Surgical Considerations for Ossification of Posterior Longitudinal Ligament (OPLL)

At Complete Orthopedics, our surgeons specialize in the treatment of complex spine conditions such as ossification of the posterior longitudinal ligament, or OPLL. We carefully plan every step of surgery to maximize benefits, minimize risks, and ensure safe recovery. Each patient receives a customized approach based on their anatomy, imaging results, and overall health.

Our offices are located throughout New York City and Long Island, with privileges at six leading hospitals that provide the latest surgical technology and advanced spinal monitoring systems.

How Common It Is and Who Gets It? (Epidemiology)

OPLL is most often seen in middle-aged and older adults, particularly in individuals of Asian descent, though it occurs worldwide. The condition tends to develop gradually and may not cause symptoms until the ossified (hardened) ligament begins pressing on the spinal cord. Men are affected slightly more often than women.

Why It Happens – Causes (Etiology and Pathophysiology)

OPLL occurs when a ligament that runs along the back of the spine’s vertebral bodies—called the posterior longitudinal ligament—gradually turns into bone. This thickened, hardened tissue can narrow the spinal canal and compress the spinal cord or nerves.

The exact cause is unknown, but aging, genetics, diabetes, and minor repetitive injuries to the spine may contribute. In some people, the spinal canal is naturally narrow (a condition known as congenital stenosis), making them more likely to develop symptoms if ossification occurs.

How the Body Part Normally Works? (Relevant Anatomy)

The posterior longitudinal ligament runs along the back surface of the vertebral bodies inside the spinal canal. Its job is to stabilize the spine and limit excessive movement. When the ligament thickens and hardens, it takes up space in the canal, squeezing the spinal cord. This pressure can interrupt signals between the brain and body, leading to numbness, weakness, or coordination problems.

What You Might Feel – Symptoms (Clinical Presentation)

Symptoms depend on how much the spinal cord is compressed. Common signs include:

• Neck stiffness or aching
• Numbness or tingling in the hands, arms, or legs
• Weakness or clumsiness of the hands
• Unsteady gait or loss of balance
• Electrical shock-like sensations when bending the neck
• In more severe cases, difficulty controlling bladder or bowel function

How Doctors Find the Problem? (Diagnosis and Imaging)

Diagnosis begins with a physical exam to assess strength, sensation, and coordination.

Imaging is crucial to confirm the diagnosis and plan treatment:

• MRI scans show pressure on the spinal cord and detect inflammation or swelling.
• CT scans clearly show the hardened ligament and help classify the type of OPLL.

OPLL is typically divided into four types: segmental, continuous, mixed, and localized (other). Understanding which type a patient has helps surgeons choose the safest approach.

Classification

OPLL is classified based on the shape and distribution of the ossification:

• Segmental: Small, separate areas of bone formation behind individual vertebrae.
• Continuous: A long stretch of bone extending across multiple vertebrae.
• Mixed: Features of both continuous and segmental patterns.
• Localized/Other: Limited to a small area or atypical pattern.

Other Problems That Can Feel Similar (Differential Diagnosis)

Conditions that can mimic OPLL include:

• Cervical spondylotic myelopathy (spinal cord compression from arthritis)
• Herniated cervical discs
• Spinal tumors or infections
• Inflammatory disorders such as ankylosing spondylitis

MRI and CT imaging help rule out these other causes.

Treatment Options

Non-Surgical Care

If symptoms are mild, OPLL may be managed conservatively with:

• Physical therapy and posture correction
• Medications to relieve pain and stiffness
• Regular monitoring with MRI to detect progression

However, once neurological symptoms such as weakness, numbness, or walking imbalance appear, surgery is usually required to prevent worsening.

Surgical Care

Surgery aims to relieve pressure on the spinal cord and stabilize the spine. The approach depends on spinal alignment, location of the ossified ligament, and number of levels involved.

Posterior (Back) Surgery
If the spine retains a normal forward curve (lordosis), decompression through the back—such as laminoplasty or laminectomy and fusion—is preferred. These methods relieve pressure without the risks associated with operating from the front of the neck.

Anterior (Front) Surgery
If the spine has lost its normal curve or is bent forward (kyphosis), surgery from the front may be needed. Procedures such as corpectomy (removal of part of the vertebral body) allow direct removal of the ossified ligament.

Each approach has unique advantages and risks, and the final decision is made based on detailed imaging and patient factors.

Recovery and What to Expect After Treatment

After OPLL surgery, patients typically stay in the hospital for several days. Early movement and physical therapy are encouraged to maintain flexibility and prevent stiffness.

Rehabilitation focuses on:

• Restoring strength and coordination
• Practicing proper neck alignment and movement
• Preventing recurrence through gentle exercise and posture training

Patients are advised to avoid heavy lifting or activities that strain the neck during recovery.

Possible Risks or Side Effects (Complications)

As with any spine surgery, complications can occur but are minimized through careful planning. Potential risks include:

• Infection or bleeding
• Nerve injury or spinal fluid leak
• Difficulty swallowing (after anterior surgery)
• Wound healing issues (especially after prior radiation)
• Hardware failure or need for revision surgery

Elderly patients and those with extensive ossification may have slightly higher complication risks.

Long-Term Outlook (Prognosis)

Surgery for OPLL generally leads to significant improvement in pain, strength, and balance. The degree of recovery depends on how much spinal cord damage occurred before surgery. Most patients report improved quality of life and reduced risk of sudden paralysis after successful decompression and stabilization.

