Ligamentum flavum hematomas: Why does it mostly occur in old Asian males? Interesting point of reported cases: Review and case report

Full-endoscopic Spine Surgery for the Treatment of Lumbar Ligamentous Flavum Hematoma

Lumbar ligamentous flavum hematoma (LFH) is a relatively rare pathology, and it is difficult to differentiate it from other cystic lesions. Full-endoscopic spine surgery (FESS), an excellent approach for clear and magnified operative visual field since it allows saline irrigation and minimizes destruction of surrounding tissues, has been applied to the treatment. This study aims to present a case series of patients with lumbar LFH treated by FESS.This case series consists of 17 lumbar LFH cases treated by FESS between May 2018 and November 2021 at a single institution. Patient background and operative data were collected from their medical records. The numerical rating scale (NRS), Oswestry Disability Index (ODI), and European Quality of Life-5 Dimensions (EQ-5D) were recorded preoperatively and postoperatively.Elderly men tend to suffer from lumbar LFH at the L4/5 vertebral level. Discontinuity with facet joint was confirmed under endoscopic visualization in all 17 cases. Blood clots were also observed in all cases under endoscope. The mean operative time was 68.6 min without complication. The patients were discharged at average 1.4 days after FESS with significant improvement of NRS score (P < 0.001). ODI and EQ-5D scores 2-year postoperatively statistically improved (P < 0.001), and there was no recurrence during followup period.The operative outcomes of lumbar LFH treated by FESS were satisfactory. FESS excels not only in the diagnosis but also in the treatment of lumbar LFH.

A patient with cervical ligamentum flavum haematoma: case report

INTRODUCTION

Ligamentum flavum haematoma (LFH) is an extremely rare entity, found mostly in the lumbar and thoracic ligamentum flavum and seldom in the cervical ligamentum flavum. Cervical LFH can cause paralysis in patients. We describe a case of LFH in the cervical spine that accepted surgical treatment.

CASE PRESENTATION

A 70-year-old man with incomplete spinal cord injury presented with sudden paralysis of his left limbs for 10 days and hemi-hypaesthesia below the level of the right clavicle. Magnetic resonance imaging (MRI) showed a space-occupying lesion in the left ligamentum flavum between the C4 and C5 laminae. The preliminary diagnoses were concluded to be incomplete spinal cord injury, spinal epidural lesions, and cervical spinal stenosis. After a posterior C3-C6 laminectomy with lateral mass screw instrumentation, the muscle strength and sensation recovered partially. The lesion was greyish black and located in the ligamentum flavum. A pathological examination identified it as a haematoma of the ligamentum flavum. The patient was discharged 15 days after the operation and commenced rehabilitation.

DISCUSSION

The LFH was mainly caused by slight trauma during gentle activities and contributed by many factors. MRI is an essential tool but pathological diagnosis is the gold standard. Most LFH patients can be treated surgically.

How does the side of lumbar disc herniation influence the psoas muscle size at the L4-5 level in patients operated for unilateral hip arthroplasty?

Study Design: Retrospective study.

Objection: There can be a relationship between degenerative diseases in the spine and hip.

Summary of Background Data: Degenerative diseases in the spine and hip may occur concomitantly. This study was done to investigate the cross-sectional area of psoas muscle size and incidence of lumbar disc herniation after unilateral hip arthroplasty.

Methods: The data files of patients who were operated on for unilateral hip arthroplasty between January 2014- and 15 May 2021 at the Recep Tayyip Erdogan University Hospital were retrospectively analysed for the relationship between the psoas muscle volume and the incidence of lumbar disc herniation. The patients were divided according to their operated sides.

Results: The data files of 48 patients were retrospectively analysed. The patients were divided into two groups according to the operated side of their hip joints. Gender and age differences were not significant, and the mean ages were 68,68 years old in the right hip arthroplasty group, and 69,39 in the left hip arthroplasty group.

Conclusions: A complex interaction between the development of lumbar disc herniations and increased contralateral cross-sectional area of the psoas muscle at the L4-5 level was observed in patients operated for unilateral hip arthroplasty. This interaction can be a compensatory mechanism to counteract the spinal imbalance.

Ligamentum flavum hematoma in the lumbar spine mimicking spinal tumor: A case report and review of the literature

Liagmentum flavum hematoma (LFH) is a rare cause of radiculopathy and low back pain, sharing similar symptomatology with disc herniation. It predominantly affects the lumbar thoracic spine. The underlying mechanism of LFH remains unclear; however, surgical removal of the hematoma has consistently demonstrated excellent outcomes. The objective of this case report is to emphasize the significance of diagnosing LFH. We present a surgically confirmed lumbar LFH case that mimicked a lumbar tumor, highlighting the challenges encountered during diagnosis and subsequent management.

