Efficacy and safety of anterior and posterior approach for the surgical treatment in ossification of the posterior longitudinal ligament: a meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

LI Shaolong ^1,2 , YE Hongji ^1,2 , SONG Pengjie ^1,2 , DONG Haitao ^1,2 , CHENG Peng ^1,2 ,  ZHOU Haiyu ^1,2

1. Department of Orthopedics, Second Hospital of Lanzhou University, Lanzhou, 730030, P.R.China;
2. Gansu Provincial Key Laboratory of Joint Diseases, Lanzhou, 730030, P.R.China;

Corresponding author：

ZHOU Haiyu, Email: zhouhy@lzu.edu.cn

Keywords：

Ossification of the posterior longitudinal ligament; Anterior approach; Posterior approach; Meta-analysis; Systematic review; Postoperative neurological improvement; Re-operation rate; Randomized controlled trial; Cohort study

DOI：

10.7507/1672-2531.201702023

Video：

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ObjectiveTo systematically review the efficacy and safety of the anterior and posterior approach for the treatment in ossification of the posterior longitudinal ligament (OPLL) of the cervical spine.MethodsAn electronical search was conducted in PubMed, EMbase, The Cochrane Library, Web of Science, WanFang Data and CNKI from inception to December 2016 to collect studies which compared the anterior cervical approach with posterior approach for OPLL. Two reviewers independently screened literature, extracted data and assessed the risk bias of included studies and then RevMan 5.3 software was used to perform meta-analysis.ResultsA total of 20 studies involving 1 263 patients were included. The results of meta-analysis showed that: compared with the posterior approach group, the anterior approach group had higher postoperative JOA score (MD=0.98, 95%CI 0.52 to 1.44, P<0.000 1), higher improvement (MD=12.18, 95% CI 6.65 to 17.71, P<0.000 1), higher re-operation rate (OR=3.21, 95%CI 1.70 to 6.08, P=0.000 3), longer operation time (MD=53.43, 95%CI 12.77 to 94.09, P=0.01) and more bleeding (MD=122.88, 95%CI 39.56 to 206.20, P=0.004), respectively. There was no significant difference in the incidence of complications between two groups (OR=1.49, 95%CI 0.88 to 2.51, P=0.14).ConclusionThe anterior approach for the treatment in OPLL of the cervical spine can achieve better postoperative neurological improvement and lower neurological deterioration, while the posterior approach for the treatment in OPLL has lower re-operation rate, less blood loss and shorter operation time. The incidence of complications between two groups is similar. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify above conclusion.

Citation： LI Shaolong, YE Hongji, SONG Pengjie, DONG Haitao, CHENG Peng, ZHOU Haiyu. Efficacy and safety of anterior and posterior approach for the surgical treatment in ossification of the posterior longitudinal ligament: a meta-analysis. Chinese Journal of Evidence-Based Medicine, 2017, 17(7): 810-819. doi: 10.7507/1672-2531.201702023 Copy

