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Badra M, Najjar E, Wardani H, Jamaleddine Y, Daccache E, Ezzeddine H, Moucharafieh R. Evaluation and Treatment of Lumbar Spine Extradural Cysts: A Narrative Review. Cureus 2024; 16:e60604. [PMID: 38894794 PMCID: PMC11185196 DOI: 10.7759/cureus.60604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
The main objective was to describe the different types and characteristics of lumbar spine extradural cysts and their optimal treatment options with a focus on endoscopic technique. We searched Pubmed, EMBASE, Medline, and Google Scholar for articles published between 1967 and 2020 using the keywords "Spinal Cyst," "Extradural Cyst," and "Lumbar Cyst." The various anatomical and histological types of the extradural cysts with their presentations, etiologies, imaging, and optimal treatment with a focus on endoscopic techniques were reviewed from the articles. Lumbar spinal cysts are relatively rare pathologies that might cause radicular symptoms similar to lumbar disc herniation. Spinal extradural cysts are classified either histologically based on the cyst lining tissues (synovial cysts or non-synovial, ganglion cysts) or anatomically based on the structure of origin (epidural cysts, ligamentum flavum cysts, discal cysts, post-discectomy pseudocysts, posterior longitudinal ligament cysts, facet cysts). Surgical excision is the recommended treatment of symptomatic cysts with endoscopic techniques being a viable option. Extradural lumbar cysts can be identified based on their histological structure or depending on their structure of origin. Regardless of their classification, they could all give similar clinical findings, and the optimal treatment would be surgical excision with endoscopic technique being a viable option with a satisfactory outcome.
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Affiliation(s)
- Mohammad Badra
- Department of Orthopedic Surgery, Faculty of Medicine, Balamand University, Beirut, LBN
- Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center, Johns Hopkins International, Beirut, LBN
| | - Elie Najjar
- Department of Orthopedics, Center for Spinal Studies and Surgery (CSSS) Queen's Medical Centee, Nottingham University Hospitals, Nottingham, GBR
| | - Hassan Wardani
- Department of Orthopedic Surgery, Faculty of Medicine, Lebanese University, Beirut, LBN
| | - Youssef Jamaleddine
- Department of Orthopedic Surgery, Lebanese American University Medical Center, Beirut, LBN
| | - Elio Daccache
- Department of Orthopedic Surgery, Lebanese American University Medical Center, Beirut, LBN
| | - Hady Ezzeddine
- Department of Orthopedic Surgery, Faculty of Medicine, Balamand University, Beirut, LBN
| | - Ramzi Moucharafieh
- Department of Orthopedic Surgery, Faculty of Medicine, Balamand University, Beirut, LBN
- Department of Orthopedics and Traumatology, Clemenceau Medical Center, Johns Hopkins International, Beirut, LBN
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Tomasi SO, Umana GE, Scalia G, Raudino G, Stevanovic V, Krainz H, Kral M, Nicoletti GF, Winkler PA. Lumbar Spinous Process-Splitting Technique for Ligamentum Flavum Cyst Removal. J Neurol Surg A Cent Eur Neurosurg 2024; 85:195-201. [PMID: 34875711 DOI: 10.1055/a-1715-3958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Laminotomy for lumbar stenosis is a well-defined procedure and represents a routine in every neurosurgical department. It is a common experience that the uni- or bilateral paraspinal muscle detachment, together with injury of the supra- and interspinous ligaments, can lead to postoperative pain. In the literature, the application of a minimally invasive technique, the lumbar spinous process-splitting (LSPS) technique, has been reported. METHODS In this study, we present a case series of 12 patients who underwent LSPS from September 2019 to April 2020. Two patients had a cyst of the ligamentum flavum, eight a single-level lumbar canal stenosis (LCS), and two a two-level LCS. Moreover, we propose a novel morphological classification of postoperative muscle atrophy and present volumetric analysis of the decompression achieved. RESULTS There were no complications related to this technique. In all patients, the vertebral canal area was more than doubled by the procedure. The muscle sparing showed grade A, according to our classification. CONCLUSION To our knowledge, this is the first description of this surgical technique and the first LSPSL case series in Europe. Furthermore, cases of ligamentum flavum cyst removal using this safe and effective technique have not yet been reported.
