Archives of Orthopaedic

Arch Orthop Traumat Surg 94, 21-23 (1979) and Traumatic Surgery
© J F Bergmann Verlag 1979

Ankylosing Spinal Hyperostosis (ASH)

and Ossification of the Posterior Longitudinal Ligament (OPLL)

H Mitsui', H Sonozaki 3 , T Juji 2, and K Kabata'

'Department of Orthopedic Surgery, Mitsui Memorial Hospital, 1, Izumicho, Kanda, Chiyoda-ku, Tokyo 101, Japan
2 Department of Blood Transfusion Service, Tokyo University
3
Komagome Metropolitan Hospital

Summary The clinical and radiological features of 70 Ossification of the posterior longitudinal ligament
patients with ankylosing spinal hyperostosis are (OPLL) was described in 1967 by Japanese authors
presented Pain in some region of the back was found (Onji et al , 1967) (Fig 2) There have been no reports
in 49 patients No significant deviations were found in on the association between ASH and OPLL Our
HLA typing. research has shown that in Japanese patients there is a
Radiologically, the most characteristic features definite association between ASH and OPLL.
were bony spurs or bridges in the dorsal spine, where
they predominated on the right and anterior aspects of
the spine, especially in the lower dorsal region Ossifica-
tion of the posterior longitudinal ligament was found
in 21 patients.

Zusammenfassung Wir berichten uiber die klinischen

und rntgenologischen Krankheitsbilder der ankylo-
sierenden Hyperostose der Wirbelsfiule bei 70 Fallen.
Rtickenschmerzen in verschiedenen Bereichen wur-
den bei 49 Fllen beobachtet HLA-Bestimmungen
zeigten keine signifikanten Abweichungen R6 ntgeno-
logisch chrakteristische Befunde waren Osteophyten-
bzw Briickenbildungen der Brustwirbelsaule, die auf
dem rechten und vorderen Teil des Wirbelk 6rpers,
besonders im kaudalen Anteil auffallig zu erkennen
waren Verkn 6 cherung des hinteren Lngsbandes
wurde bei 21 Faillen beobachtet.

Ankylosing spinal hyperostosis (ASH) is a condition

where bone is laid down on the antero-lateral aspect of
the dorsal vertebrae (Fig 1) In 1942, Oppenheim
described ,,Calcification and ossification of the verte-
bral ligaments " Forestier and Rotes-Qu 6rol named it
'senile ankylosing hyperostosis of the spine ' How-
ever, Forestier and Lagier omitted the "senile" because
the condition was also found in younger patients.
Fig 1 Lateral radiograph of the dorsal spine shows multiple
Offprint requests to: H Mitsui, M D (address see above) spurs and bridges anteriorly

0344-8444/79/0094/0021/$ 1 00
22 H Mitsui et al : Ankylosing Spinal Hyperostosis (ASH) and Ossification

Table 1 Prevalence of ASH by age and sex (70 cases)

Age Males Females Male-Female
(No of (No of ratio
patients) patients)
35-39 0 1
40-49 6 0
50-59 12 2
60-69 21 4
70 20 4
All ages 59 11 5 4:1

Table 2 Types of work in 70 patients with ASH, showing that

22 patients (31 4 %) had done heavy manual work

Fig 2 A lateral roentgenogram of the cervical spine shows that 3(

ossification of the posterior longitudinal ligament (OPLL) lies
posterior to the bodies of the third, fourth, fifth, sixth and
seventh cervical vertebrae The calcified posterior longitudinal
ligament causes compression of the extradural cervical cord 2(

Materials and Methods 10

For this study, the criteria for ASH were according to Harris et
al (1974) Seventy consecutive patients with ASH in the ortho-
pedic departments of Tokyo University Hospital and Mitsui
Memorial Hospital underwent extensive clinical, laboratory,
and radiological evaluation.

