Treatment of cervical ossification of the posterior longitudinal ligament using ultrasonic bone scalpel-assisted anterior controllable antedisplacement and fusion_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

FU Hongwei , YUAN Nenghua , CHEN Siying , WANG Ansu ,  CHEN Lin

Department of Orthopedics, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou, 563000, P. R. China;

Corresponding author：

CHEN Lin, Email: chenlinwhy@163.com

Keywords：

Ossification of the cervical posterior longitudinal ligament; ultrasonic bone scalpel; anterior controllable antedisplacement and fusion; vertebral slotting

DOI：

10.7507/1002-1892.202503004

Video：

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Objective To investigate the technical key points and effectiveness of ultrasonic bone scalpel-assisted anterior controllable antedisplacement and fusion (ACAF) for treating cervical ossification of the posterior longitudinal ligament (OPLL). Methods Between June 2022 and December 2024, 11 OPLL patients underwent ultrasonic bone scalpel-assisted ACAF. The cohort included 8 males and 3 females, aged 49-74 years (mean, 56.7 years). The OPLL classification included 5 cases of mixed-type, 4 cases of segmental-type, and 2 cases of continuous-type cases. Ossification involved 2-5 spinal segments (mean, 3.2). Disease duration ranged from 2 to 18 months (mean, 6.2 months). Operation time, intraoperative blood loss, and complications were recorded. Pain improvement was assessed using the visual analogue scale (VAS) score, and neurological function was evaluated using Japanese Orthopaedic Association (JOA) score. Postoperative cervical CT and MRI were performed to measure spinal canal encroachment rate, spinal canal area, and spinal cord sagittal diameter. Results All operations were successfully completed. The operation time ranged from 174 to 360 minutes (mean, 255.9 minutes). The intraoperative blood loss ranged from 170 to 530 mL (mean, 345.9 mL). The C₅ nerve root palsy occurred in 1 patient. No cerebrospinal fluid leakage, aggravated spinal cord injury, or recurrent/superior laryngeal nerve injuries occurred. All patients were followed 3-12 months (mean, 7.2 months). At last follow-up, VAS scores significantly decreased and JOA scores significantly increased compared to preoperative values (P<0.05). According to the JOA improvement rate, the effectiveness was rated as excellent in 2 cases, good in 8, and fair in 1, with an excellent and good rate of 90.9%. Radiological re-examination revealed no implant loosening, screw breakage, or aggravated spinal stenosis. Postoperative spinal canal encroachment rate significantly decreased, while spinal canal area and spinal cord sagittal diameter significantly increased compared to preoperative measurements (P<0.05). Conclusion For the treatment of cervical OPLL via ACAF , the intraoperative application of ultrasonic bone scalpel-assisted osteotomy enables precise vertebral groove creation and mobilization of the vertebra-ossification complex, thereby enhancing surgical safety and achieving satisfactory short-term effectiveness.

