{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:05:46Z","timestamp":1789517146261,"version":"build-2803163510"},"reference-count":18,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"11","license":[{"start":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T00:00:00Z","timestamp":1789344000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,9,14]]},"abstract":"\n BACKGROUND<\/jats:title>\n Thoracic ossification of the ligamentum flavum (T-OLF) is an important cause of progressive thoracic myelopathy and may be particularly debilitating in professional baseball pitchers, in whom surgical treatment must restore neural function while preserving the spinal biomechanics required for elite pitching. Although open laminectomy has traditionally been the standard treatment, extensive muscle dissection and disruption of posterior elements may compromise postoperative stability and return to play.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n The authors applied a refined full-endoscopic interlaminar decompression technique for single-level and multilevel T-OLF in professional pitchers. The key surgical strategy involved thinning the ossified lesion to a paper-thin shell and elevating it around a lateral hinge point, thereby minimizing direct vertical compression on the vulnerable thoracic spinal cord. When transient intraoperative neurophysiological monitoring deterioration occurred, staged decompression was performed to reduce neurological risk.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n Both patients showed marked neurological recovery and returned to professional pitching within 6 months, without evidence of biomechanical compromise. These findings suggest that full-endoscopic decompression, by preserving the posterior tension band and paraspinal musculature, may represent a viable primary surgical option for T-OLF in high-demand athletes requiring preservation of spinal mobility and kinetic chain function.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE26537<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case26537","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:56Z","timestamp":1789516856000},"source":"Crossref","is-referenced-by-count":0,"title":["Full-endoscopic decompression for thoracic ossification of the ligamentum flavum in professional pitchers: surgical technique, outcomes, and return to sport. Illustrative cases"],"prefix":"10.3171","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9649-0443","authenticated-orcid":true,"given":"Seung Hoon","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7348-0621","authenticated-orcid":true,"given":"Seung Jin","family":"Choi","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5324-950X","authenticated-orcid":true,"given":"Christoph P.","family":"Hofstetter","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-2058-0211","authenticated-orcid":true,"given":"Phil","family":"Bohlen","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington"},{"name":"Department of Orthopedics and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roshini","family":"Ramkumar","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joonho","family":"Byun","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chang Hwa","family":"Ham","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2981-7180","authenticated-orcid":true,"given":"Eun-Sang","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joo Han","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0432-8620","authenticated-orcid":true,"given":"Woo-Keun","family":"Kwon","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea;"},{"name":"Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"6","key":"bib1","series-title":"Eur Spine J","first-page":"1912","article-title":"Microendoscopic posterior decompression for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum: a technical report","volume":"25","author":"Baba","year":"2016","unstructured":"Baba SOshima YIwahori TTakano YInanami HKoga H.Microendoscopic posterior decompression for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum: a technical report. Eur Spine J. 2016;25(6):1912-1919. doi:10.1007\/s00586-015-4158-9"},{"issue":"3","key":"bib2","series-title":"Neurospine","first-page":"819","article-title":"Biportal endoscopic techniques for severe dural ossification in thoracic ossification of the ligamentum flavum: insights from preoperative imaging","volume":"22","author":"Kim","year":"2025","unstructured":"Kim JYChoi SYLee DCKim HSHeo DH.Biportal endoscopic techniques for severe dural ossification in thoracic ossification of the ligamentum flavum: insights from preoperative imaging. Neurospine. 