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Affiliation(s)
| | | | - Gianluca Scalia
- Department of Neurosurgery, National Specialist Hospital Garibaldi, Catania, Italy
| | - Giuseppe Raudino
- Department of Neurosurgery, Humanitas Centre of Oncology of Catania, Catania, Sicilia, Italy
| | - Vlado Stevanovic
- Department of Neuroradiology, Paracelsus Medical Private University, Salzburg, Austria
| | - Herbert Krainz
- Department of Neurosurgery, Paracelsus Medical Private University, Salzburg, Austria
| | - Michael Kral
- Department of Neurosurgery, Paracelsus Medical Private University, Salzburg, Austria
| | | | - Peter A Winkler
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Salzburg, Austria
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Jang JN, Song Y, Kim JW, Kim YU. Comparison of ligamentum flavum thickness between central and lateral lesions in a patient with central lumbar spinal canal stenosis. Medicine (Baltimore) 2023; 102:e34873. [PMID: 37603515 PMCID: PMC10443754 DOI: 10.1097/md.0000000000034873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/01/2023] [Indexed: 08/23/2023] Open
Abstract
Thickened ligamentum flavum has been considered as a major cause of central lumbar spinal canal stenosis (CLSCS). Previous studies have demonstrated that ligamentum flavum thickness (LFT) is correlated with aging, degenerative spinal stenosis, and disc degeneration. Thus, hypertrophy of the ligamentum flavum is a major cause of CLSCS, and measurement of LFT has been considered a morphologic parameter in the diagnosis of CLSCS. To our knowledge, comparison of LFT between central and lateral lesions has not been reported. In addition, no research has analyzed best clinical cutoff values of central ligament flavum thickness (CLFT) and lateral ligament flavum thickness (LLFT). This study aimed to compare CLFT with LLFT in patients with CLSCS and further compare the CLFT and LLFT findings between the 2 groups to analyze LFT variation. Both CLFT and LLFT samples were collected from 101 participants with CLSCS and from 103 participants in the control group who underwent lumbar magnetic resonance imaging without evidence of CLSCS. Axial T2-weighted lumbar magnetic resonance scans were acquired at the L4 to 5 facet joint level from each participant. Average CLFT value was 2.25 ± 0.51 mm in the control group and 4.02 ± 0.74 mm in the CLSCS group. Average LLFT value was 2.50 ± 0.51 mm in the control group and 3.38 ± 0.66 mm in the CLSCS group. CLSCS patients had significantly higher CLFT and LLFT (both P < .001). Regarding the validity of both CLFT and LLFT as predictors of CLSCS, a receiver operating characteristic estimation revealed that the most suitable cutoff value for CLFT was 3.10 mm, with sensitivity of 95.0%, specificity of 94.2%, and an area under the curve of 0.97. The best cut-off value of LLFT was 2.92 mm, with sensitivity of 78.2%, specificity of 77.7%, and area under the curve of 0.87. We have 4 important new findings: The mean CLFT is significantly lower than that of the mean LLFT in the normal control group; CLFT and LLFT are both significantly associated with CLSCS; Increase rate of CLFT is faster than that of LLFT in the CLSCS group; and CLFT is a more sensitive measurement parameter to predict CLSCS than LLFT.
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Affiliation(s)
- Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International ST. Mary’s Hospital, Incheon, Republic of Korea
| | - Yumin Song
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International ST. Mary’s Hospital, Incheon, Republic of Korea
| | - Jae Won Kim
- Catholic Kwandong University of Korea College of Medicine, Gangneung, Republic of Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International ST. Mary’s Hospital, Incheon, Republic of Korea
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Tang J, Liu K, Xie W, Li X, Gan X, Li Y, Lu Q, Li J. Endoscopic treatment of lumbar ligamentum flavum cyst by interlaminar approach: a minimally invasive and effective alternative to open surgery. J Orthop Surg Res 2023; 18:344. [PMID: 37165405 PMCID: PMC10170800 DOI: 10.1186/s13018-023-03824-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Lumbar ligamentum flavum cyst is a rare spinal condition that can cause significant morbidity and neurological deficits. Traditional surgical treatment involves open surgery, which can be associated with prolonged recovery time and significant morbidity. In recent years, endoscopic treatment of lumbar ligamentum flavum cyst has emerged as a minimally invasive and effective alternative to open surgery, but only a few cases have been reported in the literature. This paper describes our experience with endoscopic resection of an L4/5 ligamentum flavum cyst through an interlaminar approach and reviews the literature on the treatment of lumbar ligamentum flavum cyst. METHODS An 87-year-old man presented with lameness in the left leg, and magnetic resonance imaging (MRI) showed nerve compression by a ligamentum flavum cyst at the L4/5 intervertebral plane. The patient underwent endoscopic resection of the ligamentum flavum cyst through a left interlaminar approach with the facet joint preserved. The present study was approved by the Ethics Committee of our hospital. The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Text regarding patient consent is not applicable for this case. RESULTS Postoperative clinical results improved significantly, and postoperative MRI showed complete cyst resection. CONCLUSION Total endoscopic resection via an interlaminar approach provides a new minimally invasive approach for the surgical treatment of lumbar ligamentum flavum cyst, which can be used as a reference by clinicians.