Ligamentum Flavum Hematoma Accompanied by Intraspinal and Extraspinal Hematomas: A Case Report

Studies on ligamentum flavum hematoma (LFH) have been gradually increasing; however, no study has reported an LFH spreading to the intraspinal and extraspinal spaces. The purpose of this report is to discuss this rare condition and report that extraspinal hematoma can be formed by LFH. The authors present the case of a 78-year-old man presented with right L5 radiculopathy caused by a space-occupying lesion with intraspinal and extraspinal expansions at the L4-L5 vertebral levels demonstrated on MRI. We tentatively diagnosed these lesions as intraspinal and extraspinal hematomas originating from the ligamentum flavum based on the chronological changes seen on MRI and computed tomography-based needle biopsy. After the extirpation of these lesions, the symptoms were relieved. Three months later, the patient could walk without a cane. From the intraoperative findings and pathological examination, we concluded that the extraspinal hematoma in paravertebral muscle was caused by an LFH of unknown etiology. This case report describes the difficulty in diagnosing LFH accompanied by an extraspinal hematoma with wide-spreading expansion and highlights the usefulness of repetitive MRI over time in capturing chronological changes of the hematoma. As far as we know, this is the first study on an LFH accompanied by an extraspinal hematoma in the multifidus.

Posterior longitudinal ligament suturation after lumbar discectomy provides postoperative a large intradural area: First report

Background

Stability and flexibility of the spine are provided by the posterior longitudinal ligament (PLL). It plays a key role in the pathogenesis of lumbar disc herniation (LDH) by preventing disc protrusion. The effect of the suturing of the PLL on the intradural area was investigated.

Patients and Methods

The patients were included in whom lumbar microdiscectomy was performed between January 2021 and July 1, 2022. The patients were randomly divided into two groups as PLLs were sutured and unsutured.

Results

Forty-six (23 males and 23 females) patients were included. The PLLs were sutured in 22 patients (Group 1) and not sutured in 24 patients (Group 2). The levels, sides of LDHs, and ages and gender of patients were also analyzed in both groups, which were not statistically significant. Preoperative mean spinal intradural areas were 77.29 mm2 for the PLL unsutured group and 85.40 mm2 for the PLL sutured group (Groups 1 and 2). For patients in Groups 1 and 2, the postoperative mean spinal intradural areas grew to 134.73 mm2 and 96.12 mm2, respectively. The difference in preoperative mean spinal intradural regions between the two groups was not statistically significant; however, Group 1 showed a substantial difference (sutured PLL patients).

Conclusions

This study first time indicates that suturing PLL has a protective and supportive role in patients who were operated on for LDH.

Does the anesthesia technique of cesarean section cause persistent low back pain after delivery? A retrospective analysis

OBJECTIVE

Cesarean sections (CS) under spinal anesthesia may lead to newly developed low back pain (LBP) after anesthesia. The cause of this pain is still unknown. This subject was investigated.

METHODS

The persistent LBP after the section was retrospectively analyzed in patients who were operated on under spinal or general anesthesia between January 1, 2018, and January 1, 2020.

RESULT

General anesthesia was used in 52 women, but 251 women were operated on under spinal anesthesia. Newly developed persistent LBP was detected in 57 (18,8%) of a total of 303 patients. Of those patients with LBP, general anesthesia was used in 14 of 52 (26,9%) patients, but 43 of 251 (17.1%) patients received spinal anesthesia. Baby weight after CS was the only variable associated with persistent LBP after 3 and 6 months (P < 0.05) in multiple logistic regression analysis. Patient age and anesthesia type were not associated with persistent LBP (P > 0.05).

CONCLUSION

This study shows anesthesia type as spinal or general was not associated with increased persistent LBP. Performing more spinal than general anesthesia in the cesarean section may be false data about the increased rate of LBP after CS.

Introducing a new possible predisposing risk factor for odontoid type 2 fractures after cervical trauma; Ponticulus posticus anomaly of C1 vertebra

OBJECTIVE

Ponticulus posticus is an anomaly of the atlas. Odontoid fracture type 2 fracture occurs by hyperflexion, hyperextension, lateral flexion, and a combination of these movements. The presence of Ponticulus Posticus anomaly may affect the occurrence of odontoid fractures of the C2 vertebra. In this study, the relationship between the presence of PP anomaly and occurring of the odontoid type 2 fracture was investigated.

PATIENTS AND METHODS

Cervical CTs of a total of 14 patients with odontoid type 2 fracture were retrospectively evaluated for PP, and compared with 13 patients with cervical trauma without odontoid type 2 fracture.

RESULTS

Ponticulus posticus anomaly was noted in 7 of 14 patients with odontoid type 2 fractures on the upper cervical CT; therefore, the prevalence was 50.%, but only 3 cases (23.07%) were seen in 13 patients of the control group. In binominal regression analysis showed that the presence of PP anomaly increases 12,075 times to occur odontoid type 2 fracture after cervical trauma.