1.	Kalb S, Martirosyan NL, Perez-Orribo L, et al. Analysis of demographics, risk factors, clinical presentation, and surgical treatment modalities for the ossified posterior longitudinal ligament. Neurosurg Focus, 2011, 30(3): 11.
2.	An HS, Al-Shihabi L, Kurd M. Surgical treatment for ossification of the posterior longitudinal ligament in the cervical spine. J Am Acad Orthop Surg, 2014, 22(7): 420-429.
3.	Matsunaga S, Sakou T. Ossification of the posterior longitudinal ligament of the cervical spine: etiology and natural history. Spine, 2012, 37(5): 309-314.
4.	Kawano H, Handa Y, Ishii H, et al. Surgical treatment for ossification of the posterior longitudinal ligament of the cervical spine. J Spinal Disord, 1995, 8(2): 145-150.
5.	Tsuyama N. Ossification of the posterior longitudinal ligament of the spine. Clin Orthop Relat Res, 1984, 12(184): 71-84.
6.	Zeng X, Zhang Y, Kwong JS, et al. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta-analysis, and clinical practice guideline: a systematic review. J Evid Based Med, 2015, 8(1): 2-10.
7.	Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Available at: http://:handbook.cochrane.org.
8.	Goto S, Kita T. Long-term follow-up evaluation of surgery for ossification of the posterior longitudinal ligament. Spine, 1995, 20(20): 2247-2256.
9.	Tani T, Ushida T, Ishida K, et al. Relative safety of anterior microsurgical decompression versus laminoplasty for cervical myelopathy with a massive ossified posterior longitudinal ligament. Spine, 2002, 27(22): 2491-2498.
10.	Jain SK, Salunke PS, Vyas KH, et al. Multisegmental cervical ossification of the posterior longitudinal ligament: anterior vs posterior approach. Neurol India, 2005, 53(3): 283-286.
11.	Masaki Y, Yamazaki M, Okawa A, et al. An analysis of factors causing poor surgical outcome in patients with cervical myelopathy due to ossification of the posterior longitudinal ligament: anterior decompression with spinal fusion versus laminoplasty. J Spinal Disord Tech, 2007, 20(1): 7-13.
12.	Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 1: Clinical results and limitations of laminoplasty. Spine, 2007, 32(6): 647-653.
13.	Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 2: Advantages of anterior decompression and fusion over laminoplasty. Spine, 2007, 32(6): 654-660.
14.	Lee SH, Ahn Y, Lee JH. Laser-assisted anterior cervical corpectomy versus posterior laminoplasty for cervical myelopathic patients with multilevel ossification of the posterior longitudinal ligament. Photomed Laser Surg, 2008, 26(2): 119-127.
15.	Sun Q, Hu H, Zhang Y, et al. Do intramedullary spinal cord changes in signal intensity on MRI affect surgical opportunity and approach for cervical myelopathy due to ossification of the posterior longitudinal ligament. Eur Spine J, 2011, 20(9): 1466-1473.
16.	Chen Y, Guo Y, Lu X, et al. Surgical strategy for multilevel severe ossification of posterior longitudinal ligament in the cervical spine. J Spinal Disord Tech, 2011, 24(1): 24-30.
17.	Lin D, Ding Z, Lian K, et al. Cervical ossification of the posterior longitudinal ligament: Anterior versus posterior approach. Indian J Orthop, 2012, 46(1): 92-98.
18.	Sakai K, Okawa A, Takahashi M, et al. Five-year follow-up evaluation of surgical treatment for cervical myelopathy caused by ossification of the posterior longitudinal ligament: a prospective comparative study of anterior decompression and fusion with floating method versus laminoplasty. Spine, 2012, 37(5): 367-376.
19.	Chen Y, Liu X, Chen D, et al. Surgical strategy for ossification of the posterior longitudinal ligament in the cervical spine. Orthopedics, 2012, 35(8): 1231-1237.
20.	Liu H, Li Y, Chen Y, et al. Cervical curvature, spinal cord MRIT2 signal, and occupying ratio impact surgical approach selection in patients with ossification of the posterior longitudinal ligament. Eur Spine J, 2013, 22(7): 1480-1488.
21.	Fujimori T, Iwasaki M, Okuda S, et al. Long-term results of cervical myelopathy due to ossification of the posterior longitudinal ligament with an occupying ratio of 60% or more. Spine, 2014, 39(1): 58-67.
22.	Kim B, Yoon DH, Shin HC, et al. Surgical outcome and prognostic factors of anterior decompression and fusion for cervical compressive myelopathy due to ossification of the posterior longitudinal ligament. Spine J, 2015, 15(5): 875-884.
