• A: Diame e o he ossi ied mass
• C: A ailable spinal canal space
• B: Diame e o he en i e spinal canal
The occupancy a e is calcula ed as A/B × 100%, esul ing in an es ima ed 50%. ( igu e 2)
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3953
Figu e 1 Ce ical spine MRI (sagi al T1- and T2-weigh ed sequences) showing a hypoin ense lesion along he
an e io spinal canal om C2 o C5, wi h signi ican canal na owing—mos se e e om C2 o C4—and
in amedulla y T2 hype in ensi y sugges i e o myelomalacia, as well as hype ophy o he an e io longi udinal
ligamen a C5–C7
Axial T2-weigh ed image showing a segmen al and mul ile el hype ophy o he pos e io longi udinal ligamen ,
esul ing in canal s enosis and ocal spinal co d comp ession.
Figu e 2 Ce ical spine CT scan.Sagi al pa enchymal window images show ce ical canal na owing a C2–C4 and
C5–C7 le els due o an in acanalicula calci ied Axial images demons a e ex ensi e OPLL leading o signi ican spinal
canal s enosis lesion . he ce ical lo dosis is ela i ely p ese ed
The diagnosis o ce ical spinal co d comp ession due o OPLL was con i med. The pa ien unde wen an ex ensi e
pos e io decomp essi e laminec omy om C2 o C7. ( igu e 3) The pos ope a i e cou se was une en ul.
Neu ologically, he pa ien emained s able in he immedia e pos ope a i e phase, wi h no change in he JOA sco e. He
was discha ged ea ly and began ehabili a ion p omp ly.
A h ee-mon h ollow-up, mild imp o emen in igh -sided mo o unc ion (4/5) was no ed, while he le hemibody
de ici and u ina y symp oms pe sis ed. Follow-up assessmen s a six mon hs and one yea showed clinical s abiliza ion,
wi h he JOA sco e unchanged om baseline.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3954
Figu e 3 In aope a i e s eps o he su gical p ocedu e wi h he pa ien in he p one posi ion. A midline incision was
made om he ex e nal occipi al p o ube ance o he C7 spinous p ocess. In aope a i e iew o he spinal co d
ollowing mul ile el laminec omy om C2 o C7
3. Discussion
OPLL is a degene a i e diso de cha ac e ized by ec opic ossi ica ion o he pos e io longi udinal ligamen —a ib ous
s uc u e loca ed pos e io o he e eb al bodies wi hin he spinal canal. Ini ially desc ibed in Japan in he 1960s [4],
OPLL was once hough o be con ined o Eas Asian popula ions bu is now ecognized globally, hough i emains a e
in A ica [6].
The condi ion ypically mani es s a e age 40 and shows a ma ked male p edominance (male- o- emale a io o 2:1 o
3:1) [7]. Risk ac o s include gene ic p edisposi ion, diabe es melli us, and in lamma o y diseases such as heuma oid
a h i is [8].
The pa hogenesis o OPLL emains incomple ely unde s ood. Tsukimo o (1960) p oposed a degene a i e mechanism
in ol ing p og essi e ligamen ous calci ica ion [4]. Ma sunaga and Sakou (1998) sugges ed epe i i e ce ical
mic o auma ac i a es os eogenic cells, p omo ing ossi ica ion [5]. Gene ic mu a ions associa ed wi h OPLL ha e been
iden i ied by Guo e al. (2014) [6]. Li e al. (2018) demons a ed ha in lamma o y cy okines such as IL-6 can s imula e
ossi ica ion in ligamen ous issue [7]. Kawaguchi e al. (2003) p oposed a ole o diabe es, in which ch onic
hype glycemia may al e ligamen s uc u e and a o ec opic bone o ma ion [8].
Clinically, ce ical OPLL p esen s wi h p og essi e myelopa hy. Ea ly-s age symp oms may include axial pain and
adiculopa hy, while ad anced s ages ea u e mo o and senso y de ici s, gai dis u bances, and sphinc e dys unc ion.
