64 yr old male, presented with gradually progressive spastic quadreparesis, with associated imbalance while walking in dark, for past 2 years, urinary urge for past 2 months, O/E asymmetrical weakness R>L power of 4-/5, all DTR brisk, hoffmans positive, Imapired JPS, vibration, dec pain on R side upto c4 dermatome. what should be the approach for this case ?

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I totally agree with Dr Shrivastav 1.Anterior approach:more for young patients.Patients with kyphosis.It has definitive results overall better than posterior.There are few approaches like Central Corpectomy,Oblique corpectomy where in some have iused uninstrumented fibular grafts and have given good results.This surgery requires a lot of expertise.If OPLL cannot be completely removed-a techniques called Floating the OPLL can be done.All said and done-please explain high chances of deterioration post-operatively and refer the patient to higher centre.

You are right in mentioning that even releasing the PLL without excision, "Floating" it , will result in some relief. That is what I meant in calling it as releasing the PLL.
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patient has multilevel segmented OPLL with cervical myelopathy.Any co-morbidities-go for simple posterior laminectomy.A complete detailed anterior corpectomy with fixation might lead to neurological deterioration

This patient has high cervical OPLL-long segment disease with loss of lordosis.If no comorbidities-anterior approach.If co-morbidities-then posterior decompression.Outcome highly guarded.

Dear Dr Sonal, you have put it very crisply and succinctly .
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Problem is at C5/6/7 level Bony canal stenosis Marked retropulsion at C6 level Symptoms correlate with significant cord compression with long tract signs and urinary symptoms Bladder becoming automatic Need early surgery Anterior corpectomy and fusion I have seen similar cases operated Neurological recovery is guarded prognosis But can expect significant improvement with surgery and progression can be arrested

Severe OPLL with compression extending right up to C1 and possibly a little beyond. Ideally needs anterior corpectmies and reconstruction along with excision of thick posterior longitudinal ligament. Risky ,yes. Posterior decompression ie.. Laminectomy entails a very high risk of failure and an unreasonably high risk of quadriplegia. But then one has to bite the bullet!

more than 3 segments invloved but reversal of lordosis, what to do ?
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As I see it, there are two definite areas - C2-3and the C5-6-7+ ? D1. Median corpectmies, Dural detachment or excision will most likely be achieved. The fixation depends on the surgeons choice and experience with a particular type of implant.

there is OPLL in cervical segment that is causing compression of the nerve roots. send for physiotherapy with neck collar with pregabalin. and opt for surgical measures to do laminectomy

There are different grades of OPLL with complete ossification of the posterior longitudinal ligament to patchy ossification . Even if the ligament can be detached and excised in part , it can provide relief. I have noted the response of my colleagues who all find laminectomy/ laminotomy/ laminoplasty with all the details / technical nuances of fixation the right option. Be that as it may, am sure that they are all very aware of the high incidence of worsening with posterior approaches for anterior disease. The anterior approach is technically demanding and needs careful assessment and execution. Having done the posterior approach and burned my fingers early on, I just think that this is a very difficult decision.

what all levels of corpectomy would be advisable in this case ?
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posterior osteophyte complex c56 with chord compression needs spinal decompression and stabilization procedure

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