1.	Abiola R, Rubery P, Mesfin A. Ossification of the posterior longitudinal ligament: etiology, diagnosis, and outcomes of nonoperative and operative management. Global Spine J, 2016, 6(2): 195-204.
2.	Chen T, Wang Y, Jiang W, et al. Comparison of anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion in the treatment of localized ossification of the posterior longitudinal ligament. J Orthop Surg (Hong Kong), 2023, 31(1): 10225536231167704. doi: 10.1177/10225536231167704.
3.	Head J, Rymarczuk G, Stricsek G, et al. Ossification of the posterior longitudinal ligament: surgical approaches and associated complications. Neurospine, 2019, 16(3): 517-529.
4.	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.
5.	Zhang Q, Guo R, Fang S, et al. The clinical efficacy of laminectomy fusion fixation and posterior single open-door laminoplasty in the treatment of multilevel cervical ossification of the posterior longitudinal ligament (OPLL): a retrospective study. BMC Surg, 2023, 23(1): 380. doi: 10.1186/s12893-023-02289-9.
6.	Fujiyoshi T, Yamazaki M, Kawabe J, et al. A new concept for making decisions regarding the surgical approach for cervical ossification of the posterior longitudinal ligament: the K-line. Spine (Phila Pa 1976), 2008, 33(26): E990-E993.
7.	Koda M, Mochizuki M, Konishi H, et al. Comparison of clinical outcomes between laminoplasty, posterior decompression with instrumented fusion, and anterior decompression with fusion for K-line (–) cervical ossification of the posterior longitudinal ligament. Eur Spine J, 2016, 25(7): 2294-2301.
8.	Sun J, Shi J, Jia L, et al. Anterior controllable antidisplacement and fusion surgery for the treatment of multilevel severe ossification of the posterior longitudinal ligament with myelopathy: preliminary clinical results of a novel technique. Eur Spine J, 2018, 27(6): 1469-1478.
9.	Kong QJ, Luo X, Tan Y, et al. Anterior controllable antedisplacement and fusion (ACAF) vs posterior laminoplasty for multilevel severe cervical ossification of the posterior longitudinal ligament: retrospective study based on a two-year follow-up. Orthop Surg, 2021, 13(2): 474-483.
10.	Yang H, Sun J, Shi J, et al. Anterior controllable antedisplacement fusion (ACAF) for severe cervical ossification of the posterior longitudinal ligament: comparison with anterior cervical corpectomy with fusion (ACCF). World Neurosurg, 2018, 115: e428-e436.
11.	Zhang B, Sun J, Xu X, et al. Skip corpectomy and fusion (SCF) versus anterior controllable antedisplacement and fusion (ACAF): which is better for patients with multilevel cervical OPLL? Arch Orthop Trauma Surg, 2019, 139(11): 1533-1541.
12.	Shriver MF, Lewis DJ, Kshettry VR, et al. Dysphagia rates after anterior cervical diskectomy and fusion: a systematic review and meta-analysis. Global Spine J, 2017, 7(1): 95-103.
13.	Tong YJ, Xie YM, Chen B, et al. Delayed hemorrhage followed by vertebral artery injury during cervical anterior controllable antedisplacement and fusion surgery: case report and literature review. Orthop Surg, 2022, 14(10): 2788-2795.
14.	Yang H, Sun J, Shi J, et al. Anterior controllable antedisplacement fusion as a choice for 28 patients of cervical ossification of the posterior longitudinal ligament with dura ossification: the risk of cerebrospinal fluid leakage compared with anterior cervical corpectomy and fusion. Eur Spine J, 2019, 28(2): 370-379.
15.	Yan C, Zhao TY, Ji CL, et al. Anterior controllable antedisplacement and fusion: quantitative analysis of a single surgeon’s learning experience. Spine J, 2022, 22(6): 941-950.
16.	李华强, 高书涛, 栾昊鹏, 等. 超声骨刀与高速磨钻应用于颈椎后路单开门椎管扩大成形术的有效性及安全性的Meta分析. 中国脊柱脊髓杂志, 2021, 31(9): 783-793.
17.	Özgen U, Başak AT, Hekimoğlu M, et al. Safety and efficacy of ultrasonic bone scalpel compared with a high-speed drill in spinal surgery: our experience in sixty cases. Int Orthop, 2025, 49(5): 1199-1210.
18.	李玉伟, 严晓云, 潘传红, 等. 超声骨刀系统行椎板切除、后纵韧带骨化块切断联合去后凸矫形治疗多节段胸椎后纵韧带骨化症. 中国修复重建外科杂志, 2024, 38(9): 1086-1091.
19.	Suzuki K, Wanibuchi M, Minamida Y, et al. Heat generation by ultrasonic bone curette comparing with high-speed drill. Acta Neurochir (Wien), 2018, 160(4): 721-725.
20.	Lee DH, Cho JH, Lee CS, et al. A novel anterior decompression technique (vertebral body sliding osteotomy) for ossification of posterior longitudinal ligament of the cervical spine. Spine J, 2018, 18(6): 1099-1105.
21.	Kong QJ, Sun XF, Fu ZY, et al. Anatomical evaluation of spinal nerve and cervical intervertebral foramina in anterior controllable antedisplacement and fusion surgery: a cadaveric and radiologic study. Orthop Surg, 2022, 14(2): 331-340.
22.	Pang Q, Ling S, Zhang B, et al. Cervical Anatomical landmarks indicate the amount of vertebra resection during acaf surgery: a semi-quantitative anatomical parameter study on imaging data. Orthop Surg, 2022, 14(10): 2641-2647.
23.	Yan C, Jia HC, Tan HY, et al. How much space of the spinal canal should be restored by hoisting the vertebrae-OPLL complex for sufficient decompression in anterior controllable antedisplacement and fusion? A multicenter clinical radiological study. Spine J, 2021, 21(2): 273-283.
24.	孙璟川, 史建刚. 颈椎前路椎体骨化物化复合体可控前移融合术的关键技术和并发症预防. 中国脊柱脊髓杂志, 2020, 30(3): 282-288.
25.	Ito K, Ishizaka S, Sasaki T, et al. Safe and minimally invasive laminoplastic laminotomy using an ultrasonic bone curette for spinal surgery: technical note. Surg Neurol, 2009, 72(5): 470-475.
26.	Neo M, Fujibayashi S, Miyata M, et al. Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations. Spine (Phila Pa 1976), 2008, 33(7): 779-785.
27.	江剑峰, 马俊, 杨茂宇, 等. 以钩椎关节“拐点”作为颈椎前路减压手术定位标志的影像解剖学研究. 中国修复重建外科杂志, 2025, 39(3): 332-340.
28.	Sun JC, Zhang B, Shi J, et al. Can K-Line predict the clinical outcome of anterior controllable antedisplacement and fusion surgery for cervical myelopathy caused by multisegmental ossification of the posterior longitudinal ligament? World Neurosurg, 2018, 116: e118-e127.
29.	史建刚. 正确认识及规范椎体-后纵韧带骨化物复合体可控前移技术. 中国脊柱脊髓杂志, 2022, 32(5): 385-386.