2025;22(3):819-828. doi:10.14245\/ns.2550338.169"},{"key":"bib3","series-title":"Clin Neurol Neurosurg","first-page":"108815","article-title":"Predictive factors of poor surgical outcome in thoracic ossified ligamentum flavum: a multivariate analysis","volume":"250","author":"Nagesh","year":"2025","unstructured":"Nagesh MMishra APrabhuraj ARPredictive factors of poor surgical outcome in thoracic ossified ligamentum flavum: a multivariate analysis. Clin Neurol Neurosurg. 2025;250:108815. doi:10.1016\/j.clineuro.2025.108815"},{"issue":"5","key":"bib4","series-title":"Neurol Med Chir (Tokyo)","first-page":"184","article-title":"Differences in the demographics and clinical characteristics between the ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum in patients who underwent thoracic spinal surgery for compressive myelopathy","volume":"64","author":"Yoshida","year":"2024","unstructured":"Yoshida SNakamura SSaita KOya SOgihara S.Differences in the demographics and clinical characteristics between the ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum in patients who underwent thoracic spinal surgery for compressive myelopathy. Neurol Med Chir (Tokyo). 2024;64(5):184-191. doi:10.2176\/jns-nmc.2023-0137"},{"issue":"1","key":"bib5","series-title":"Neurosurg Rev","first-page":"345","article-title":"Comparison of endoscopic decompression to open laminectomy in patients with thoracic ossified ligamentum flavum\u2014a systematic review and meta-analysis","volume":"47","author":"Kumar","year":"2024","unstructured":"Kumar VBansal PKsheerasagar VPDhatt SS.Comparison of endoscopic decompression to open laminectomy in patients with thoracic ossified ligamentum flavum\u2014a systematic review and meta-analysis. Neurosurg Rev. 2024;47(1):345. doi:10.1007\/s10143-024-02591-x"},{"issue":"2","key":"bib6","series-title":"Sports Health","first-page":"133","article-title":"Youth baseball pitching mechanics: a systematic review","volume":"10","author":"Thompson","year":"2018","unstructured":"Thompson SFGuess TMPlackis ACSherman SLGray AD.Youth baseball pitching mechanics: a systematic review. Sports Health. 2018;10(2):133-140. doi:10.1177\/1941738117738189"},{"key":"bib7","series-title":"World Neurosurg","first-page":"8","article-title":"Percutaneous endoscopic spine minimally invasive technique for decompression therapy of thoracic myelopathy caused by ossification of the ligamentum flavum","volume":"114","author":"Miao","year":"2018","unstructured":"Miao XHe DWu TCheng X.Percutaneous endoscopic spine minimally invasive technique for decompression therapy of thoracic myelopathy caused by ossification of the ligamentum flavum. World Neurosurg. 2018;114:8-12. doi:10.1016\/j.wneu.2018.02.152"},{"issue":"16","key":"bib8","series-title":"J Neurosurg Case Lessons","first-page":"CASE24413","article-title":"Multilevel thoracic myelopathy: full-endoscopic solution. Illustrative case","volume":"8","author":"Sura","year":"2024","unstructured":"Sura SDave HReddy Mallepally AMultilevel thoracic myelopathy: full-endoscopic solution. Illustrative case. J Neurosurg Case Lessons. 2024;8(16):CASE24413. doi:10.3171\/CASE24413"},{"issue":"1","key":"bib9","series-title":"Acta Neurochir (Wien)","first-page":"43","article-title":"How I do it: biportal endoscopic thoracic decompression for ossification of the ligamentum flavum","volume":"164","author":"Kang","year":"2022","unstructured":"Kang MSChung HJYou KHPark HJ.How I do it: biportal endoscopic thoracic decompression for ossification of the ligamentum flavum. Acta Neurochir (Wien). 2022;164(1):43-47. doi:10.1007\/s00701-021-05031-7"},{"issue":"12","key":"bib10","series-title":"Ann Transl Med","first-page":"977","article-title":"Thoracic full-endoscopic unilateral laminotomy with bilateral decompression for treating ossification of the ligamentum flavum with myelopathy","volume":"9","author":"Lin","year":"2021","unstructured":"Lin YPLin RChen SThoracic full-endoscopic unilateral laminotomy with bilateral decompression for treating ossification of the ligamentum flavum with myelopathy. Ann Transl Med. 2021;9(12):977. doi:10.21037\/atm-21-2181"},{"issue":"23","key":"bib11","series-title":"Ann Transl Med","first-page":"1606","article-title":"The diagnostic accuracy of CT-based \u201cbanner cloud sign\u201d for dural ossification in patients with thoracic ossification of the ligamentum flavum: a prospective, blinded, diagnostic accuracy study protocol","volume":"8","author":"Chen","year":"2020","unstructured":"Chen GZhang