In his case, he pa ien exhibi ed la e-s age signs wi h se e e e apa esis and u ina y incon inence. To assess
neu ological se e i y and guide ea men , wo main sco ing sys ems a e employed: he JOA sco e, which e alua es
uppe and lowe limb unc ion and sphinc e con ol (sco es <12 sugges se e e disease)( able 1 ) , and he Nu ick
g ade, which ocuses on ambula o y s a us.( able2)
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3955
Table 1 Japanese O hopaedic Associa ion (JOA) Sco e o Ce ical Myelopa hy
Func ion
Max Sco e
Sco ing C i e ia
Uppe limb mo o unc ion
4
0: Unable o use hands
1: Can hold a spoon
2: Can ea wi h di icul y
3: Can use chops icks wi h di icul y
4: No mal
Lowe limb mo o unc ion
4
0: Unable o walk
1: Can walk on la g ound wi h suppo
2: Can climb s ai s wi h suppo
3: Can walk wi hou suppo bu wi h di icul y
4: No mal
Senso y unc ion – uppe limbs
2
0: Comple e loss1: Dec eased sensa ion
2: No mal
Senso y unc ion – lowe limbs
2
0: Comple e loss
1: Dec eased sensa ion
2: No mal
Senso y unc ion – unk
2
0: Comple e loss
1: Dec eased sensa ion
2: No mal
Bladde unc ion (sphinc e con ol)
3
0: Comple e e en ion o incon inence
1: Se e e dys unc ion
2: Mild o mode a e dys unc ion
3: No mal
To al Sco e: 17 poin s
Table 2 Nu ick G ade – Ambula o y S a us
G ade
Desc ip ion
0
Signs o symp oms o spinal co d comp ession bu no di icul y in walking
1
Mild gai in ol emen ; able o wo k ull- ime
2
Di icul y walking bu able o wo k; no equi ing assis ance
3
Able o walk only wi h assis ance; no able o wo k
4
Able o walk only wi h suppo a home; mos ly con ined o home
5
Chai bound o bed idden
MRI emains he gold s anda d o e alua ing spinal co d comp ession and in amedulla y changes such as T2
hype in ensi ies, indica i e o ch onic myelopa hy. CT p o ides de ailed cha ac e iza ion o he ossi ied mass, including
i s mo phology, dis ibu ion, and deg ee o canal comp omise. The Japanese Minis y o Public Heal h and Wel a e
classi ica ion dis inguishes OPLL sub ypes—segmen al, con inuous, mixed, and localized—each wi h implica ions o
su gical planning [13].
Radiological indices such as he occupying a io (>60% indica es se e e comp ession) and he K-line help de e mine
he su gical app oach (an e io s pos e io ) ( able 3 ) . While no speci ic bioma ke s exis o OPLL, associa ed
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3956
me abolic condi ions like diabe es, hype insulinemia, hype u icemia, and calcium me abolism diso de s may in luence
managemen .
Gi en he ex en o OPLL in ou pa ien (C2–C5), a pos e io decomp essi e app oach was selec ed. Pos e io
laminec omy is ecommended when he ce ical spine is s able, ypically con i med wi h dynamic imaging. Ka o e al.
[18] epo ed a eco e y a e o 44.2% a 1 yea , dec easing o 32.8% a 10 yea s. Laminoplas y o e s an al e na i e
wi h a o able long- e m ou comes while p ese ing s abili y—Mo imo o e al. [20] epo ed JOA sco e imp o emen
om 9 o 14.1 a h ee yea s and a 96% usion a e.
An e io app oaches (e.g., an e io ce ical discec omy and usion [ACDF], an e io co pec omy and usion [ACF]) allow
di ec decomp ession. Kawano e al. [17] no ed a 78% neu ological imp o emen pos -an e io su ge y, compa ed o
46.1% wi h pos e io app oaches. Howe e , complica ions such as pseuda h osis (up o 13%) may occu . Dynamic
pla ing imp o es usion a es (up o 97.9%) and educes complica ion isk [18-17-20].
In cases in ol ing mul ile el co pec omies, pos e io usion may be equi ed o p e en pos ope a i e ins abili y.
Techniques include pos e io ension bands, la e al mass sc ews, o pedicle sc ew- od cons uc s. Ki kpa ick e al. [21]
showed a 62% educ ion in sagi al mobili y wi h pos e io usion, compa ed o 43% wi h an e io usion alone.
