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1.  Ligamentum Flavum Cyst of Lumbar Spine: A Case Report and Literature Review 
Korean Journal of Spine  2014;11(1):18-21.
Ligamentum flavum cysts have rarely been reported and known to be the uncommon cause of spinal compression and radiculopathy. A 63-year-old man presented right sciatica lasting for 1 month. Lumbar computerized tomography and magnetic resonance imaging demonstrated an extradural cystic mass adjacent to the L5-S1 facet joints. Partial hemilaminectomy and flavectomy at the L5-S1 space were performed, and then the cystic mass was excised. Histopathology confirmed a connective tissue cyst, which is consistent with the ligamentum flavum. Microscopic examination of the cyst wall revealed that it is closely packed collagen fibril. The symptom of patient was improved after surgery. Because of rarity of ligamentum flavum cysts and nonspecific clinical and radiologic findings, the preoperative diagnosis is not easy. The histologic features of ligamentum flavum cysts are distinct from other cystic lesion of lumbar spine. This study presents a case and literature review of ligamentum flavum cyst. We summarize the pathophysiology, occurrence, differential diagnosis of rare ligamentum flavum cyst, especially on lumbar spine.
doi:10.14245/kjs.2014.11.1.18
PMCID: PMC4040634  PMID: 24891868
Cyst; Ligamentum flavum; Lumbar vertebrae
2.  A cervical ligamentum flavum cyst in an 82-year-old woman presenting with spinal cord compression: a case report and review of the literature 
Introduction
We report on a very rare case of a cervical ligamentum flavum cyst, which presented with progressive myelopathy and radiculopathy. The cyst was radically extirpated and our patient showed significant recovery. A review of the relevant literature yielded seven cases.
Case presentation
An 82-year-old Greek woman presented with progressive bilateral weakness of her upper extremities and causalgia, cervical pain, episodes of upper extremity numbness and significant walking difficulties. Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Magnetic resonance imaging of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level, significantly compressing the spinal cord at this level, in close proximity to the yellow ligament and the C3 left lamina. The largest diameter of this lesion was 1.4 cm, and there was no lesion enhancement after the intravenous administration of a paramagnetic contrast. The lesion was surgically removed after a bilateral C3 laminectomy. The thick cystic wall was yellow and fibro-elastic in consistency, while its content was gelatinous and yellow-brownish. A postoperative cervical-spine magnetic resonance image was obtained before her discharge, demonstrating decompression of her spinal cord and dural expansion. Her six-month follow-up evaluation revealed complete resolution of her walking difficulties, improvement in the muscle strength of her arms (4+/5 in all the affected muscle groups), no causalgia and a significant decrease in her preoperative upper extremity numbness.
Conclusion
Cervical ligamentum flavum cysts are rare benign lesions, which should be included in the list of differential diagnosis of spinal cystic lesions. They can be differentiated from other intracanalicular lesions by their hypointense appearance on T1-weighted and hyperintense appearance on T2-weighted magnetic resonance images, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. The outcome of these cysts is excellent with no risk of recurrence.
doi:10.1186/1752-1947-6-92
PMCID: PMC3325862  PMID: 22458344
3.  Congenital lumbar spinal stenosis with ossification of the ligamentum flavum in achondroplasia: a case report 
Introduction
Achondroplasia is a genetic disorder of bone growth. Congenital spinal stenosis is a well-known complication of this disease, but, to the best of our knowledge, no cases involving combined stenosis with congenital lumbar spinal stenosis and ossification of the ligamentum flavum in achondroplasia have been reported previously. In this report, we describe a case of a patient with congenital spinal stenosis with achondroplasia combined with ossification of the ligamentum flavum at the lumbar spine, which we treated with decompressive surgery.
Case presentation
A 75-year-old Japanese woman with achondroplasia was unable to walk due to a neurological deficit of the lower extremities caused by congenital spinal stenosis that resulted from achondroplasia and ossification of the ligamentum flavum at the lumbar spine. Congenital spinal stenosis was observed from L1 to L5, and ossification of the ligamentum flavum was identified from L1/2 to L3/4. A decompressive laminectomy from L1 to L5 and removal of the ossification of the ligamentum flavum were performed. The patient’s neurological symptoms improved after surgery. She could walk with T-cane at the time of her four-year follow-up examination.
