Cervical radiculomyelopathy due to calcification of the ligamenta flava

The Spine is the Tree of Life: A Systematic Review and Meta-Analysis of the Radiographic Findings Related to Spinal Injuries in Athletes

This review article explores spinal injuries in athletes participating in various sporting activities. It also highlights the various mechanisms of injuries that contribute to spinal injuries in each sport. Electronic databases such as PubMed, Cochrane Library, Web of Science, Embase, MEDLINE Ovid, and Google Scholar were searched for articles from 2000 to 2022 on spine injuries in sports and radiological studies discussing the various injury patterns among athletes. Studies were scoured in accordance with the inclusion criteria, and relevant data such as the number of participants, sporting activities, spine injuries, and outcomes were retrieved. Fifteen articles that met the inclusion criteria were included in the study. Cervical spine injuries are common in athletes who participate in contact sports such as football. Similarly, athletes in collision sports such as football, rugby, and hockey are likely to suffer stingers due to traction and compression injuries. Players engaged in such as soccer, baseball, and swimming, are likely to suffer from spondylolysis. Soccer players are more prone to multiple lesions compared to athletes in sports such as baseball because the sport involves training exercises such as jogging and running without kicking any ball. In swimmers, spondylolysis is common in breaststroke and butterfly styles since they involve repeated flexion and hyperextension of the lumbar spine. CT is essential for diagnosing spondylolysis as it demonstrates the lesions more accurately. Ice hockey is associated with a significant incidence of cervical spine injuries, mostly due to players being constantly checked/pushed from behind. Spine injuries are common in elite athletes across several sports. About 10% of spinal injuries in the United States result from sports activities. In diagnosing spine injuries, imaging modalities such as MRI, CT, or plain radiographs are essential. From a radiologist's perspective, these tests help immensely in deciding which treatment is required for a particular athlete or how the injury can be optimally managed. Achieving recovery from a specific spine injury usually depends on the kind of injury and the rehabilitation process the athletes undergo before returning to play.

Multilevel calcium pyrophosphate dihydrate deposition in cervical ligamentum flavum: clinical characteristics and imaging features

BACKGROUND

Involvement in cervical ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease. Only few cases of this condition have been reported. We revealed eighteen cases of CPPD in cervical ligamentum flavum that diagnosed at a single medical center. In our case series, clinical characteristics and magnetic resonance imaging findings of patients are described.

METHODS

We retrospectively reviewed the medical charts and imaging studies of the eighteen patients with pseudogout attack of the cervical ligamentum flavum. In addition, we discussed the differences between this disease and ossification of ligamentum flavum in image manifestations.

RESULTS

There were fourteen men and four women aged between 59 and 87 years. Diabetes mellitus and hypertension were the most common comorbidities. Myelopathy and neck pain were presented in most patients. C4-5 and C5-6 were attacked most frequently, and multiple- rather than single-level involvement could be observed in our series. "Acute on chronic phenomenon" was a specific magnetic resonance image finding in patients whose symptom durations were between 2 to 5 months. Compared to ossification of ligamentum flavum, calcium pyrophosphate dihydrate crystal deposition had different image signs, including morphology, side of the involved ligament, no continuity with the lamina, acute on chronic phenomenon, and presence of retro-odontoid mass.

CONCLUSIONS

Nodular calcifications in cervical ligamentum flavum raise highly suspicion for calcium pyrophosphate dihydrate deposition and must be diagnosed by histological examination and polarized light microscopy. This disease is different from ossification of ligamentum flavum, and it could be recognized by specific image features.

Ossified Ligamentum Flavum causing Cervical Myelopathy

Ossification of the ligamentum flavum (OLF) causing compressive cervical myelopathy or radiculopathy is rare. A 50-year-old male was admitted for progressive hypesthesia and paresthesia of both hands and a gradually worsening gait. MRI and CT scans demonstrated ossification of the left ligamentum flavum with dural sac and cord compression at the C5-6 level. The ossified ligamentum flavum was removed through a subtotal laminectomy and left side foraminotomy of the C5-6. Postoperatively, his gait improved remarkably and the sensory symptoms gradually resolved.