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Affiliation(s)
- Jin Tang
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
- Wuhan Sports University, Wuhan, China
| | - Kui Liu
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
| | - Wei Xie
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
| | - Xugui Li
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
| | - Xuewen Gan
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
| | - Ying Li
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
| | - Qilin Lu
- Department of Minimally Invasive Spinal Surgery, The Affiliated Hospital of Wuhan Sports University, NO 279 Luoyu Road, Hongshan District, Wuhan, 430079, Hubei, China
- Wuhan Sports University, Wuhan, China
| | - Junjie Li
- Department of Spine Surgery, The Fisrt Affiliated Hosptial, and College of Clinica Medicine of Henan University of Science and Technology, Luoyang, 471003, China.
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Kalidindi KKV, Bhat MR, Gupta M, Mannem A, Chhabra HS. Ligamentum Flavum Cyst With Acute Onset Motor Deficit: A Literature Review and Case Series. Int J Spine Surg 2020; 14:544-551. [PMID: 32986576 DOI: 10.14444/7072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Ligamentum flavum cysts have been rarely described in the literature and are one of the rare causes of neural compression and canal stenosis. Very few cases of their association with neurologic deficits are reported to date, and association with acute onset weakness is even rarer. CLINICAL PRESENTATION We report our experience with 3 cases of ligamentum flavum cyst that presented with acute onset weakness and also present a comprehensive literature review on lumbar ligamentum flavum cysts reported to date. All 3 patients had symptoms of severe neurogenic claudication and presented to us with acute onset of motor weakness in lower limbs. Ligamentum flavum cyst was located in the midline in 2 cases and laterally in 1 case. We performed excision of the cyst and decompression with fusion in 2 cases and decompression alone in 1 case. All 3 cases had significant improvement in their neurologic status postoperatively. Histopathological examination confirmed ligamentum flavum cyst in all 3 cases. We performed a PUBMED and EMBASE database search using the MeSH (Medical Subject Headings) terms "ligamentum flavum" and "cysts" for articles published to April 2019. We could identify 7 studies describing 20 cases of lumbar ligamentum flavum cysts with motor weakness in the literature. Only 1 case had been described with an acute onset of weakness. CONCLUSIONS Ligamentum flavum cysts should remain in the differential diagnosis of a patient who has symptoms of lumbar canal stenosis and presents with acute onset of neurological deficits. Such patients have a good improvement with surgery.
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Affiliation(s)
| | - Mohd Rafiq Bhat
- Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India
| | - Mayank Gupta
- Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India
| | - Abhishek Mannem
- Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India
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Sharma SB, Lin GX, Kim JS. Full-Endoscopic Resection of Ligamentum Flavum Cyst in Lumbar Spine. World Neurosurg 2019; 130:427-431. [PMID: 31349083 DOI: 10.1016/j.wneu.2019.07.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cysts of the ligamentum flavum (LF) are rare occurrences, with only a few cases reported in literature. They are a result of age-related degenerative changes in the LF. The cyst compresses the neural elements and causes neurogenic symptoms. Endoscopic resection of the LF cyst has not been described in literature. In this report, we describe our experience with endoscopic resection of an LF cyst in the L3-L4 region. CASE DESCRIPTION A 54-year-old female patient presented with claudication in both lower limbs and evidence on magnetic resonance imaging of a LF cyst in the L3-L4 region compressing the neural elements. The patient underwent full endoscopic resection of the LF cyst through the interlaminar approach from the left side with preservation of facet joints. The postoperative clinical outcomes improved significantly, and postoperative magnetic resonance imaging revealed a complete removal of the cyst. CONCLUSIONS Full-endoscopic resection may be considered as a viable option for treatment of LF cyst in the lumbar region.
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Affiliation(s)
- Sagar B Sharma
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, South Korea
| | - Guang-Xun Lin
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, South Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, South Korea.
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