Out-of-Pocket Cost

Medicare

CPT Code 63050 – Posterior Cervical Laminoplasty: $362.34

For patients under Medicare, the program covers approximately 80% of the approved amount for this type of cervical spine surgery once the annual deductible has been met. The remaining 20% is typically the patient’s responsibility. However, supplemental insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover this 20% coinsurance, meaning patients often have no additional expenses for Medicare-approved procedures. These plans are structured to work in conjunction with Medicare, ensuring comprehensive coverage for necessary surgical care.

Secondary insurance—such as Employer-Based Plans, TRICARE, or Veterans Health Administration (VHA)—acts as a secondary payer after Medicare. Once your deductible is satisfied, these plans may cover any remaining costs, including co-insurance or uncovered charges. Most secondary insurance plans carry a modest deductible ranging from $100 to $300, depending on the specific policy and whether the procedure is performed at an in-network facility.

Workers’ Compensation
If your OPLL (Ossification of the Posterior Longitudinal Ligament) with cervical lordosis is related to a work injury, Workers’ Compensation will pay for all treatment-related expenses. This includes the laminoplasty, hospital stay, and rehabilitation, with no out-of-pocket cost to the patient.

No-Fault Insurance
If your spinal condition was aggravated or caused by a motor vehicle accident, No-Fault Insurance will fully cover all medical and surgical costs associated with your OPLL treatment, including posterior laminoplasty. The only potential charge would be a small deductible, depending on your individual insurance policy terms.

Example
Robert, a 61-year-old patient with cervical OPLL and progressive lordosis, underwent a posterior laminoplasty (CPT 63050). His estimated Medicare out-of-pocket cost was $362.34. Since Robert carried supplemental insurance through Blue Cross Blue Shield, the remaining 20% portion not paid by Medicare was fully covered, leaving him with no out-of-pocket expense for the surgery.

Frequently Asked Questions (FAQ)

Q. Is surgery always necessary for OPLL?
A. No. If symptoms are mild and stable, your doctor may recommend monitoring and physical therapy. Surgery is advised if nerve compression worsens.

Q. Which surgery is safer—anterior or posterior?
A. Each approach has its place. Posterior surgery avoids major front-of-neck structures, while anterior surgery allows direct removal of the ossified ligament in certain cases. Your surgeon will determine which is best for your spine alignment and anatomy.

Q. How long does recovery take?
A. Most patients return to light activities within a few weeks and continue improving for several months with therapy.

Q. Can OPLL return after surgery?
A. It’s uncommon, but ossification may slowly progress over time. Regular follow-up imaging helps monitor any changes.

Summary and Takeaway

Ossification of the posterior longitudinal ligament (OPLL) is a condition where a spinal ligament hardens and presses on the spinal cord. When symptoms progress, surgery is the most effective way to relieve pressure and protect nerve function. With careful surgical planning and rehabilitation, most patients experience meaningful pain relief, improved mobility, and long-term stability.

Clinical Insight & Recent Findings

A recent study developed a predictive model to identify patients at higher risk of postoperative ossification progression following cervical surgery for ossification of the posterior longitudinal ligament (OPLL). The study analyzed 271 patients and found that younger age, greater initial ossification thickness, involvement of more than three spinal levels, and continuous or mixed OPLL types were independent risk factors for disease progression after posterior surgery.

Using these factors, researchers created a nomogram—a clinical tool that allows surgeons to estimate the likelihood of postoperative ossification growth and tailor follow-up or rehabilitation accordingly. The model demonstrated strong accuracy, with a C-index above 0.9 in both training and validation sets, and its decision curve analysis confirmed significant clinical value.

These findings emphasize the importance of careful preoperative planning, patient selection, and long-term monitoring to prevent progression and improve surgical outcomes in OPLL. (Study of postoperative ossification progression risk modeling in OPLL – See PubMed.)

Who Performs This Treatment? (Specialists and Team Involved)

Treatment is performed by orthopedic spine surgeons or neurosurgeons experienced in complex cervical procedures. The team also includes anesthesiologists, neurophysiologists, and rehabilitation specialists to ensure safe surgery and full recovery.

When to See a Specialist?

You should see a spine specialist if you experience:

• Progressive neck stiffness or pain
• Numbness or weakness in the arms or legs
• Trouble with coordination or balance
• Difficulty controlling bladder or bowel function

When to Go to the Emergency Room?

Go to the ER if you experience:

• Sudden paralysis or severe weakness
• Loss of bladder or bowel control
• New or worsening numbness in the hands or feet

These are signs of spinal cord compression that require urgent care.

What Recovery Really Looks Like?

After surgery, most patients notice gradual improvement in strength and coordination. Neck soreness is normal at first but lessens with time. Physical therapy helps restore mobility and ensures proper spinal alignment during healing.

What Happens If You Ignore It?

Untreated OPLL can lead to progressive spinal cord damage, increasing the risk of paralysis even from minor injury. Early diagnosis and timely treatment are essential for preventing irreversible nerve damage.

How to Prevent It?

While OPLL cannot always be prevented, maintaining a healthy lifestyle and protecting spinal health can help:

• Maintain good posture and neck alignment
• Avoid repetitive strain or high-impact sports
• Keep a healthy weight and manage chronic conditions like diabetes
• Schedule regular checkups if you have a family history of OPLL

Nutrition and Bone or Joint Health

A balanced diet with calcium, vitamin D, and protein supports bone health and recovery after surgery. Avoid smoking and excessive alcohol, as they can weaken bone and delay healing.

Activity and Lifestyle Modifications

After recovery, continue gentle exercises such as walking or swimming. Avoid sudden neck movements and heavy lifting. Good ergonomics at work and home—such as proper desk height and supportive seating—help protect your spine long-term.