Clinical analysis of thoracic ossified ligamentum flavum without ventral compressive lesion

The aim of this study was to analyze the clinical characteristics of thoracic ossified ligamentum flavum (OLF) and to elucidate prognostic factors as well as effective surgical treatment modality. The authors analyzed 106 thoracic OLF cases retrospectively from January 1999 to December 2008. The operative (n = 40) and the non-operative group (n = 66) were diagnosed by magnetic resonance imaging (MRI) and/or computed tomography (CT) imaging. We excluded cases exhibiting ventral compressive lesions causing subarachnoid space effacement in thoracic vertebrae as well as those with a coexisting cervical compressive myelopathy. Those in the operative group were treated with decompressive laminectomy as well as resection of OLF. The preoperative neurologic status and postoperative outcomes of patients, as indicated by their modified Japanese Orthopedic Association (mJOA) scores and recovery rate (RR), Modic changes, the axial (fused or non-fused) and sagittal (omega or beak) configurations of OLF, and the ratios of the cross-sectional area (CSA) and anteroposterior diameter (APD) of the most compressed level were studied. The most commonly affected segment was the T10-11 vertebral body level (n = 49, 27.1%) and the least affected segment was the T7-8 level (n = 1, 0.6%). The ratios of the CSA in non-fused and fused types were 77.3 and 59.3% (p < 0.001). When Modic changes were present with OLF, initial mJOA score was found to be significantly lower than those without Modic change (7.62 vs. 9.09, p = 0.033). Neurological status improved after decompressive laminectomy without fusion (preoperative vs. last mJOA; 7.1 ± 2.01 vs. 8.57 ± 1.91, p < 0.001). However, one patient exhibited transient deterioration of her neurological status after surgery. In the axial configuration, fused-type OLF revealed a significant risk for a decreased postoperative mJOA score (0-7, severe and moderate) (Odds ratio: 5.54, χ (2) = 4.41, p = 0.036, 95% CI: 1.014-30.256). The results indicated that the new categorization of axial-type of OLF is a helpful predictor of postoperative patient outcome and fused type was related with poor prognosis. In OLF cases free from ventral lesions compressing the spinal cord, decompressive laminectomy is enough for successful surgical outcome. Therefore, early surgical treatment will be considered in cases with fused-type OLF compressing spinal cord even though they do not have myelopathic symptoms.

CERVICAL TUMORAL CALCIUM PYROPHOSPHATE DIHYDRATE DEPOSITION DISEASE 28 YEARS AFTER SUBOCCIPITAL CRANIOTOMY

OBJECTIVE

To describe a rare case of tumoral cervical chondrocalcinosis that appeared 28 years after the patient had undergone suboccipital craniotomy.

CLINICAL PRESENTATION

A 42-year-old woman suffered from cervicalgia associated with a firm mass at the occipitocervical region. Plain x-ray and computed tomographic and magnetic resonance images revealed a calcified lesion in a scar from a previous suboccipital craniotomy.

INTERVENTION

The patient underwent tumorectomy and histopathology, which revealed an exuberant tumoral chondrocalcinosis. Laboratory test results revealed no secondary cause for the chondrocalcinosis.

CONCLUSION

Identification of chondrocalcinosis beyond the cervical region is very rare. Localization of chondrocalcinosis in a scar from a previous suboccipital craniotomy has not been previously reported. Surgery appears to be the treatment of choice for this form of chondrocalcinosis.

Disorders of Tumoral Calcification of the Spine

Tumoral calcium pyrophosphate dihydrate crystal deposition disease and tumoral calcinosis (TC) are rare non-neoplastic conditions which may cause symptoms of spinal cord compression when they manifest in the perispinal tissues. There is little information available to compare these conditions with each other. We report a case of a patient with such a calcified mass impinging on the spinal cord. A 39-year-old woman on hemodialysis presents with progressive quadriparesis and monoplegia and is found to have a large calcified mass impinging on the spinal cord at the level of C3-4. The mass is excised by an anterior approach with corpectomy and fusion. Pathology was tumoral calcium pyrophosphate dihydrate crystal deposition disease versus TC. Both conditions are very rare in the perispinal tissues with 21 reported cases of tumoral calcium pyrophosphate dihydrate deposition disease and 39 cases of TC. Both cause compressive symptoms depending on the site of occurrence. Tumoral calcium pyrophosphate deposition disease is characterized by smaller, round, masses typically in ligamentous structures which may erode into adjacent bone. Tumoral calcinosis displays larger, lobulated, irregular lesions which do not erode into bone. Either lesion may contain calcium pyrophosphate dihydrate or hydroxyapatite. Treatment is surgical decompression, though lesions may recur.