CONCLUSION

Ponticulus posticus is often not recognized, but this study shows that ponticulus posticus is a risk factor for odontoid type 2 fracture after cervical trauma.

Intraorbital Expansion of an Intradiploic Frontal Epidermoid Cyst: A Case Report and Short Review of the Literature

Patient: Male, 58-year-old

Final Diagnosis: Epidermoid cyst

Symptoms: Exophthalmos

Medication:—

Clinical Procedure: —

Specialty: Neurosurgery

Ligamentum flavum hematoma following a traffic accident: A case report

BACKGROUND

Ligamentum flavum hematoma (LFH) can cause compression of the spinal cord or nerve root, which results in neurological symptoms. We report a case of lumbar radicular pain due to LFH following a traffic accident.

CASE SUMMARY

A 59-year-old man complained of left buttock and lateral thigh pain that was dull in nature after a traffic accident 18 d prior to presentation. Magnetic resonance imaging (MRI), taken 17 d after the traffic accident, revealed a mass lesion at the L4-5 Level. These MRI findings suggested subacute LFH. The patient’s pain was not alleviated with conservative treatment, including oral medication and epidural steroid injection. After a partial-hemilaminectomy and removal of LFH, the patient’s pain completely disappeared.

CONCLUSION

Because early operation for decompression is important for a good outcome, clinicians should be able to determine LFH from MRI results and be aware of the possibility of LFH, especially in patients with a history of trauma.

A Finite Element Study on the Treatment of Thoracolumbar Fracture with a New Spinal Fixation System

Objective

In this study, the mechanical properties of the new spinal fixation system (NSFS) in the treatment of thoracolumbar fractures were evaluated by the finite element analysis method, so as to provide a mechanical theoretical basis for the later biomechanical experiments and clinical experiments.

Methods

T12-L2 bone model was constructed to simulate L1 vertebral fracture, and three models of internal fixation systems were established on the basis of universal spinal system (USS): Model A: posterior short-segment fixation including the fractured vertebra (PSFFV); Model B: short-segment pedicle screw fixation (SSPF); Model C: new spinal fixation system (NSFS). After assembling the internal fixation system and fracture model, the finite element analysis was carried out in the ANSYS Workbench 18.0 software, and the stress of nail rod system, fracture vertebral body stress, vertebral body mobility, and vertebral body displacement were recorded in the three models.

Results

The peak values of internal fixation stress, vertebral body stress, vertebral body maximum displacement, and vertebral body maximum activity in Model C were slightly smaller than those in Model B.

Conclusions

Compared with the traditional internal fixation system, the new spinal internal fixation system may have the mechanical advantage and can provide sufficient mechanical stability for thoracolumbar fractures.

A new experimental evidence that olfactory bulb lesion may be a causative factor for substantia nigra degeneration; preliminary study

Background: Anosmia has been considered as the first diagnostic criteria of Parkinson disease (PD), we investigated the effect of the olfactory bulbectomy (OBX) on histopathological features of the substantia nigra in an animal model.Methods: Twenty-seven male rats were used in this study. Animals were divided into three groups as five (control), six SHAM and sixteen study (OBL) groups. Nothing was done in the control group, the only burr hole was done in the SHAM group, OBL was not applied, and bilateral OBL was performed in the study group, and followed ten weeks, then animals were decapitated. Olfactory bulb volumes were measured by macro anatomically. The olfactory bulbs and substantia nigra sections were analyzed by a stereological method to evaluate olfactory glomerulus and neuron density of substantia nigra per cubic centimeter and compared with statistically.Results: The mean olfactory bulb volume, degenerated olfactory glomerulus density and degenerated neuron density of substantia nigra were measured as:(4.14 ± 0.20) mm³, (1 ± 1)/mm³ and (7 ± 2)/mm³ in control (Group I); (3.6 ± 0.16)/mm³, (4 ± 1)/mm³ and(32 ± 7)/mm³ in SHAM (Group II) and (2.2 ± 0.9)/mm³, (112 ± 18)/mm³ and (1543 ± 115)/mm³in study group (Group III). Diminished olfactory bulb volume was observed in Group III animals.Conclusions: We concluded that OBL may lead to the degeneration of substantia nigra.

Successful treatment of lumbar ligamentum flavum hematoma using a spinal full-endoscopic system

Background

Percutaneous endoscopic lumbar discectomy (PELD) is a relatively less invasive treatment for lumbar disc herniation (LDH). This study investigated the usefulness of a full-endoscopic system for PELD in lumbar ligamentum flavum hematoma (LFH) treatment.