23.	Yoshii T, Sakai K, Hirai T, et al. Anterior decompression with fusion versus posterior decompression with fusion for massive cervical ossification of the posterior longitudinal ligament with a ≥50% canal occupying ratio: a multicenter retrospective study. Spine J, 2016, 16(11): 1351-1357.
24.	陈德玉, 陈宇, 王新伟, 等. 颈椎后纵韧带骨化症的手术治疗及疗效分析. 中国矫形外科杂志. 2006, 14(1): 9-11.
25.	雷涛, 申勇, 王林峰, 等. 节段型严重颈椎后纵韧带骨化症前路、后路手术的疗效比较与选择策略. 中华骨科杂志, 2013, 33(2): 189-192.
26.	鲁世金, 潘汉升, 刘汝专, 等. 老年重度颈椎节段型后纵韧带骨化症的手术疗效. 中国脊柱脊髓杂志, 2013, 7(4): 352-358.
27.	汪文龙, 海涌, 关立, 等. 前路或后路手术治疗颈椎后纵韧带骨化症的中期疗效观察. 中国脊柱脊髓杂志, 2016, 10(7): 577-584.
28.	徐晓光, 韩月红. 颈椎后纵韧带骨化发生机制的研究. 中国实用医药, 2012, 33(7): 135-139.
29.	Furlan JC, Kalsi-Ryan S, Kailaya-Vasan A, et al. Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: a prospective study of 81 cases. J Neurosurg Spine, 2011, 14(3): 348-355.
30.	王亚楠, 侯海涛, 邵诗泽, 等. 不同手术入路治疗颈椎后纵韧带骨化症疗效的 Meta 分析. 中国矫形外科杂志, 2016, 18(15): 1384-1389.
31.	Chen Z, Liu B, Dong J, et al. Comparison of anterior corpectomy and fusion versus laminoplasty for the treatment of cervical ossification of posterior longitudinal ligament: a meta-analysis. Neurosurg Focus, 2016, 40(6): 8.
32.	刘金柱, 常楚, 张兴华, 等. 颈椎后纵韧带骨化症前后路手术疗效比较的 meta 分析. 中国骨与关节外科, 2013, 24(3): 247-251.
33.	Chiba K, Yamamoto I, Hirabayashi H, et al. Multicenter study investigating the postoperative progression of ossification of the posterior longitudinal ligament in the cervical spine: a new computer-assisted measurement. J Neurosurg Spine, 2005, 3(1): 17-23.
34.	Hori T, Kawaguchi Y, Kimura T. How does the ossification area of the posterior longitudinal ligament progress after cervical laminoplasty. Spine, 2006, 31(24): 2807-2812.
35.	Takatsu T, Ishida Y, Suzuki K, et al. Radiological study of cervical ossification of the posterior longitudinal ligament. J Spinal Disord, 1999, 12(3): 271-273.
36.	Fraser JF, Hartl R. Anterior approaches to fusion of the cervical spine: a meta-analysis of fusion rates. J Neurosurg Spine, 2007, 6(4): 298-303.
37.	Li H, Dai LY. A systematic review of complications in cervical spine surgery for ossification of the posterior longitudinal ligament. Spine J, 2011, 11(11): 1049-1057.
38.	Liu W, Hu L, Chou PH, et al. Comparison of anterior decompression and fusion versus laminoplasty in the treatment of multilevel cervical ossification of the posterior longitudinal ligament: a systematic review and meta-analysis. Ther Clin Risk Manag, 2016, 12(3): 675-685.
39.	Chen Y, Yang L, Liu Y, et al. Surgical results and prognostic factors of anterior cervical corpectomy and fusion for ossification of the posterior longitudinal ligament. PLoS One, 2014, 9(7): 102008.
40.	Mehdi SK, Alentado VJ, Lee BS, et al. Comparison of clinical outcomes in decompression and fusion versus decompression only in patients with ossification of the posterior longitudinal ligament: a meta-analysis. Neurosurg Focus, 2016, 40(6): 9.
41.	Chen G, Luo Z, Nalajala B, et al. Expansive open-door laminoplasty with titanium miniplate versus sutures. Orthopedics, 2012, 35(4): 543-548.
42.	Sun Y, Zhang F, Wang S, et al. Open door expansive laminoplasty and postoperative axial symptoms: a comparative study between two different procedures. Evid Based Spine Care J, 2010, 1(3): 27-33.
43.	Tsuji T, Asazuma T, Masuoka K, et al. Retrospective cohort study between selective and standard C3-7 laminoplasty. Minimum 2-year follow-up study. Eur Spine J, 2007, 16(12): 2072-2077.
44.	Hosono N, Yonenobu K, Ono K. Neck and shoulder pain after laminoplasty. A noticeable complication. Spine, 1996, 21(17): 1969-1973.
45.	Katsumi K, Yamazaki A, Watanabe K, et al. Can prophylactic bilateral C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty?: a prospective study. Spine, 2012, 37(9): 748-754.
46.	Hirabayashi K, Watanabe K, Wakano K, et al. Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine, 1983, 8(7): 693-699.
47.	Rhee JM, Register B, Hamasaki T, et al. Plate-only open door laminoplasty maintains stable spinal canal expansion with high rates of hinge union and no plate failures. Spine, 2011, 36(1): 9-14.
48.	Matsumoto M, Watanabe K, Tsuji T, et al. Risk factors for closure of lamina after open-door laminoplasty. J Neurosurg Spine, 2008, 9(6): 530-537.