Cervical spine injuries in pediatric athletes: mechanisms and management

✓Sports-related injuries to the spine, although relatively rare compared with head injuries, contribute to significant morbidity and mortality in children. The reported incidence of traumatic cervical spine injury in pediatric athletes varies, and most studies are limited because of the low prevalence of injury. The anatomical and biomechanical differences between the immature spine of pediatric patients and the mature spine of adults that make pediatric patients more susceptible to injury include a greater mobility of the spine due to ligamentous laxity, shallow angulations of facet joints, immature development of neck musculature, and incomplete ossification of the vertebrae. As a result of these differences, 60 to 80% of all pediatric vertebral injuries occur in the cervical region. Understanding pediatric injury biomechanics in the cervical spine is important to the neurosurgeon, because coaches, parents, and athletes who place themselves in positions known to be associated with spinal cord injury (SCI) run a higher risk of such injury and paralysis. The mechanisms of SCI can be broadly subclassified into five types: axial loading, dislocation, lateral bending, rotation, and hyperflexion/hyperextension, although severe injuries often result from a combination of more than one of these subtypes. The aim of this review was to detail the characteristics and management of pediatric cervical spine injury.

Unilateral ossification of the ligamentum flavum in the cervical spine with atypical radiological appearance

We report a case of symptomatic unilateral ossification of the ligamentum flavum with unusual radiological presentation in the cervical spine. The patient was a 64 year old man with numbness and weakness of the left upper extremity who was admitted to our hospital. Computerized tomography revealed a triangular-shaped high density mass severely compressing the spinal cord at C6. Concomitant small ossification of the posterior longitudinal ligament was noted from C3 to C6. The ossified mass was completely removed via a unilateral osteoplastic laminectomy of the left C6 and C7.

Tumoral calcinosis in the upper cervical spine causing progressive radiculomyelopathy--case report

A 54-year-old woman with chronic renal failure presented with tumoral calcinosis manifesting as progressive radiculomyelopathy. Magnetic resonance imaging revealed a spinal epidural mass in the C-2 to C-4 levels. The clinical and radiological findings suggested malignant tumor. Resection of the lesion was performed with total C-2 laminectomy and C-3 and C-4 laminoplasty. The symptoms totally disappeared after surgery. The histological diagnosis was tumoral calcinosis. Tumoral calcinosis is a rare tumoral calcium pyrophosphate dihydrate crystal deposition disease which presents as periarticular soft tissue calcification. Tumoral calcinosis should be considered in patients with a mass lesion involving the upper cervical spine and associated with metabolic abnormalities. Surgical excision is the treatment of choice, because this is completely curative without known recurrence.

Unusual appearance of an en plaque meningioma of the cervical spinal canal. A case report and literature review

STUDY DESIGN

A case report of a patient with cervical spinal cord and nerve root compression caused by a meningioma en plaque together with calcification of the posterior longitudinal ligament is presented,with a review of the literature.

OBJECTIVE

To present the diagnosis of a calcified dural meningioma en plaque, with extradural extension into the ligamentum flavum, in a woman with cervical myelopathy and neuropathy.

SUMMARY OF BACKGROUND DATA

This case demonstrates that the cervical spine can be involved in dural meningioma en plaque with calcifications, in a manner mimicking ossification of the ligamentum flavum, which has never been previously reported.

METHODS

A patient presenting with cervical cord and nerve root compression caused by ossification of the posterior longitudinal ligament and a concurrent calcified dural meningioma en plaque was treated surgically and has made a gradual recovery. Imaging studies,surgical findings, and histopathologic evaluation were analyzed to support the diagnosis.

RESULTS

At surgery, ossification of the posterior longitudinal ligament was noted, along with a calcified lesion involving the posterior cervical dura and the adjacent ligamentum flavum. A calcified meningioma was diagnosed by histopathologic examination of the dural-based lesion.

CONCLUSION

Although previously not described, the diagnosis of calcified dural meningioma en plaque should be considered in all patients presenting with spinal cord and/or nerve root compression,even at cervical levels. Although ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum are more common etiologies of partially circumferential spinal calcification, dural-based meningiomas with extension into the surrounding ligaments demand early recognition because they can be associated with a poorer prognosis.

