Cord compression secondary to cervical disc herniation associated with calcification of the ligamentum flavum: case report

OBJECTIVE AND IMPORTANCE

Calcification of the ligamentum flavum is a rare disease that occurs almost exclusively in elderly Japanese people. We report the case of a young Caucasian woman who presented with a C5-C6 disc herniation associated with a cervical calcified ligamentum flavum.

CLINICAL PRESENTATION

The patient presented with a cord compression syndrome of 76 hours' evolution. At exploration, a Brown-Sequard syndrome at the C6 level was found. Magnetic resonance imaging and computed tomography led to a correct diagnosis and planning for decompression.

INTERVENTION

We operated on the patient through a combined anterior and posterior approach. After the patient underwent anterior discectomy with intersomatic arthrodesis, we performed posterior decompression. During the operation, we observed that the dura mater could not be separated from the ligamentum, so an en bloc excision of both structures was performed. Microscopic examination indicated that the excised ligamentum had calcification, and total integration of the dura mater into the structure of the ligamentum was demonstrated. To our knowledge, this circumstance has never been described before. A posterior C3-C7 arthrodesis was performed to prevent postoperative kyphosis. Recovery was successful, with total recovery from neurological deficits 4 months later.

CONCLUSION

Calcification of the ligamentum flavum is a progressive disease that starts early in life and becomes symptomatic later in life when spinal stenosis occurs. Magnetic resonance imaging and computed tomography provide adequate diagnosis and allow proper surgical planning for decompression. The presence of hyperintense areas within the spinal cord parenchyma, in the absence of a traumatic antecedent, does not preclude a complete recovery.

Cyst of the ligamentum flavum

We report the case of a patient with sciatica resulting from a cyst of the ligamentum flavum.

Femoral neuropathy secondary to ossification of the ligamentum flavum

Radiculopathy resulting from ossification of the ligamentum flavum (OLF) is extremely rare and concerns only intercostal neuralgias. We describe a 37-year-old Caucasian woman with a lumbar radiculopathy revealing an OLF. Her symptoms were completely and definitively relieved by surgery.

[Prevalence, morphology, and pathologic implications of ossification of lumbar ligamenta flava: a large prospective CT study]

Ossifications of the ligamenta flava are described in all parts of the spine, particularly in the dorsal segment where they can produce thoracic myelopathy. Rarely reported in the cervical spine, they are only occasionally mentioned in the lumbar spine where the main reported pathology of the ligamentum flavum is the arthrosynovial cyst. To study the morphological appearances, the prevalence and the pathological implications of the lumbar ossified ligamenta flava, 1021 lower lumbar CT studies are prospectively reviewed totalizing 6080 ligamenta flava. The prevalence of clearly defined ossifications is 5.44%; it appears relatively independent from the age, sex, vertebral level and presence of spondylolysis. It significant increases with the presence and the stage of articular osteoarthritis. In more than 96% of cases, the ossifications remain confined to the lateral articular portion of the ligament and more central ossifications are very rare; therefore, the essential differential diagnosis is osteophytosis. The ossifications never cause radiculopathy except rarely, in association with more classical processes such as disk protrusions and osteophytosis. Our findings favours an essentially idiopathic and--to a lessen extent--a mechanical cause to explain ossification of the ligamenta flava.

Thoracic myelopathy in the Japanese: epidemiological and clinical observations on the cases in Miyagi Prefecture

Surgeries for thoracic myelopathy for 7 years in a northeastern prefecture (population, 2.26 million) and surrounding areas were reviewed. Eighty-one residents in the prefecture were operated on. The annual operation rate per one million people was 5.1. The rate corresponded to 9% of that reported for cervical myelopathy in the same prefecture. The mean age at operation was 55 years. Fifty-five patients (68%) were male and 26 (32%), female. Twenty-eight % of the patients had preoperative periods longer than two years, and 23% had severe disabilities. Anterior decompression was performed in 27%, posterior decompression in the others. The postoperative recovery rate averaged 48%. The lowest rate was 31% in patients with a preoperative duration of more than 2 years (p < 0.05). Sixty-four % of the patients had ossification of the ligamentum flavum; 20%, posterior spur; 19%, disc herniation; 16%, ossification of the posterior longitudinal ligament; 1%, calcification of the ligamentum flavum; 1%, degenerative spondylolisthesis. Seventy-nine % had one of the above spinal factors and 21% had two.

[Aneurysm of the celiac trunk. Etiopathogenic role of the arcuate ligament]

INTRODUCTION

Aneurysms of arteries supplying the digestive tract are uncommon and usually asymptomatic.

CLINICAL REPORT

A 58-year-old woman presented weight-loss with intestinal angina and a painful abdomen. Explorations induced an arteriogram of the aorta and the digestive arteries which showed an aneurysm of the celiac trunk located immediately below a stenosis facing the arcuate ligament.

DISCUSSION

The discovery of an aneurysm of the celiac trunk in a patient without any history of hypertension or artheromatous disease led us to implicate the arcuate ligament as the causal agent. Radiography and histology findings favored this hypothesis.