BTao LChen ZSun C.The diagnostic accuracy of CT-based \u201cbanner cloud sign\u201d for dural ossification in patients with thoracic ossification of the ligamentum flavum: a prospective, blinded, diagnostic accuracy study protocol. Ann Transl Med. 2020;8(23):1606. doi:10.21037\/atm-20-5439"},{"issue":"2","key":"bib12","series-title":"Quant Imaging Med Surg","first-page":"1466","article-title":"Imaging signs for preoperative diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum: a blind, randomized diagnostic accuracy study","volume":"14","author":"Chen","year":"2024","unstructured":"Chen GTao LChen ZImaging signs for preoperative diagnosis of dural ossification in patients with thoracic ossification of the ligamentum flavum: a blind, randomized diagnostic accuracy study. Quant Imaging Med Surg. 2024;14(2):1466-1476. doi:10.21037\/qims-23-634"},{"key":"bib13","series-title":"World Neurosurg","first-page":"127","article-title":"Complications of endoscopic thoracic spine surgery: overview and complication avoidance","volume":"179","author":"Park","year":"2023","unstructured":"Park MKPark JYSon SK.Complications of endoscopic thoracic spine surgery: overview and complication avoidance. World Neurosurg. 2023;179:127-132. doi:10.1016\/j.wneu.2023.08.067"},{"issue":"7","key":"bib14","series-title":"Medicina (Kaunas)","first-page":"1303","article-title":"Navigation-assisted micro-window excision of thoracic ossification of ligamentum flavum (Mishima surgery) in professional baseball pitchers: a case report and technical note","volume":"59","author":"Ishii","year":"2023","unstructured":"Ishii KIsogai NUrata RNavigation-assisted micro-window excision of thoracic ossification of ligamentum flavum (Mishima surgery) in professional baseball pitchers: a case report and technical note. Medicina (Kaunas). 2023;59(7):1303. doi:10.3390\/medicina59071303"},{"issue":"11","key":"bib15","series-title":"J Int Med Res","first-page":"3000605211059465","article-title":"Progressive enlargement of thoracic ossification of the ligamentum flavum in professional baseball pitchers: a report of two cases","volume":"49","author":"Kato","year":"2021","unstructured":"Kato KOtoshi KHakozaki MKonno SI.Progressive enlargement of thoracic ossification of the ligamentum flavum in professional baseball pitchers: a report of two cases. J Int Med Res. 2021;49(11):3000605211059465. doi:10.1177\/03000605211059465"},{"issue":"11","key":"bib16","series-title":"Spine (Phila Pa 1976)","first-page":"1353","article-title":"Hypertrophied ligamentum flavum in lumbar spinal canal stenosis. Pathogenesis and morphologic and immunohistochemical observation","volume":"17","author":"Yoshida","year":"1992","unstructured":"Yoshida MShima KTaniguchi YTamaki TTanaka T.Hypertrophied ligamentum flavum in lumbar spinal canal stenosis. Pathogenesis and morphologic and immunohistochemical observation. Spine (Phila Pa 1976). 1992;17(11):1353-1360. doi:10.1097\/00007632-199211000-00015"},{"issue":"9","key":"bib17","series-title":"Int Orthop","first-page":"2071","article-title":"Unilateral biportal endoscopic decompression for symptomatic thoracic ossification of the ligamentum flavum: a case control study","volume":"46","author":"Deng","year":"2022","unstructured":"Deng YYang MXia CChen YXie Z.Unilateral biportal endoscopic decompression for symptomatic thoracic ossification of the ligamentum flavum: a case control study. Int Orthop. 2022;46(9):2071-2080. doi:10.1007\/s00264-022-05484-0"},{"issue":"5","key":"bib18","series-title":"Cureus","first-page":"e59429","article-title":"Early recurrence of thoracic ossification of the ligamentum flavum after posterior decompression surgery: a case report","volume":"16","author":"Asanuma","year":"2024","unstructured":"Asanuma SMiura KFunayama TKoda MYamazaki M.Early recurrence of thoracic ossification of the ligamentum flavum after posterior decompression surgery: a case report. Cureus. 2024;16(5):e59429. doi:10.7759\/cureus.59429"}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/12\/11\/article-CASE26537.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/12\/11\/article-CASE26537.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/12\/11\/article-CASE26537.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:56Z","timestamp":1789516856000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/12\/11\/article-CASE26537.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,14]]},"references-count":18,"journal-issue":{"issue":"11"},"URL":"https:\/\/doi.org\/10.3171\/case26537","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,14]]}}}