1. Kalb S, Martirosyan NL, Perez-Orribo L, et al. Analysis of demographics, risk factors, clinical presentation, and surgical treatment modalities for the ossified posterior longitudinal ligament. Neurosurg Focus, 2011, 30(3): 11.
2. An HS, Al-Shihabi L, Kurd M. Surgical treatment for ossification of the posterior longitudinal ligament in the cervical spine. J Am Acad Orthop Surg, 2014, 22(7): 420-429.
3. Matsunaga S, Sakou T. Ossification of the posterior longitudinal ligament of the cervical spine: etiology and natural history. Spine, 2012, 37(5): 309-314.
4. Kawano H, Handa Y, Ishii H, et al. Surgical treatment for ossification of the posterior longitudinal ligament of the cervical spine. J Spinal Disord, 1995, 8(2): 145-150.
5. Tsuyama N. Ossification of the posterior longitudinal ligament of the spine. Clin Orthop Relat Res, 1984, 12(184): 71-84.
6. Zeng X, Zhang Y, Kwong JS, et al. The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta-analysis, and clinical practice guideline: a systematic review. J Evid Based Med, 2015, 8(1): 2-10.
7. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Available at: http://:handbook.cochrane.org.
8. Goto S, Kita T. Long-term follow-up evaluation of surgery for ossification of the posterior longitudinal ligament. Spine, 1995, 20(20): 2247-2256.
9. Tani T, Ushida T, Ishida K, et al. Relative safety of anterior microsurgical decompression versus laminoplasty for cervical myelopathy with a massive ossified posterior longitudinal ligament. Spine, 2002, 27(22): 2491-2498.
10. Jain SK, Salunke PS, Vyas KH, et al. Multisegmental cervical ossification of the posterior longitudinal ligament: anterior vs posterior approach. Neurol India, 2005, 53(3): 283-286.
11. Masaki Y, Yamazaki M, Okawa A, et al. An analysis of factors causing poor surgical outcome in patients with cervical myelopathy due to ossification of the posterior longitudinal ligament: anterior decompression with spinal fusion versus laminoplasty. J Spinal Disord Tech, 2007, 20(1): 7-13.
12. Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 1: Clinical results and limitations of laminoplasty. Spine, 2007, 32(6): 647-653.
13. Iwasaki M, Okuda S, Miyauchi A, et al. Surgical strategy for cervical myelopathy due to ossification of the posterior longitudinal ligament: Part 2: Advantages of anterior decompression and fusion over laminoplasty. Spine, 2007, 32(6): 654-660.
14. Lee SH, Ahn Y, Lee JH. Laser-assisted anterior cervical corpectomy versus posterior laminoplasty for cervical myelopathic patients with multilevel ossification of the posterior longitudinal ligament. Photomed Laser Surg, 2008, 26(2): 119-127.
15. Sun Q, Hu H, Zhang Y, et al. Do intramedullary spinal cord changes in signal intensity on MRI affect surgical opportunity and approach for cervical myelopathy due to ossification of the posterior longitudinal ligament. Eur Spine J, 2011, 20(9): 1466-1473.