Six cases of cervical ligamentum flavum calcification in Blacks in the French West Indies

OBJECTIVE

Calcification of the ligamentum flavum at the cervical spine is an uncommon condition reported mainly in Japanese patients. We describe the clinical manifestations, imaging study findings, and outcomes in six cases seen in the French West Indies.

MATERIAL AND METHODS

We retrospectively reviewed the medical charts of six patients admitted to an orthopedics department for spinal cord compression shown upon computed tomography to be caused by calcification of the ligamentu flavum. There were five women and one man, mean age at admission was 71.7 years (range, 64-79 years) and all six patients were Black.

RESULTS

Five patients had cervical myelopathy and one was asymptomatic. All five symptomatic patients had cervical spinal stenosis, explaining the rapid symptom onset (within six and a half months) and severe motor loss. Computed tomography reconstruction in the sagittal plane ruled out ossification of the ligamentum flavum. Magnetic resonance imaging of the neck failed to demonstrate the calcifications but was useful in evaluating the severity of the spinal cord compression. One patient had articular chondrocalcinosis in both knees and another had calcifications in the basal ganglia. Surgical decompression by the posterior route was performed in two patients and was effective in both, whereas two of the three symptomatic patients who did not have surgery experienced worsening neurological loss. Analysis of the operative specimens from the two surgically treated patients showed a mixture of calcium pyrophosphate dihydrate crystals and apatite microcrystals.

CONCLUSION

Calcification of the ligamentum flavum is probably underrecognized in blacks. This condition causes severe neurological loss. Imaging studies provide the diagnosis. The pathogenesis remains unclear.

Calcification of the cervical ligamentum flavum--case report

A 52-year-old male presented with calcification of the cervical ligamentum flavum manifesting as hypesthesia of the bilateral middle, ring, and little fingers and ulnar halves of both forearms, as well as motor weakness in the bilateral upper extremities and gait disturbance. Cervical x-ray tomography detected a round calcified mass on the posterior wall of the cervical canal at the C-5 level. Computed tomography showed the round, nodular calcified mass more clearly. Magnetic resonance imaging showed an epidural low intensity mass compressing and distorting the cervical cord at the C-5 level on both T1- and T2-weighted images. Administration of gadolinium-diethylenetriaminepenta-acetic acid caused marginal enhancement of the mass. The lesion was eventually removed by posterior laminectomy. The mass was composed of a very hard crystal-like calcified deposition in the ligamentum flavum. X-ray diffraction analysis of the histological specimen showed calcium pyrophosphate dihydrate (CPPD) and hydroxyapatite in the crystal-like substance, confirming that CPPD is responsible for calcification of the cervical ligamentum flavum.

Calcium carbonate apatite deposition in the cervical spine with associated vertebral destruction. Case report

This 52-year-old woman developed crystal deposition disease involving the cervical vertebrae. She presented with symptomatic spinal cord compression secondary to extensive calcified lesions in the posterior elements of the cervical spine. Surgical decompression with posterior fusion was performed. Histological examination showed hardened deposits of calcium carbonate involving the soft tissue, and dissolution of the vertebral bone trabeculae. There was no inflammatory response to these deposits. One year postoperatively the patient developed severe pulmonary disease associated with the collagen-vascular disorder, scleroderma (calcinosis, Raynaud's phenomenon, esophageal hypomotility, sclerodactyly, and telangiectasia [CREST] syndrome). Calcium carbonate deposition disease represents an unusual clinical entity that is possibly associated with scleroderma or other collagen-vascular diseases, and it is distinct from ligamentum flavum calcification, calcium pyrophosphate deposition disease, and hydroxyapatite deposition disease.

