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

Ossification of the ligamentum flavum

Ossification of the ligamentum flavum is a rare cause of thoracic myelopathy. It develops in East Asians more frequently than in people from other areas. The exact pathophysiology has not been elucidated yet; however, it largely depends on biomechanical alterations, especially changes in the tensile force. Because the spinal cord is compressed from the posterior side, the first and most common clinical manifestation is usually loss of functional gait and spastic paralysis, which develop as the spinal cord compression progresses. The choice of diagnostic imaging is T2 sagittal magnetic resonance imaging scanning. Whole spine scanning is mandatory to identify multiple areas of compression and any associated distal lumbar diseases. Fine computed tomography imaging is necessary to make a differential diagnosis and set up a precise surgical plan. Conservative treatment does not work in this disorder. Decompression surgery is the only option and prognosis after surgical treatment is better with this disorder than with other causes of thoracic myelopathy. The severity of preoperative symptoms and the time interval before surgical treatment are the most important prognostic factors.

Identifying myelopathy caused by thoracic syringomyelia: a case report

Myelopathy is a form of neurological disease caused by compression of the spinal cord. Upper and lower quarter screens are commonly used in identifying myelopathy, although most of the screen components demonstrate poor or unstudied diagnostic value. The purpose of this case report is to describe the diagnostic process in detecting syringomyelia, an intramedullary lesion that may cause myelopathy. The patient was a 47-year-old female with a thoracic syrinx that was discovered by spinal magnetic resonance imaging (MRI) following a complicated and delayed clinical diagnostic course. Following surgical intervention and a two-week inpatient rehabilitation stay, the patient was discharged using a rolling walker for ambulation and was performing most transfers with modified independence. A complicating pattern of signs and symptoms combined with a diagnostic process guided by poorly studied screen components demonstrates the diagnostic dilemma associated with identifying the cause of myelopathy within the thoracic spine. This also indicates the need for further investigation of individual and clustered components of the neurological screen to improve the ability to identify patients in need of complete imaging studies in a more timely fashion.

Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain

When a patient presents with pain in the different regions of the spine, the clinician executes a region-appropriate basic examination that includes appropriate historical cues and specific physical examination tests that can be used to identify red flags. The clinical tests include a specific examination of the sensory and motor systems. Test outcomes are best interpreted in context with the entire examination profile, where the sensitivity and specificity of these tests can influence their utility in uncovering red flags. These red flags can be categorized based on the nature and severity or the specific elements of the patient's presentation. Many general red flags can be observed in any region of the spine, while specific red flags must be categorized and discussed for each spinal region. This categorization can guide the clinician in the direction of management, whether that management is aimed at redirecting the patient's care to another specialist, reconsidering the presentation and observing for clusters of findings that may suggest red flags, or managing the patient within the clinician's specialty in context with the severity of the patient's presentation.

Pathophysiology of cervical myelopathy

BACKGROUND CONTENT

Cervical myelopathy is a group of closely related disorders usually caused by spondylosis or by ossification of the posterior longitudinal ligament and is characterized by compression of the cervical spinal cord or nerve roots by varying degrees and number of levels. The decrease in diameter of the vertebral canal secondary to disc degeneration and osteophytic spurs compresses the spinal cord and nerve roots at one or several levels, producing direct damage and often secondary ischemic changes.

PURPOSE

Clinicians who treat cervical myelopathy cord injuries should have a basic understanding of the pathophysiology and the processes that are initiated after the spinal cord has been injured.

STUDY DESIGN/SETTING

Literature review.

METHODS

Literature review of human cervical myelopathy and clinically relevant animal models to further our understanding of the pathological mechanisms involved.

RESULTS

The pathophysiology of cervical myelopathy involves static factors, which result in acquired or developmental stenosis of the cervical canal and dynamic factors, which involve repetitive injury to the cervical cord. These mechanical factors in turn result in direct injury to neurons and glia as well as a secondary cascade of events including ischemia, excitotoxicity, and apoptosis; a pathobiology similar to that occurring in traumatic spinal cord injury.

CONCLUSIONS

This review summarizes some of the significant pathophysiological processes involved in cervical myelopathy.

Spinal compression due to ossified yellow ligament: a short series of 5 patients and literature review

BACKGROUND

Ossification of ligamentum flavum in the thoracic region causing compressive myelopathy among middle-aged patients is a poorly described entity.

CASE DESCRIPTION

Five patients of Indian origin with OYL are described. Their clinical presentations, surgical options, and long-term outcome are presented. Radiologic and clinical follow-up of one of the patient is described over a span of 10 years.

CONCLUSIONS

Decompressive laminectomy and excision of the OYL is the commonly performed surgical procedure. A rapid neurologic improvement follows decompression. The persistent spasticity in certain patients is attributed to irreversible changes within the cord. The disease is thought to be progressive in nature. The prolonged follow-up of these patients suggests that the long-term prognosis is poor. Selective racial involvement and variable clinical presentations, with treatment options, are discussed.