Su gical s a egy should be indi idualized based on neu ological s a us, alignmen , OPLL ex en , and su geon expe ise.
An e io app oaches a e p e e ed o comp ession in ol ing ≤3 le els, especially wi h kyphosis, K-line nega i i y, o
high occupying a ios. Pos e io decomp ession is a o ed o ex ensi e lesions (>3 le els), neu al o lo do ic
alignmen , o minimal an e io symp oms.
In ou case, he pos e io app oach was chosen due o mul ile el in ol emen and p ese ed spinal alignmen .
Conse a i e ea men is ese ed o asymp oma ic o mildly symp oma ic cases. Howe e , 40–50% o un ea ed
pa ien s de elop clinical myelopa hy, unde sco ing he need o su eillance wi h sequen ial MRIs.
Pos ope a i e ca e includes ce ical immobiliza ion wi h a so colla o igid o hosis o wo mon hs. Co icos e oids
may be adminis e ed o educe ai way edema. D ain emo al is ypically pe o med on pos ope a i e day one, and
adiog aphs con i m g a placemen .
Pos ope a i e complica ions a y wi h he su gical app oach and include ins abili y, in ec ion, and esidual de ici s.
Unde s anding hese isks is essen ial o su gical planning and p ognosis.A me a-analysis o 27 s udies in ol ing 1,558
pa ien s summa ized complica ion a es and eco e y ou comes ( igu e 9).
Neu ological imp o emen is o en pa ial, especially in ad anced cases. Ou pa ien showed sligh mo o imp o emen
wi hou esolu ion o sphinc e dys unc ion. P ognosis co ela es wi h symp om du a ion and p eope a i e se e i y
[18]. Ea ly su ge y (<6 mon hs om symp om onse ) yields be e ou comes, wi h a e age imp o emen a es o 50–
70%. Recu ence is a e a e pos e io decomp ession (5–10%) bu mo e equen a e an e io su ge y wi h
incomple e usion.
Long- e m ollow-up is essen ial due o he isk o OPLL p og ession pos -su ge y. Iwasaki e al. epo ed p og ession
in 70% o pa ien s a e laminoplas y o e 10 yea s [18]. Ho i e al. ound simila a es (71%) in a e ospec i e coho
[132]. Chiba e al. documen ed 56.5% p og ession wo yea s a e pos e io decomp ession alone. No ably, p og ession
was lowe in pos e io usion g oups (PDF) han in laminoplas y (2.0% s. 7.5% annually, p < 0.0001) [17].
4. Conclusion
OPLL is a a e bu inc easingly ecognized cause o ce ical myelopa hy beyond Eas Asia. Ea ly diagnosis and imely
su gical in e en ion a e c ucial o p e en ing i e e sible neu ological de ici s. The choice o su gical app oach should
be ailo ed based on adiological, ana omical, and clinical ac o s. Pos e io decomp ession emains a sa e and e ec i e
op ion o mul ile el OPLL wi h p ese ed alignmen , while an e io o combined app oaches may be wa an ed in
selec cases. Long- e m ollow-up is essen ial due o he isk o pos ope a i e p og ession.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3957
Compliance wi h e hical s anda ds
Disclosu e o con lic o in e es
No con lic o in e es o be disclosed.
S a emen o in o med consen
In o med consen was ob ained om he pa ien o publica ion o his case epo and any accompanying images.
Re e ences
[1] Ma sunaga, S., Sakou, T. (2012). Ossi ica ion o he pos e io longi udinal ligamen o he ce ical spine: e iology
and na u al his o y. Spine, 37(5), 309-314.
[2] Fu ukawa, K. (2010). P e alence and pa hogenesis o ossi ica ion o he pos e io longi udinal ligamen in Japan.
Jou nal o Bone and Join Su ge y, 92(2), 219-223.
[3] Moon, S. H., e al. (2011). Epidemiology and clinical signi icance o ossi ica ion o he pos e io longi udinal
ligamen . Asian Spine Jou nal, 5(4), 267-276.
[4] Tsukimo o, H. (1960). Ossi ica ion o he pos e io longi udinal ligamen o he spine. Jou nal o he Japanese
O hopaedic Associa ion, 34(1), 457-472.