1. Abiola R, Rubery P, Mesfin A. Ossification of the posterior longitudinal ligament: etiology, diagnosis, and outcomes of nonoperative and operative management. Global Spine J, 2016, 6(2): 195-204.
2. Chen T, Wang Y, Jiang W, et al. Comparison of anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion in the treatment of localized ossification of the posterior longitudinal ligament. J Orthop Surg (Hong Kong), 2023, 31(1): 10225536231167704. doi: 10.1177/10225536231167704.
3. Head J, Rymarczuk G, Stricsek G, et al. Ossification of the posterior longitudinal ligament: surgical approaches and associated complications. Neurospine, 2019, 16(3): 517-529.
4. 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.
5. Zhang Q, Guo R, Fang S, et al. The clinical efficacy of laminectomy fusion fixation and posterior single open-door laminoplasty in the treatment of multilevel cervical ossification of the posterior longitudinal ligament (OPLL): a retrospective study. BMC Surg, 2023, 23(1): 380. doi: 10.1186/s12893-023-02289-9.
6. Fujiyoshi T, Yamazaki M, Kawabe J, et al. A new concept for making decisions regarding the surgical approach for cervical ossification of the posterior longitudinal ligament: the K-line. Spine (Phila Pa 1976), 2008, 33(26): E990-E993.
7. Koda M, Mochizuki M, Konishi H, et al. Comparison of clinical outcomes between laminoplasty, posterior decompression with instrumented fusion, and anterior decompression with fusion for K-line (–) cervical ossification of the posterior longitudinal ligament. Eur Spine J, 2016, 25(7): 2294-2301.
8. Sun J, Shi J, Jia L, et al. Anterior controllable antidisplacement and fusion surgery for the treatment of multilevel severe ossification of the posterior longitudinal ligament with myelopathy: preliminary clinical results of a novel technique. Eur Spine J, 2018, 27(6): 1469-1478.
9. Kong QJ, Luo X, Tan Y, et al. Anterior controllable antedisplacement and fusion (ACAF) vs posterior laminoplasty for multilevel severe cervical ossification of the posterior longitudinal ligament: retrospective study based on a two-year follow-up. Orthop Surg, 2021, 13(2): 474-483.
10. Yang H, Sun J, Shi J, et al. Anterior controllable antedisplacement fusion (ACAF) for severe cervical ossification of the posterior longitudinal ligament: comparison with anterior cervical corpectomy with fusion (ACCF). World Neurosurg, 2018, 115: e428-e436.
11. Zhang B, Sun J, Xu X, et al. Skip corpectomy and fusion (SCF) versus anterior controllable antedisplacement and fusion (ACAF): which is better for patients with multilevel cervical OPLL? Arch Orthop Trauma Surg, 2019, 139(11): 1533-1541.
12. Shriver MF, Lewis DJ, Kshettry VR, et al. Dysphagia rates after anterior cervical diskectomy and fusion: a systematic review and meta-analysis. Global Spine J, 2017, 7(1): 95-103.
13. Tong YJ, Xie YM, Chen B, et al. Delayed hemorrhage followed by vertebral artery injury during cervical anterior controllable antedisplacement and fusion surgery: case report and literature review. Orthop Surg, 2022, 14(10): 2788-2795.