Thoracic myelopathy caused by ossification of the ligamentum flavum: a report of 18 cases

OBJECT

Thoracic myelopathy caused by ossification of the ligamentum flavum (OLF) is a rare entity, most evident in Japan. The authors studied the clinical manifestations, radiological aspects, surgical treatment, and pathogenesis of this disease.

METHODS

Eighteen patients with OLF-induced thoracic myelopathy underwent laminectomy. The severity of myelopathy varied. Complete paraplegia was seen in three cases. Compression of the upper and middle third of the thoracic spine was evident in six cases and of the lower third in 12 cases. Multilevel OLF was demonstrated in 13 cases. In most cases, the ossified ligamentum flavum appears as a V-shaped lesion on computerized tomography and magnetic resonance images. In all patients the diameter of the posterior spinal canal, already narrowed, was further exacerbated by the OLF. Laminectomy was limited to the levels of compression, and the ligamentum flavum was resected in all cases. The symptoms and signs improved in 13 cases and stabilized in four cases. In one case symptoms recurred as a result of ossified lesions forming at other sites. Histological examination showed that the mode of development of the ossified ligaments was endochondral ossification.

CONCLUSIONS

Reports of OLF-induced myelopathy are rare and mainly described in Japan. The incidence also seems high in North Africa. An early laminectomy limited to the level of compression is recommended. Ossified ligamentum flavum is different from the calcification of the ligamentum flavum, which is due to crystal deposits.

Ossification of the ligamentum flavum

We report the case of a 32-year-old South Korean male who presented with bilateral leg weakness, spastic gait and associated sensory loss from below the T5 dermatome. MRI and CT scans of the spine confirmed the presence of calcified ligamentum flavum from T1-T6. A thoracic laminectomy resulted in an excellent post-operative recovery with full return of all functions. This case review will discuss the differences that exist between ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF), but also the similarities at a molecular and possibly at a genetic level. We have reviewed the reported literature of patients presenting with progressive lower limb spacity due to OLF, and an excellent outcome is achieved using decompressive laminectomy.

Disc Related and Non-Disc Related Disorders of the Thoracic Spine

Different anatomical structures and pathophysiological functions can be responsible for lumbar pain, each producing a distinctive clinical profile. Pain can arise from the intervertebral disc, either acutely as a primary disc related disorder, or as result of the degradation associated with chronic internal disc disruption. In either case, greatest pain provocation will be associated with movements and functions in the sagittal plane. Lumbar pain can also arise from afflictions within the zygapophyseal joint mechanism, as a result of synovitis or chondropathy. Either of these conditions will produce the greatest pain provocation during three-dimensional movements, due to maximal stress to either the synovium or joint cartilage. Finally, patients can experience different symptoms associated with irritation to the dural sleeve, dorsal root ganglion, or chemically irritated lumbar nerve root. Differential diagnosis of these conditions requires a thorough examination and provides information that can assist the clinician in selecting appropriate management strategies.

Thoracic myelopathy due to enlarged ossified yellow ligaments. Case report and review of the literature

Enlarged ossified yellow ligaments are a rare and poorly understood cause of thoracic myelopathy. The authors report the case of a patient in whom thoracic myelopathy was caused by enlarged ossified yellow ligaments.

Spinal cord compression caused by unusual location and extension of ossified ligamenta flava in a Caucasian male. A case report and literature review

STUDY DESIGN

A case report of a spinal cord compression caused by ossification of the ligamenta flava is presented together with a review of the literature.

OBJECTIVE

To present the diagnosis of ossification of the ligamenta flava in a Caucasian man with a proximal thoracic myelopathy.

SUMMARY OF BACKGROUND DATA

This case shows that the upper parts of the thoracic spine can be involved in ossification of the ligamenta flava, which never before has been reported in Caucasian individuals. Furthermore, it is advised that computed tomography scanning and magnetic resonance imaging be combined to provide an accurate diagnosis and proper preoperative evaluation of the bony changes, spinal cord, and compression of the spinal cord.

METHODS

A patient with a thoracic spinal cord compression caused by ossification of the ligamenta flava was treated surgically and made a good clinical recovery. Imaging studies, surgical findings, and results of histopathologic investigations were analyzed to substantiate the diagnosis.

RESULTS

The results of the surgical findings seemed to be in contrast with those of the imaging studies. This contrast was occasioned by the uncommon perioperative finding of a fusion of the completely ossified upper and lower parts of the involved adjacent ligamenta flava. Ossification of the ligamenta flava was diagnosed by histopathologic examination, which revealed endochondral ossification and lamellar bone formation without fragments of ligamenta flava.

CONCLUSION

Although rarely reported in whites, ossification of the ligamenta flava should be considered in all patients presenting with a spinal cord compression, even at high thoracic levels. The prognosis after decompressive surgery can be good, especially if intramedullary hyperintensities are absent on preoperatively performed T2-weighted magnetic resonance images.

[Thoracic spinal cord compression at two levels due to ligamentum flavum calcification. Case report]

Calcification and/or ossification of the ligamenta flava is a well reported clinicopathologic entity causing narrowing of the spinal canal cord compression. It has been described almost exclusively in Japanese people. The authors present the case of a non Japanese patient with thoracic myelopathy caused by ossification of the ligamentum flavum.