Spinal intermittent claudication due to cervical and thoracic degenerative spine disease

STUDY DESIGN

Neurogenic intermittent claudication can be caused by spinal cord compression. In this study, 20 patients with spinal intermittent claudication due to degenerative spine diseases were evaluated.

OBJECTIVES

This study clarified the clinical features and pathomechanism of spinal intermittent claudication due to degenerative spine diseases.

SUMMARY OF BACKGROUND DATA

Spinal intermittent claudication may either be produced by intrinsic or extrinsic lesions. Little is known about spinal intermittent claudication due to extrinsic lesions such as spinal cord compression. Twenty patients with spinal intermittent claudication, caused by cervical or thoracic lesions, who were given surgical treatment except for one, were studied. Their main subjective symptoms were tightness, weakness, and numbness in the lower limbs and a strangulated sensation in the trunk to lower limbs. The objective findings were occurrence and/or aggravation of spinothalamic signs.

METHODS

The gait loading test was performed on these 20 patients. Selective spinal angiography was performed on the patients with thoracic myelopathy and its therapeutic effects were evaluated. A radiographic assessment was made in all patients.

RESULTS

The subjective symptoms and objective findings were reproduced by the gait loading test. Selective spinal angiography temporarily relieved or improved the spinal intermittent claudication due to the thoracic myelopathy. Spinal intermittent claudication disappeared immediately after surgical treatment.

CONCLUSIONS

Circulatory impairment of the spinal cord seems to be closely related to the etiology of spinal intermittent claudication. Besides providing diagnostic information, selective spinal angiography may also have a temporary therapeutic effect.

Cyst of the ligamentum flavum

STUDY DESIGN

A patient with sciatica resulting from a hemorrhagic cyst of the ligamentum flavum is reported. Surgical removal of the cyst relieved the patient of her sciatic symptoms.

SUMMARY OF BACKGROUND DATA

Cyst of ligamentum flavum is an uncommon cause of radiculopathy. There are 13 cases in the literature.

CONCLUSIONS

The differential diagnosis of benign interspinal extradural mass lesions includes spinal synovial cysts, ligamentum flavum cysts, perineural cysts, dermoid cysts, and parasitic cysts.

Calcification of ligamentum flavum causing spinal cord compression in a stroke patient

Hypertrophy or calcification of the ligamentum flavum may be a cause of spinal cord compression. Most cases have been reported to occur in either the cervical or thoracolumbar region. We report an unusual case of a 59-year-old man admitted to the rehabilitation service with a recent diagnosis of right cerebrovascular accident with left hemiparesis. The patient had a history of gait disturbance, motor weakness, and bowel/bladder changes. Admission FIM scores were approximately 62 with complete dependence in mobility (ie, transfers) and locomotion. Fluctuating changes in his neurological status were observed; further testing led to an uncommon diagnoses of thoracic radiculomyelopathy caused by calcification of the ligamentum flavum. This diagnosis, although rare, should be considered in the diagnosis of patients suspected to have spinal cord compression.

Ligamentum flavum and apophyseal cysts as an unusual cause of root compression

Patients with symptoms and signs of radicular compression often present to neurosurgeons and orthopaedic surgeons. In an elderly population metastatic disease is often the cause, but degenerative disc disease also occurs. This case shows an alternative benign condition that may be overlooked, and the clinical implications are discussed.

[Ossification and calcification of the cervical ligamentum flavum--case reports]

Ossification of ligamentum flavum was reported usually lower thoracic and lumbar region, and rarely seen in the cervical region. Calcification of cervical ligamentum flavum is also relatively rare. We report a case of ossification and another of calcification of cervical ligamentum flavum, and discussed the difference of the clinical and radiological features in these conditions. Case 1: A 55-year-old man presented with numbness of the left shoulder and urinary dysfunction. Neurological examination revealed weakness, muscle atrophy and elevated deep tendon reflexes of the left extremities. CT showed ossified mass protruding into the right side of the canal and compressing the spinal cord at C 3/4 and C 4/5. MRI showed low intensity mass both on T1- and T2-weighted images and severe compression of the spinal cord. Left side partial hemilaminectomy with foraminotomy, so called "key hole" foraminotomy, satisfactorily decompressed the cord with clinical improvement. Case 2: A 70-year-old woman complained numbness of both hands for two years. She had sensory disturbance of both hands and spastic gait disturbance. Cervical X-ray films showed calcified nodules on the inner surface of lamina at C4/5. Axial CT demonstrated calcification in the ligamentum flavum at the C4/5 and C5/6 levels. MRI showed posterior spinal cord compression at the C4/5 and C5/6 levels. Osteoplastic laminotomy and removal of the affected ligamentum flavum were performed with successful result. Only 8 cases ossification of cervical ligamentum flavum above C6/7 have been so far reported. All are Japanese; four male and four female cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Radicular compression syndrome due to protrusion of the ligamentum flavum]

O autor apresenta um caso de protrusão de ligamento amarelo, ao nível de L4, que se mostrava espessado. O paciente exibia sintomatologia clínica idêntica à da hérnia discal, com déficit motor e perturbações sensitivas localizadas. A hemilaminectomia curou o doente de suas manifestações dolorosas e sensitivas; hipotonia muscular muito diminuída quatro meses após a operação.