14. Yang H, Sun J, Shi J, et al. Anterior controllable antedisplacement fusion as a choice for 28 patients of cervical ossification of the posterior longitudinal ligament with dura ossification: the risk of cerebrospinal fluid leakage compared with anterior cervical corpectomy and fusion. Eur Spine J, 2019, 28(2): 370-379.
15. Yan C, Zhao TY, Ji CL, et al. Anterior controllable antedisplacement and fusion: quantitative analysis of a single surgeon’s learning experience. Spine J, 2022, 22(6): 941-950.
16. 李华强, 高书涛, 栾昊鹏, 等. 超声骨刀与高速磨钻应用于颈椎后路单开门椎管扩大成形术的有效性及安全性的Meta分析. 中国脊柱脊髓杂志, 2021, 31(9): 783-793.
17. Özgen U, Başak AT, Hekimoğlu M, et al. Safety and efficacy of ultrasonic bone scalpel compared with a high-speed drill in spinal surgery: our experience in sixty cases. Int Orthop, 2025, 49(5): 1199-1210.
18. 李玉伟, 严晓云, 潘传红, 等. 超声骨刀系统行椎板切除、后纵韧带骨化块切断联合去后凸矫形治疗多节段胸椎后纵韧带骨化症. 中国修复重建外科杂志, 2024, 38(9): 1086-1091.
19. Suzuki K, Wanibuchi M, Minamida Y, et al. Heat generation by ultrasonic bone curette comparing with high-speed drill. Acta Neurochir (Wien), 2018, 160(4): 721-725.
20. Lee DH, Cho JH, Lee CS, et al. A novel anterior decompression technique (vertebral body sliding osteotomy) for ossification of posterior longitudinal ligament of the cervical spine. Spine J, 2018, 18(6): 1099-1105.
21. Kong QJ, Sun XF, Fu ZY, et al. Anatomical evaluation of spinal nerve and cervical intervertebral foramina in anterior controllable antedisplacement and fusion surgery: a cadaveric and radiologic study. Orthop Surg, 2022, 14(2): 331-340.
22. Pang Q, Ling S, Zhang B, et al. Cervical Anatomical landmarks indicate the amount of vertebra resection during acaf surgery: a semi-quantitative anatomical parameter study on imaging data. Orthop Surg, 2022, 14(10): 2641-2647.
23. Yan C, Jia HC, Tan HY, et al. How much space of the spinal canal should be restored by hoisting the vertebrae-OPLL complex for sufficient decompression in anterior controllable antedisplacement and fusion? A multicenter clinical radiological study. Spine J, 2021, 21(2): 273-283.
24. 孙璟川, 史建刚. 颈椎前路椎体骨化物化复合体可控前移融合术的关键技术和并发症预防. 中国脊柱脊髓杂志, 2020, 30(3): 282-288.
25. Ito K, Ishizaka S, Sasaki T, et al. Safe and minimally invasive laminoplastic laminotomy using an ultrasonic bone curette for spinal surgery: technical note. Surg Neurol, 2009, 72(5): 470-475.
26. Neo M, Fujibayashi S, Miyata M, et al. Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations. Spine (Phila Pa 1976), 2008, 33(7): 779-785.
27. 江剑峰, 马俊, 杨茂宇, 等. 以钩椎关节“拐点”作为颈椎前路减压手术定位标志的影像解剖学研究. 中国修复重建外科杂志, 2025, 39(3): 332-340.
28. Sun JC, Zhang B, Shi J, et al. Can K-Line predict the clinical outcome of anterior controllable antedisplacement and fusion surgery for cervical myelopathy caused by multisegmental ossification of the posterior longitudinal ligament? World Neurosurg, 2018, 116: e118-e127.
29. 史建刚. 正确认识及规范椎体-后纵韧带骨化物复合体可控前移技术. 中国脊柱脊髓杂志, 2022, 32(5): 385-386.

Chinese Journal of Reparative and Reconstructive Surgery

Latest ArticlesTreatment of cervical ossification of the posterior longitudinal ligament using ultrasonic bone scalpel-assisted anterior controllable antedisplacement and fusion

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