16. Chen Y, Guo Y, Lu X, et al. Surgical strategy for multilevel severe ossification of posterior longitudinal ligament in the cervical spine. J Spinal Disord Tech, 2011, 24(1): 24-30.
17. Lin D, Ding Z, Lian K, et al. Cervical ossification of the posterior longitudinal ligament: Anterior versus posterior approach. Indian J Orthop, 2012, 46(1): 92-98.
18. Sakai K, Okawa A, Takahashi M, et al. Five-year follow-up evaluation of surgical treatment for cervical myelopathy caused by ossification of the posterior longitudinal ligament: a prospective comparative study of anterior decompression and fusion with floating method versus laminoplasty. Spine, 2012, 37(5): 367-376.
19. Chen Y, Liu X, Chen D, et al. Surgical strategy for ossification of the posterior longitudinal ligament in the cervical spine. Orthopedics, 2012, 35(8): 1231-1237.
20. Liu H, Li Y, Chen Y, et al. Cervical curvature, spinal cord MRIT2 signal, and occupying ratio impact surgical approach selection in patients with ossification of the posterior longitudinal ligament. Eur Spine J, 2013, 22(7): 1480-1488.
21. Fujimori T, Iwasaki M, Okuda S, et al. Long-term results of cervical myelopathy due to ossification of the posterior longitudinal ligament with an occupying ratio of 60% or more. Spine, 2014, 39(1): 58-67.
22. Kim B, Yoon DH, Shin HC, et al. Surgical outcome and prognostic factors of anterior decompression and fusion for cervical compressive myelopathy due to ossification of the posterior longitudinal ligament. Spine J, 2015, 15(5): 875-884.
23. Yoshii T, Sakai K, Hirai T, et al. Anterior decompression with fusion versus posterior decompression with fusion for massive cervical ossification of the posterior longitudinal ligament with a ≥50% canal occupying ratio: a multicenter retrospective study. Spine J, 2016, 16(11): 1351-1357.
24. 陈德玉, 陈宇, 王新伟, 等. 颈椎后纵韧带骨化症的手术治疗及疗效分析. 中国矫形外科杂志. 2006, 14(1): 9-11.
25. 雷涛, 申勇, 王林峰, 等. 节段型严重颈椎后纵韧带骨化症前路、后路手术的疗效比较与选择策略. 中华骨科杂志, 2013, 33(2): 189-192.
26. 鲁世金, 潘汉升, 刘汝专, 等. 老年重度颈椎节段型后纵韧带骨化症的手术疗效. 中国脊柱脊髓杂志, 2013, 7(4): 352-358.
27. 汪文龙, 海涌, 关立, 等. 前路或后路手术治疗颈椎后纵韧带骨化症的中期疗效观察. 中国脊柱脊髓杂志, 2016, 10(7): 577-584.
28. 徐晓光, 韩月红. 颈椎后纵韧带骨化发生机制的研究. 中国实用医药, 2012, 33(7): 135-139.
29. Furlan JC, Kalsi-Ryan S, Kailaya-Vasan A, et al. Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: a prospective study of 81 cases. J Neurosurg Spine, 2011, 14(3): 348-355.
30. 王亚楠, 侯海涛, 邵诗泽, 等. 不同手术入路治疗颈椎后纵韧带骨化症疗效的 Meta 分析. 中国矫形外科杂志, 2016, 18(15): 1384-1389.
31. Chen Z, Liu B, Dong J, et al. Comparison of anterior corpectomy and fusion versus laminoplasty for the treatment of cervical ossification of posterior longitudinal ligament: a meta-analysis. Neurosurg Focus, 2016, 40(6): 8.
32. 刘金柱, 常楚, 张兴华, 等. 颈椎后纵韧带骨化症前后路手术疗效比较的 meta 分析. 中国骨与关节外科, 2013, 24(3): 247-251.
33. Chiba K, Yamamoto I, Hirabayashi H, et al. Multicenter study investigating the postoperative progression of ossification of the posterior longitudinal ligament in the cervical spine: a new computer-assisted measurement. J Neurosurg Spine, 2005, 3(1): 17-23.