Conclusion
In this report, we describe what is, to the best of our knowledge, the first known published case of ossification of the ligamentum flavum in congenital spinal stenosis associated with achondroplasia at the lumbar spine. Although resection of the ossification of the ligamentum flavum at the congenital spinal stenosis at the lumbar spine was technically difficult because of congenital narrowing of the spinal canal, thickening of the lamina and adhesion of the ossified ligamentum flavum, a wide laminectomy and resection of the ossification of the ligamentum flavum resulted in acceptable improvement of the patient’s neurological symptoms.
doi:10.1186/1752-1947-8-88
PMCID: PMC3973881  PMID: 24597928
Achondroplasia; Lumbar spinal stenosis; Ossification of the ligamentum flavum
4.  Ligamentum Flavum Hematoma in the Adjacent Segment after a long Level Fusion 
Ligamentum flavum hematoma (LFH) is a very rare condition of dural compression; most are observed in the mobile cervical and lumbar spine regions. A 67-year-old man who had a long level interbody fusion at L3-S1 four years ago presented with symptoms suggestive of dural compression. Magnetic resonance imaging showed a posterior semicircular mass located at the adjacent L2-L3 level. After decompression of the spinal canal and removal of the mass lesion, pathological examination of the surgical specimen revealed a hematoma within the ligamentum. The patient fully recovered to normal status after surgery. Here, we report our experience with a LFH in the adjacent segment after a long level fusion procedure and discuss the possible associated mechanisms.
doi:10.3340/jkns.2011.49.1.58
PMCID: PMC3070897  PMID: 21494365
Ligamentum flavum; Hematoma; Adjacent segment
5.  Fluorotic cervical compressive myelopathy, 20 years after laminectomy: A rare event 
Background:
Spinal cord compression in flourosis is a common complication. These complications are mainly due to compression of the spinal cord by thickening and ossification of posterior longitudinal ligament and ligamentum flavum. Surgical decompression is the treatment of choice for fluorotic spinal cord compression. The recurrence of spinal cord compression after surgical decompression in flourosis is a rare event.
Case Description:
We are presenting a case of a 63-year-old man who belonged to Kanpur, an endemic fluorosis region in India, with symptoms of cervical cord compression cranial to the operative site, 20 years after laminectomy for cervical fluorotic myelopathy. Urinary and serum fluoride levels were elevated. The patient underwent a skeletal survey: computed tomography and magnetic resonance imaging of the cervical spine showed a postoperative defect of laminectomy, osteosclerosis, osteophyte formation, calcification of the intraosseus membrane in the forearm, thickening and ossification of the posterior longitudinal ligament at C1, thickening and ossification of the residual ligamentum flavum at C1/C2, and dural calcification at the C2 vertebral level and compressive myelopathy. The patient refused surgical decompression and was managed with tizanidine HCl (an antispasticity medicine), a sublingual single night dose, 8 mg for symptomatic relief.
Conclusion:
The recurrence of spinal cord compression in the fluorotic spine 20 years after laminectomy is a very unusual event and hence the patient should be kept under observation for a long duration. This case report contributes to the literature associated with the management of fluorotic spine.
doi:10.4103/2152-7806.76148
PMCID: PMC3031074  PMID: 21297933
Fluorosis; compressive myelopathy; laminectomy; magnetic resonance imaging; cervical
6.  Thoracic ossification of ligamentum flavum caused by skeletal fluorosis 
European Spine Journal  2006;16(8):1119-1128.
