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Obesity has been suggested as a potential risk factor for the severity of OPLL. We aimed to investigate whether non-alcoholic fatty liver disease (NAFLD) is associated with OPLL severity. We assessed the severity of NAFLD by a liver-to-spleen (L\/S) ratio on computed tomography (CT) scans of 85 symptomatic OPLL patients at a single institution in Japan. We also assessed the severity of OPLL by CT reconstruction sagittal and axial images. The prevalence of NAFLD in middle-aged patients (age\u2009&lt;\u200970\u00a0years, n\u2009=\u200950) was 80.3%, which was 2.5\u20138 times higher than that in the general Japanese population (9\u201330%). The ossification index of the spinal ligaments increased in proportion to the severity of fatty liver. The L\/S ratio was revealed as a significant risk factor associated with the total ossification index (standardized \u03b2: -0.40, 95% confidence interval \u2212\u200954.34 to \u2212\u20094.22). This study suggests the potential contribution of NAFLD to the progression of OPLL. 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