Banner cloud sign: a novel method for the diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum

Chen, Guanghui; Chen, Zhong‐Qiang; Li, Weishi; Yu, Junsheng; Guo, Xiaotong; Zhang, Baoliang; Tao, Liyuan; Song, Chen; Sun, Chuiguo

doi:10.1007/s00586-022-07267-y

Cited by 8 publications

(11 citation statements)

References 19 publications

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“…DO represents a difficult condition in the surgical management of OLF ( 14 , 15 ). Its incidence in OLF patients varies from 11% to 62% and it is the major cause of dura tear and CSF leakage ( 6 , 16 ). Previous studies ( 5 , 6 , 11 ) reported that DO causes about 78.8–85.7% of CSF leakage in OLF patients.…”

Section: Discussionmentioning

confidence: 99%

“…Dural ossification (DO), characterized by ossified dura mater fused with ossified ligamentum flavum, is the main cause of CSF leakage ( 4 ). It is reported that 78.8–85.7% of patients with postoperative CSF leakage have DO ( 5 , 6 ). In addition, some other complications, such as pseudocyst, nervous system infection, and wound dehiscence secondary to CSF leakage, can also lead to catastrophic events if not managed properly ( 7 ).…”

Section: Introductionmentioning

confidence: 99%

“…To improve the preoperative diagnostic accuracy of DO, we have previously introduced a new imaging sign, namely, Banner cloud sign (BCs) ( 6 ), and published a protocol to investigate its diagnostic value ( 12 ). Its clinical characteristics and correlation with DO have also been preliminary studied ( 6 ). However, its diagnostic value has not yet been fully investigated.…”

Section: Introductionmentioning

confidence: 99%

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Imaging signs for preoperative diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum: a blind, randomized diagnostic accuracy study

Chen,

Tao,

Chen

et al. 2024

Quant Imaging Med Surg

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Background Dural ossification (DO) is the leading cause of surgery-related dural tear in patients with ossification of the ligamentum flavum (OLF). An accurate preoperative diagnosis of DO is conducive to the selection of appropriate surgical methods. Although several imaging signs, such as Banner cloud sign (BCs), tram-track sign (TTs), and comma sign (Cs) have been proposed for the preoperative diagnosis of DO, their diagnostic value has not been well studied. The aim of this study was to explore the diagnostic value of BCs, TTs, and Cs, and provide evidence-based data for their clinical application. Methods This is a blind, randomized diagnostic study using retrospectively collected data from 102 consecutive patients who were diagnosed with OLF and underwent decompression surgery between January 2018 and June 2019. A total of 8 surgeons with different qualifications were recruited to read these imaging signs to identify the presence of DO. Surgical records were used as the reference standard. Sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve (AUC) were used to evaluate the diagnostic accuracy of each imaging sign and their different combinations. Results Of the 102 patients, 21 were diagnosed with DO. BCs had a significantly higher diagnostic accuracy than TTs and Cs, with the AUC of 0.704, 0.607, and 0.593, respectively. The specificity of BCs, Cs, TTs, and their combination in diagnosing DO was 91.5%, 92.1%, 68.3%, and 62.2%, respectively. In the combined diagnostic test, the results showed that the combined diagnosis accuracy of BCs and Cs was the highest, and the AUC was 0.738. The combination of BCs, Cs, and TTs increased the sensitivity of diagnosing DO (77.5%), but did not improve the diagnostic accuracy, and the AUC was 0.699. Conclusions BCs had higher diagnostic accuracy than TTs and Cs. BCs and Cs were highly specific for DO, whereas TTs could be confusing due to their non-specific presentations. The combination of BCs, TTs, and Cs improved the sensitivity of DO diagnosis, but not the specificity and accuracy.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Imaging signs for preoperative diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum: a blind, randomized diagnostic accuracy study

Chen,

Tao,

Chen

et al. 2024

Quant Imaging Med Surg

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“…The following three tips may help inexperienced surgeons shorten the learning curve for en bloc laminectomy and avoid serious complications. First, preoperative radiographic data should be carefully evaluated to discover the related manifestations of dural ossification, including tram track, comma, and banner signs, to prepare for intraoperative dural repair in advance 16,32,33 . Second, pedicle screws, which can be used as anatomical markers to avoid accidental injury to the spinal cord, should be inserted before laminectomy.…”

Section: Discussionmentioning

confidence: 99%

Learning Curve and Clinical Outcomes of Ultrasonic Osteotome‐based En Bloc Laminectomy for Thoracic Ossification of the Ligamentum Flavum

