Surgical management of ossified posterior longitudinal ligament: a review

Ossification of the posterior longitudinal ligament (OPLL) is a progressive disorder characterized by abnormal ectopic bone formation along the posterior longitudinal ligament, often leading to spinal canal stenosis and cervical myelopathy. OPLL is increasingly recognized worldwide due to advancements in imaging technology. Surgical management remains the mainstay of treatment for symptomatic patients, but the optimal approach continues to be debated. This review aims to provide a practical workflow based on the current evidence on the pathophysiology, classification, diagnostic imaging, and the surgical management of OPLL, while highlighting the advantages, limitations, and outcomes of anterior, posterior, and combined approaches. Evidence indicates that surgical management significantly improves neurological function in symptomatic patients. Anterior approaches provide direct decompression and correction of cervical alignment but are associated with higher complication rates such as CSF leaks and dysphagia. Posterior approaches allow for indirect decompression and wider canal expansion, though they may predispose to kyphosis and OPLL progression. Laminoplasty offers motion preservation but carries a risk of disease progression. Patient selection guided by factors such as canal occupancy ratio, cervical alignment, and K-line status is critical in optimizing outcomes. However, surgical decision-making in OPLL must be individualized, balancing disease severity, anatomical considerations, and long-term risks. Further prospective studies are warranted to refine surgical guidelines and improve long-term outcomes, especially when new technologies such as robotics or augmented reality are used.