34. Hori T, Kawaguchi Y, Kimura T. How does the ossification area of the posterior longitudinal ligament progress after cervical laminoplasty. Spine, 2006, 31(24): 2807-2812.
35. Takatsu T, Ishida Y, Suzuki K, et al. Radiological study of cervical ossification of the posterior longitudinal ligament. J Spinal Disord, 1999, 12(3): 271-273.
36. Fraser JF, Hartl R. Anterior approaches to fusion of the cervical spine: a meta-analysis of fusion rates. J Neurosurg Spine, 2007, 6(4): 298-303.
37. Li H, Dai LY. A systematic review of complications in cervical spine surgery for ossification of the posterior longitudinal ligament. Spine J, 2011, 11(11): 1049-1057.
38. Liu W, Hu L, Chou PH, et al. Comparison of anterior decompression and fusion versus laminoplasty in the treatment of multilevel cervical ossification of the posterior longitudinal ligament: a systematic review and meta-analysis. Ther Clin Risk Manag, 2016, 12(3): 675-685.
39. Chen Y, Yang L, Liu Y, et al. Surgical results and prognostic factors of anterior cervical corpectomy and fusion for ossification of the posterior longitudinal ligament. PLoS One, 2014, 9(7): 102008.
40. Mehdi SK, Alentado VJ, Lee BS, et al. Comparison of clinical outcomes in decompression and fusion versus decompression only in patients with ossification of the posterior longitudinal ligament: a meta-analysis. Neurosurg Focus, 2016, 40(6): 9.
41. Chen G, Luo Z, Nalajala B, et al. Expansive open-door laminoplasty with titanium miniplate versus sutures. Orthopedics, 2012, 35(4): 543-548.
42. Sun Y, Zhang F, Wang S, et al. Open door expansive laminoplasty and postoperative axial symptoms: a comparative study between two different procedures. Evid Based Spine Care J, 2010, 1(3): 27-33.
43. Tsuji T, Asazuma T, Masuoka K, et al. Retrospective cohort study between selective and standard C3-7 laminoplasty. Minimum 2-year follow-up study. Eur Spine J, 2007, 16(12): 2072-2077.
44. Hosono N, Yonenobu K, Ono K. Neck and shoulder pain after laminoplasty. A noticeable complication. Spine, 1996, 21(17): 1969-1973.
45. Katsumi K, Yamazaki A, Watanabe K, et al. Can prophylactic bilateral C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty?: a prospective study. Spine, 2012, 37(9): 748-754.
46. Hirabayashi K, Watanabe K, Wakano K, et al. Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine, 1983, 8(7): 693-699.
47. Rhee JM, Register B, Hamasaki T, et al. Plate-only open door laminoplasty maintains stable spinal canal expansion with high rates of hinge union and no plate failures. Spine, 2011, 36(1): 9-14.
48. Matsumoto M, Watanabe K, Tsuji T, et al. Risk factors for closure of lamina after open-door laminoplasty. J Neurosurg Spine, 2008, 9(6): 530-537.

Chinese Journal of Evidence-Based Medicine

Efficacy and safety of anterior and posterior approach for the surgical treatment in ossification of the posterior longitudinal ligament: a meta-analysis

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