Dong

et al. 2023

Orthopaedic Surgery

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ObjectiveDespite rapid advances in minimally invasive surgery, en bloc laminectomy remains the most common surgical approach for treating thoracic ossification of the ligamentum flavum (TOLF). However, the learning curve of this risky operation is rarely reported. Therefore, we aimed to describe and analyze the learning curve of ultrasonic osteotome‐based en bloc laminectomy for TOLF.MethodsAmong 151 consecutive patients with TOLF who underwent en bloc laminectomy performed by one surgeon between January 2012 and December 2017, we retrospectively analyzed their demographic data, surgical parameters, and neurological function. Neurological outcome was evaluated with the modified Japanese Orthopaedic Association (mJOA) scale, and the Hirabayashi method was used to calculate the neurological recovery rate. The learning curve was assessed with logarithmic curve‐fitting regression analysis. Univariate analysis methods were used for statistical analysis, including t‐test, rank sum test, and chi‐square test.ResultsA total of 50% of learning milestones could be reached in approximately 14 cases, and the asymptote in 76 cases. Therefore, 76 of the 151 enrolled patients were defined as the “early group,” and the remaining 75 were delimitated as the “late group” for comparison. There was a significant intergroup difference in the corrected operative time (94.80 ± 27.77 vs 65.93 ± 15.67 min, P < 0.001) and the estimated blood loss (median 240 vs 400 mL, P < 0.001). The overall follow‐up was 83.1 ± 18.5 months. The mJOA significantly increased from a median of 5 (IQR: 4–5) before the surgery to 10 (IQR: 9–10) at the last follow‐up (P < 0.001). The overall complication rate was 37.1%, and no significant intergroup difference was found, except for the incidence of dural tears (31.6% vs 17.3%, p = 0.042).ConclusionInitially, mastering the en bloc laminectomy technique using ultrasonic osteotome for TOLF treatment can be challenging, but the surgeon's experience improves as the operative time and blood loss decrease. Improved surgical experience reduced the risk of dural tears but was not associated with the overall complication rate or long‐term neurological function. Despite the relatively long learning curve, en bloc laminectomy is a secure and valid technique for TOLF treatment.

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“…Preoperative diagnosis of DO assists surgeons in making comprehensive preparations for the surgical procedure. Although the incidence of DO in patients with OLF is as high as 43.4%, the accurate diagnosis of DO has presented a difficult problem for surgical management (8,10). Radiological studies regarding OLF-DO are relatively rare, and the diagnostic accuracy of imaging signs still needs to be improved (11,12).…”

Section: Introductionmentioning

confidence: 99%

Three-dimensional imaging analysis for the diagnosis of dural ossification in thoracic ossification of the ligamentum flavum: a multicenter study

Chen¹,

Ling²,

Zhao³

et al. 2023

Quant Imaging Med Surg

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Background: Unforeseen dural ossification (DO) increases the risk of complications in the surgical management of thoracic ossification of the ligamentum flavum (OLF). Several methods have been proposed to identify DO; however, these approaches either have low diagnostic accuracy or poor feasibility.Therefore, we aimed to determine the relationship between DO and the severity and range of thoracic OLF compression using a 3-dimensional (3D) imaging analysis and to evaluate its superiority in diagnosing DO over conventional measurement methods.Methods: A total of 114 consecutive patients who underwent decompressive laminectomy for thoracic OLF in 4 institutions were retrospectively enrolled and divided into DO and non-DO groups. Univariate analysis was performed to determine the relationship between OLF compression and DO. We measured the 3D occupying ratio (OR; 3D OR = OLF volume/normal canal volume × 100%), calculated its cutoff values, and compared its diagnostic value in DO with that of conventional 1D and 2D radiological parameters in the whole thoracic spine.Results: The 3D OR in the DO group (50.9%±7.9%) was significantly higher than that in the non-DO group (30.8%±7.5%; P<0.01). The overall reliability and reproducibility for measurements of the 3D OR (intra-and interobserver correlation coefficients 0.94 and 0.90, respectively) were excellent. Thus, the 3D OR could be used as an indicator to distinguish between DO and non-DO, with high diagnostic accuracy (91.2%). Moreover, a 3D OR of >43%, known as the "ossification zone", was indicative of DO in OLF, whereas a value of <37% was considered the "safe zone". Additionally, the 3D OR [area under the curve (AUC) =0.98, 95% confidence interval (CI): 0.93-0.99] showed a statistically higher diagnostic value for DO in the upper, middle, lower, and whole thoracic spine than did both 1D (AUC =0.81; 95% CI: 0.73-0.88) and 2D (AUC =0.87; 95% CI: 0.79-0.92) parameters (P<0.01).Conclusions: DO was significantly associated with the severity and range of OLF compression. The 3D OR could be used as a critical diagnostic indicator for identifying DO in the whole thoracic spine, owing to its superiority over conventional radiological parameters. Classification of the 3D OR could maximize the clinical feasibility and thus help surgeons to decrease the incidence of DO-related surgical complications.

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Banner cloud sign: a novel method for the diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum

Cited by 8 publications

References 19 publications

Imaging signs for preoperative diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum: a blind, randomized diagnostic accuracy study

Imaging signs for preoperative diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum: a blind, randomized diagnostic accuracy study

Learning Curve and Clinical Outcomes of Ultrasonic Osteotome‐based En Bloc Laminectomy for Thoracic Ossification of the Ligamentum Flavum

Three-dimensional imaging analysis for the diagnosis of dural ossification in thoracic ossification of the ligamentum flavum: a multicenter study

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