What is the best treatment approach for a patient with neck pain, multilevel degenerative disc disease (DDD), and ossification of the posterior longitudinal ligament (OPLL) at C2-C3?

Treatment Approach for Neck Pain with Multilevel DDD and OPLL at C2-C3

For a patient with neck pain, multilevel degenerative disc disease, and ossification of the posterior longitudinal ligament at C2-C3, obtain CT cervical spine to fully characterize the OPLL extent, thickness, and degree of canal stenosis, followed by MRI to assess for cord compression or signal changes if neurologic symptoms develop. 1

Initial Diagnostic Workup

Imaging Strategy for Known OPLL

• CT cervical spine is the most reliable modality for identifying OPLL type, thickness, length of involved segments, and quantifying neuroforaminal and spinal canal narrowing 1
• CT provides superior spatial resolution compared to radiographs for evaluating the full extent of ossification and associated stenosis 1
• MRI has limited sensitivity (32-44.3%) for detecting OPLL itself, but its primary utility is assessing cord abutment, signal changes secondary to spinal canal narrowing, and evaluating nerve roots if radiculopathy develops 1
• The combination of CT and MRI provides comprehensive evaluation when neurologic symptoms are present 1, 2

Clinical Correlation Requirements

• Degenerative changes on imaging correlate poorly with neck pain in patients over 30 years of age, so imaging findings must be interpreted cautiously in the context of symptoms 1
• In a 10-year longitudinal study, cervical disc degeneration progressed in 85% of patients, but symptoms developed in only 34% 1
• OPLL predisposes patients to progressive spinal canal narrowing and potential cord abutment, typically presenting in the fifth or sixth decade with a 2:1 male-to-female ratio 1

Conservative Management Approach

Initial Treatment for Neck Pain Without Myelopathy

• Non-operative management is successful in 75-90% of cervical radiculopathy cases and should be the initial approach for neck pain without progressive neurologic deficits 3, 4
• Conservative therapy includes physical therapy, anti-inflammatory medications, activity modification, and possible cervical collar immobilization for a minimum of 6 weeks 4
• Physical therapy demonstrates statistically significant clinical improvement and can achieve comparable outcomes to surgical intervention at 12 months, though surgery provides more rapid relief within 3-4 months 4

Monitoring for Progression

• OPLL is a progressive condition that can lead to spinal cord compression over time, requiring vigilant monitoring for development of myelopathic symptoms 1, 2
• Patients developing symptoms show more frequent progression including anterior compression of the dura and spinal cord, posterior disc protrusion, disc space narrowing, and foraminal stenosis 1
• Serial neurologic examinations should assess for gait instability, fine motor deterioration, hyperreflexia, and Hoffman's sign indicating myelopathy 4, 2

Surgical Indications and Approach

When Surgery Becomes Necessary

• Surgical intervention is indicated for patients with neurologic symptoms (myelopathy or radiculopathy), severe stenosis, or progressive neurologic deficits despite adequate conservative management 4, 2, 5
• Minimally symptomatic patients can continue nonsurgical management, but those with myelopathy or severe stenosis require surgical decompression 5, 6
• The natural history of cervical spondylotic myelopathy shows 55-70% of patients experience progressive deterioration without intervention 4

Surgical Approach Selection for OPLL

Anterior approach (corpectomy and fusion):

• Indicated when OPLL occupies >50-60% of the canal diameter 5, 6
• Provides direct decompression and superior outcomes for focal, segmental OPLL 7, 5, 6
• Associated with increased technical difficulty and higher complication rates, particularly risk of dural tear and CSF leak 5, 6
• Superior results have been reported with anterior versus posterior surgery in OPLL patients (41 anterior vs 10 posterior patients in one series) 7

Posterior approach (laminectomy/fusion or laminoplasty):

• Technically easier and allows decompression of the entire cervical spine 5, 6
• Preferred for multilevel OPLL, continuous-type OPLL, or when cervical lordosis is preserved 8, 5, 6
• Patients may experience late deterioration (29-37% rate) due to disease progression 4, 5
• Associated with axial neck pain and potentially less improvement in myelopathy scores compared to anterior approaches 6

Combined approach:

• Reserved for severe, extensive OPLL with both anterior and posterior compression 6

Instrumentation Considerations

• For multilevel cervical disease requiring fusion, anterior cervical plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% 3, 4
• Instrumentation provides greater stability and maintains cervical lordosis, particularly important for multilevel constructs 3, 4

Critical Pitfalls to Avoid

• Do not rely on MRI alone to diagnose or characterize OPLL - CT is mandatory for accurate assessment of ossification extent and canal compromise 1
• Avoid premature surgical intervention without adequate conservative trial (minimum 6 weeks) unless progressive myelopathy is present 4
• Do not assume imaging findings correlate with symptoms - clinical correlation is essential, as degenerative changes are common in asymptomatic individuals over 30 1
• Monitor for development of myelopathy vigilantly, as OPLL is progressive and 55-70% of untreated myelopathy patients deteriorate 4, 2
• Continuous intraoperative somatosensory evoked potential (SSEP) monitoring appears to limit operative morbidity in OPLL surgery 7