Methods

Between May 2017 and Jun 2018, a total of five patients with leg pain due to LFH underwent surgery using a full-endoscopic system for PELD. A percutaneous endoscopic translaminar approach (PETA) was performed right above the LFH. Pathological examination of the hematoma capsule was performed in all cases.

Results

The mean age of the patients was 64 years; there were 3 male and 2 female patients. Leg pain improved immediately after operation in all cases. Intraoperative findings and pathological examination revealed that the synovium at adjacent facet joints was not involved.

Conclusions

Full-endoscopic system is not only a safe and effective minimally invasive system for the treatment of lumbar LFH, but is also superior to acquire a correct diagnosis.

A Succession of MRI Scans Supports the Diagnosis of Lumbar Ligamentum Flavum Hematoma: A Case Report and Review of the Literature

Ligamentum flavum hematoma (LFH) is a rare cause of spinal nerve compression. This condition remains challenging to diagnose using MRI due to the changing intensity of the hematoma on imaging. The aim of this study was to describe the patient with LFH who had a succession of MRI scans carried out. We report on a 71-year-old woman with a mass at L4/5 and decompression surgery was performed for her left leg symptom. She had MRI carried out in a previous hospital and also had MRI again in our hospital. In a 2^nd MRI of the same area, after a 2-week interval, a newly isointense mass was present within the anterior part of the previously identified lesion on T1-weighted image and the hyperintense area in the lesion was a little extended on T2-weighted imaging. Her symptoms were resolved immediately after decompression surgery. Following a review of previous cases, we suggest that consecutive MRI scanning may support the diagnostic process for LFH.

Sudden death and cervical spine: A new contribution to pathogenesis for sudden death in critical care unit from subarachnoid hemorrhage; first report - An experimental study

Context:

Sudden death from subarachnoid hemorrhage (SAH) is not uncommon.

Aims:

The goal of this study is to elucidate the effect of the cervical spinal roots and the related dorsal root ganglions (DRGs) on cardiorespiratory arrest following SAH.

Settings and Design:

This was an experimental study conducted on rabbits.

Materials and Methods:

This study was conducted on 22 rabbits which were randomly divided into three groups: control (n = 5), physiologic serum saline (SS; n = 6), SAH groups (n = 11). Experimental SAH was performed. Seven of 11 rabbits with SAH died within the first 2 weeks. After 20 days, other animals were sacrificed. The anterior spinal arteries, arteriae nervorum of cervical nerve roots (C6–C8), DRGs, and lungs were histopathologically examined and estimated stereologically.

Statistical Analysis Used:

Statistical analysis was performed using the PASW Statistics 18.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Intergroup differences were assessed using a one-way ANOVA. The statistical significance was set at P < 0.05.

Results:

In the SAH group, histopathologically, severe anterior spinal artery (ASA) and arteriae nervorum vasospasm, axonal and neuronal degeneration, and neuronal apoptosis were observed. Vasospasm of ASA did not occur in the SS and control groups. There was a statistically significant increase in the degenerated neuron density in the SAH group as compared to the control and SS groups (P < 0.05). Cardiorespiratory disturbances, arrest, and lung edema more commonly developed in animals in the SAH group.

Conclusion:

We noticed interestingly that C6–C8 DRG degenerations were secondary to the vasospasm of ASA, following SAH. Cardiorespiratory disturbances or arrest can be explained with these mechanisms.

First report of perforation of ligamentum flavum by sequestrated lumbar intervertebral disc

Disc fragments are well known to migrate to superior, inferior, or lateral sites in the anterior epidural space, posterior epidural migrated lumbar disc fragments is an extremely rare disorder, 61 cases have been reported to date. However, there were no cases with perforated ligamentum flavum (LF). We report a different case with perforation of ligamentum ligamentum by disc fragment. To the best of our knowledge, this is the first report of perforation LF by a posterior epidural migrated sequester disc.

Inequality in leg length is important for the understanding of the pathophysiology of lumbar disc herniation

Objective:

Inequality in leg length may lead to to abnormal transmission of load across the endplates and degeneration lumbar spine and the disc space. There has been no study focusing on lumbar disc herniation (LDH) and leg length discrepancy. This subject was investigated in this study.

Materials and Methods:

Consecutive adult patients with leg length discrepancy and low back pain (LBP) admitted to our department were respectivelly studied.

Results:

A total number of 39 subjects (31 women and eight men) with leg length discrepancy and LBP and 43 (25 females and 18 males) patients with LBP as a control group were tested. Occurrence of disc herniation is statistically different between patients with hip dysplasia and control groups (P < 0.05).

Conclusion:

The results of this study showed a statistically significant association between leg length discrepancy and occurrence of LDH. The changes of spine anatomy with leg length discrepancy in hip dysplastic patients are of importance in understanding the nature of LDH.