Ossification of the ligamentum flavum causing thoracic myelopathy: a case report

Ossification of the ligamentum flavum is a well reported clinicopathologic entity causing narrowing of the spinal canal and subsequent spinal cord compression. The patient described in this case report complained of 9 mo of middle and lower back pain, difficulty with balance, progressive gait disturbance, and recent onset of bladder retention. Magnetic resonance imaging and computed tomographic scan revealed a bone density mass at the T2-3 level causing 25% cord compression and edema. A decompressive laminectomy was performed at T-2. The etiology of the compression was found to be attributable to an ossified ligamentum flavum at the T-2 level, which was confirmed by histologic examination. His neurologic signs and symptoms and functional status markedly improved after surgery and subsequent comprehensive rehabilitation. The patient was able to ambulate independently with a walker as opposed to previously being wheelchair-bound. Prompt surgical intervention and appropriate rehabilitation management play a key role in improving the functional outcome of myelopathy caused by ossified ligamentum flavum. This article acquaints rehabilitation personnel with the clinical features, proposed etiologies, association with other diseases, work-up, treatment, and rehabilitation concerns of patients with myelopathy caused by ossified ligamentum flavum.

Ossification of the cervical ligamentum flavum

A case of a 61-year-old man with ossification of the cervical ligamentum flavum is reported. The ossification was located on the left side of C3-4. The symptoms improved with laminectomy and resection. Ossification of the ligamentum flavum usually occurs in the lower thoracic spine, and is rare in the cervical region. Including the present one, only eight cases have been reported to our knowledge. The clinical features and pathogenesis are discussed.

Calcified ligamenta flava in a patient with Coffin-Lowry syndrome: biochemical analysis of glycosaminoglycans

Glycosaminoglycans in calcified cervical ligamenta flava from a male patient with Coffin-Lowry syndrome were analyzed biochemically. Hexuronate content based on the tissue dry weight was 8-fold and 5-fold concentrated in the calcified center as compared with the peripheral area and with age-matched, normal ligamenta flava, respectively. Two-dimensional electrophoresis of glycosaminoglycan preparations on cellulose acetate film revealed that, although dermatan sulfate was the major glycosaminoglycan in the normal ligamenta flava, chondroitin sulfate was the predominant glycosaminoglycan in the pathological tissue. Relative amounts of chondroitin sulfate disaccharide units were determined after digestion of glycosaminoglycans with chondroitinase, and the ratio of chondroitin 6-sulfate to chondroitin 4-sulfate tended to decrease with the distance from the calcified center to the peripheral area. These observations suggest that an alteration in glycosaminoglycan metabolism may be a contributing factor in calcification of ligamenta flava in Coffin-Lowry syndrome.

Symptomatic calcification and ossification of the cervical ligamentum flavum: clinical, radiological and pathological features

Four surgical cases of symptomatic calcification or ossification of the cervical ligamentum flavum are reported. Both of these conditions occurred in the lower cervical spine of older women, and are best demonstrated on axial computerized tomography (CT) scan. All of our patients showed marked improvement after surgical decompression.

Calcium pyrophosphate dihydrate crystal deposition disease in the cervical ligamentum flavum

The authors describe three cases of cervical radiculomyelopathy caused by calcium pyrophosphate dihydrate crystal deposition disease (CPPDcdd). Radiological investigations revealed nodular calcifications, 5 to 7 mm in diameter, in the cervical ligamentum flavum compressing the spinal cord. Light microscopic, scanning electron microscopic, and x-ray diffraction studies were performed on all three surgical specimens obtained by laminectomy. In two of the cases x-ray microanalysis and transmission electron microscope studies were also performed. This study defined the presence of two patterns of crystal deposition in the ligamentum flavum. One is a nodular deposit, in which hydroxyapatite crystals are seen in the central part of the nodules, with calcium pyrophosphate dihydrate (CPPD) being distributed thinly around them. The other pattern is a linear deposit seen in multiple ligaments and composed of pure CPPD, which causes minimal thickening of the ligaments. A transitional pattern between the two types was also observed. This study revealed details of the nodular deposition of crystals in the ligamentum flavum and demonstrates that CPPDcdd and so-called "calcification of the ligamentum flavum" are the same disease: namely, CPPDcdd. Hydroxyapatite is assumed to have been transformed from CPPD.

Computed tomographic demonstration of calcification of the ligamenta flava of the lumbosacral spine in ankylosing spondylitis

An axial computed tomographic (CT) scan of the lumbosacral regions was performed in 65 patients. The patient population was divided into two groups. The first (control) group included 40 elderly patients without calcification of the ligamenta flava. The second group included 25 patients with ankylosing spondylitis. More than 90% of those in the second group showed calcified lumbosacral ligamenta flava. In two patients these calcifications produced spinal stenosis. The diagnostic and practical importance of these findings are discussed.