Full-endoscopic decompression for thoracic ossification of the ligamentum flavum in professional pitchers: surgical technique, outcomes, and return to sport. Illustrative cases

BACKGROUND: 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. OBSERVATIONS: 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. LESSONS: 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. https://thejns.org/doi/10.3171/CASE26537.