Table 3 Complications of ASH

Clinical and LaboratoryEvaluation
Complication No of patients %
A complete rheumatologic and neurologic history and physical
examination were obtained for each patient Any trauma to the OPLL 21 30 0
back or a history of diabetes mellitus were also recorded The Spinal canal stenosis of lumbar spine 10 14 3
following examinations were performed: hematocrit, white cell
count, erythrocyte sedimentation rate, serum calcium, phos- DM 12 17 1
phorus, alkaline phosphatase, uric acid, glucose, serological test Hypertension 5 71
for syphilis, rheumatoid factor and CRP The urine was tested Gastric ulcer 3 43
for glucose In 40 of 70 patients HLA typing was done. CDH 1 14
OPLL: Ossification of the posterior longitudinal ligament
Radiological Evaluation
DM : Diabetes mellitus
Antero-posterior and lateral views of the entire spine were CDH: Congenital dislocation of hip
taken, and radiographs of the pelvis including the hip were also
obtained for all patients.
in the low back or back It was characteristically dull,
non-radiating, and associated with stiffness Peripheral
Results
arthralgia was found in seven patients Most of these
complaints were mild gonalgia Twenty had neuro-
Clinical and Laboratory Study
logical disturbance due to OPLL or spinal canal
Seventy patients were studied: Fifty-nine men aged 40 stenosis, which are complications of ASH (Table 3).
to 82 years (mean 66) and eleven women aged 35 to 75 Laboratory abnormalities included mild elevation of
years (mean 64) (Table 1) No patient had any history sedimentation rates in 10 patients, and glucose toler-
of trauma to the spine, but 22 patients had done heavy ance tests suggested diabetes mellitus in 12 others No
manual work (Table 2) Forty-nine patients had pain significant deviations were found in HLA typing.
H Mitsui et al : Ankylosing Spinal Hyperostosis (ASH) and Ossification
Table 4 Levels of the dorsal spine involvement with spurs or
bridges in 70 patients with ASH
RIGHT LEFT
Radiology Study
Radiologically, the most characteristic pattern of bony
spurs or bridges was seen in the dorsal spine, where
they predominated on the right and anterior aspects of
the vertebrae, especially in the lower dorsal region
(Table 4) Ossification of the posterior longitudinal
ligament (OPLL) was found in 21 ( 30 %) of the 70
patients Most of this was found in the cervical spine.
Discussion
There have been no reports on the association in white
people, between ASH and OPLL Our research has
revealed that a definite association exists in Japanese
patients The high frequency of OPLL (30 %) was
unexpected Exactly why this relationship should exist
in Japanese patients and not in white people is of
interest Julkunen (1975) reported that ASH in white
people was found in about 3 % of the normal popula-
23
tion above 40 years This shows that ASH is not rare
in white people However, OPLL is significantly less
common in white people than in Japanese The dis-
crepancy of the incidence of OPLL between white
people and Japanese may be due to racial differences.
However, biochemically, both ASH and OPLL are the
same phenomenon in the terms of ligament ossifica-
tion ASH is much more frequent in the dorsal spine,
while OPLL is more commonly found in the cervical
spine This fact suggests that these ossifications may
be related to a mechanical factor, which may explain
why the incidence of OPLL is significantly higher in
Japanese than in white people The life style of
Japanese differs somewhat from that of white people,
and most Japanese have more opportunity in their
daily lives to extend the neck which may cause a
mechanical stress in the cervical posterior longitudinal
ligament This may provide the stimulus necessary to
generate OPLL.
References
Forestier, J , Lagier, R : Ankylosing hyperostosis of the spine.
Clin Orthop 74, 63 (1970)
Harris, J , Carter, A R , Glick, E N , Storey, G O : Ankylosing
hyperostosis 1 Clinical and radiological features Ann.
Rheum Dis 33, 210 (1974)
Julkunen, H , Heinonen, O P , Knekt, P , Maatela, J : The
epidemiology of the spine together with its symptoms and
related mortality in a general population Scand J Rheum.
4, 23 (1975)
Minagi, H , Gronner, A T : Calcification of the posterior longi-
tudinal ligament: A cause of cervical myelopathy Am J.
Roentgenol 105, 365 (1969)
Onji, Y , Akiyama, H , Shimomura, Y , Ono, K , Fukuda, S ,
Mizuno, S : Posterior paravertebral ossification causing
cervical myelopathy: report of eighteen cases J Bone Jt.
Surg 49-A, 1314 (1967)
Oppenheimer, A : Calcification and ossification of vertebral
ligaments (spondylitis ossificans ligamentosa): Roentgen
study of pathogenesis and clinical significance Radiology
38, 160 (1942)
Received February 5, 1979 / Accepted April 30, 1979