[5] Ma sunaga, S., Sakou, T. (1998). Mechanisms o ossi ica ion o he pos e io longi udinal ligamen in he ce ical
spine. Clinical O hopaedics and Rela ed Resea ch, 35(2), 108-114.
[6] Guo, X., e al. (2014). Gene ic and clinical ea u es o ossi ica ion o he pos e io longi udinal ligamen . Clinical
O hopaedics and Rela ed Resea ch, 472(2), 396-403.
[7] Li, H., e al. (2018). The ole o in lamma o y cy okines in he pa hogenesis o ossi ica ion o he pos e io
longi udinal ligamen . Jou nal o Clinical Neu oscience, 51, 12-17.
[8] Kawaguchi, Y., e al. (2003). Me abolic ac o s con ibu ing o ossi ica ion o he pos e io longi udinal ligamen .
Jou nal o Bone and Mine al Resea ch, 18(5), 751-757.
[9] Moon, S. H., e al. (2011). Epidemiology and clinical signi icance o ossi ica ion o he pos e io longi udinal
ligamen . Asian Spine Jou nal, 5(4), 267-276.
[10] Nakajima, M., e al. (2009). Me abolic implica ions in ossi ica ion o he pos e io longi udinal ligamen . Spine,
34(1), 85-91.
[11] Pa k, Y., e al. (2017). Clinical and imaging classi ica ions o ossi ica ion o he pos e io longi udinal ligamen :
implica ions o su gical planning. Neu osu gical Re iew, 40(4), 587-595.
[12] Chiba, K., e al. (2005). The ole o MRI and CT in diagnosing and s aging ossi ica ion o he pos e io longi udinal
ligamen . Spine Jou nal, 5(5), 496-501.
[13] Mizuno, J., Nakagawa, H. (2001). Ossi ied pos e io longi udinal ligamen : managemen s a egies and ou comes.
Jou nal o Neu osu ge y: Spine, 5(1), 10-16.
[14] Resnick, D., & Niwayama, G. (1978). Radiog aphic and Pa hologic Fea u es o Spinal In ol emen in Di use
Idiopa hic Skele al Hype os osis (DISH). Radiology, 126(2), 457-474.
[15] Eps ein, N. E. (2008). Ossi ica ion o he pos e io longi udinal ligamen in e olu ion: epidemiology and
p ognosis. Neu osu gical Focus, 24(1), E9.
[16] Fujimu a, Y., Nishi, Y. (1993). Laminoplas y o ossi ica ion o he pos e io longi udinal ligamen in ce ical
spine. Spine, 18(4), 15-18.
[17] Kawaguchi, Y., e al. (2003). Su gical ea men o ho acic ossi ica ion o he pos e io longi udinal ligamen .
Jou nal o Neu osu ge y: Spine, 98(4), 12-18.
[18] Hasegawa, K., e al. (2009). Long- e m ollow-up o pa ien s wi h ossi ica ion o he pos e io longi udinal
ligamen a e su ge y. Clinical Spine Su ge y, 22(2), 101-109.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(01), 3951-3958
3958
[19] OKAMOTO K, KOBASHI G, WASHIO M, SASAKI S, YOKOYAMA T, MIYAKE Y, ET AL. Die a y habi s and isk o
ossi ica ion o he pos e io longi udinal ligamen s o he spine (OPLL); indings om a case-con ol s udy in
Japan. J Bone Mine Me ab 22:612–617, 2004.
[20] Kobashi G, Oh a K, Washio M, Okamo o K, Sasaki S, Yokoyama T, e al. Va ian o i amin D ecep o gene and
ac o s ela ed o a he oscle osis associa ed wi h ossi ica ion o he pos e io longi udinal ligamen o he spine:
a mul ihospi al case-con ol s udy. Spine 33:E553–E558, 2008.
[21] CHIBA K, YAMAMOTO I, HIRABAYASHI H, IWASAKI M, GOTO H, YONENOBU K, ET AL.Mul icen e s udy
in es iga ing he pos ope a i e p og ession o ossi ica ion o he pos e io longi udinal ligamen in he ce ical
spine: a new compu e -assis ed measu emen . J Neu osu g Spine 3:17–23, 2005.
