Current progress and controversies in thoracic ossification of the ligamentum flavum: pathogenesis, diagnosis and surgical management

Thoracic ossification of ligamentum flavum (TOLF) is the primary pathological driver of thoracic spinal stenosis (TSS), characterized by insidious clinical onset, high surgical complexity, and a elevated risk of permanent neurological deficits. This systematic review synthesizes the epidemiological landscape and genetic, mechanical, and inflammatory pathogeneses ofTOLF. We provide a comprehensive evaluation of current radiological classification systems and critically appraise different decompressive procedures—ranging from classic open laminectomies to emerging minimally invasive biportal and uniportal endoscopic techniques. By assessing surgical outcomes, complications (e.g., cerebrospinal fluid leakage), and clinical indicators, this review aims to provide clinicians with an evidence-based framework for individualized surgical decision-making in managing TOLF.