Thoracic ossification of ligamentum flavum (OLF) caused by skeletal fluorosis is rare. Only six patients had been reported in the English literature. This study reports findings from the first clinical series of this disease. This was a retrospective study of patients with thoracic OLF due to skeletal fluorosis who underwent surgical management at the authors’ hospital between 1993 and 2003. Diagnosis of skeletal fluorosis was made based on the epidemic history, clinical symptoms, radiographic findings, and urinalysis. En bloc laminectomy decompression of the involved thoracic levels was performed in all cases. Cervical open door decompression or lumbar laminectomy decompression was performed if relevant stenosis was present. Neurological status was evaluated preoperatively, at the third day postoperatively, and at the end point of follow-up using the Japanese Orthopaedic Association (JOA) scoring system of motor function of the lower extremities. A total of 23 cases were enrolled, 16 (69.6%) males and 7 (30.4%) females, age ranging from 42 to 72 years (mean 54.8 years). All patients came from a high-fluoride area, and 22 (95.7%) had dental fluorosis. Medical imaging showed OLF together with ossification of many ligaments and interosseous membranes, including interosseous membranes of the forearm (18/23 patients 78.3%), leg (14/23 patients 60.9%), and ribs (11/23 patients 47.8%). OLF was classified into five types based on MRI findings: localized (4/23 patients 17.4%), continued (12/23 patients 52.2%), skip (3/23 patients 13.0%), combining with anterior pressure (2/23 patients 8.7%), and combining with cervical and/or lumbar stenosis (2/23 patients, 8.7%). Urinalysis showed a markedly high urinary fluoride level in 14 of 23 patients (60.9%). Patients were followed up for an average duration of 4 years, 5 months. Paired t-test showed that the JOA score was slightly but nonsignificantly increased relative to preoperative measurement 3 days after surgery (P = 0.0829) and significantly increased at the end of follow-up (P = 0.0001). In conclusion, Fluorosis can cause ossification of thoracic ligamentum flavum, as well as other ligaments. Comparing with other OLF series, a larger number of spinal segments were involved. The diagnosis of skeletal fluorosis was made by the epidemic history, clinical symptom, imaging study findings, and urinalysis. En bloc laminectomy decompression was an effective method.
doi:10.1007/s00586-006-0242-5
PMCID: PMC2200777  PMID: 17075705
Ossification of ligamentum flavum; Thoracic spinal stenosis; Skeletal fluorosis; Operation; Classification
7.  Multiple-level ossification of the ligamentum flavum in the cervical spine combined with calcification of the cervical ligamentum flavum and posterior atlanto-axial membrane 
European Spine Journal  2012;22(Suppl 3):416-420.
Objective
Ossification of the ligamentum flavum (OLF) is rarely identified in cervical spine and its pathogenesis has not been established. We report a case of multiple-level OLF, combined with the calcification of the cervical ligamentum flavum and posterior atlanto-axial membrane.
Clinical presentation
A 42-year-old man without any systemic background presented with one month history of pain from the neck to the right shoulder and right leg numbness. Cervical computed tomography demonstrated OLF from C2 to C5, a small area of calcification of the ligamentum flavum (CLF) from C5/6 to C7/T1 and extensive calcification of the posterior atlanto-axial membrane, resulting in spinal canal stenosis. Magnetic resonance imaging showed spinal canal stenosis and severe spinal cord compression from C2 to C5. Thoracic X-ray also showed ossification of the posterior longitudinal ligament (OPLL). We performed laminectomy from C1 to C5 and resected the calcified posterior atlanto-axial membrane and OLF. Histopathological examination demonstrated calcified granules within degenerated fibrous tissue in the posterior atlanto-axial membrane and mature bony trabeculae, bone marrow and residual ligament tissue in the OLF.
Conclusions
Simultaneous development of cervical OLF and CLF in this case seems unlikely to have occurred coincidentally and suggests that the pathogenesis of OLF and CLF may share a common initiation factor.
doi:10.1007/s00586-012-2521-7
PMCID: PMC3641269  PMID: 23053758
Cervical spine; Calcification; Ligamentum flavum; Ossification
8.  Analysis of the Prevalence and Distribution of Cervical and Thoracic Compressive Lesions of the Spinal Cord in Lumbar Degenerative Disease 
Asian Spine Journal  2014;8(1):19-26.
Study Design
Retrospective study.
Purpose
The aim of the present study is to analyze the prevalence and distribution of cervical and thoracic compressive lesions of the spinal cord in lumbar degenerative disease, using whole-spine postmyelographic computed tomography.
Overview of Literature
Of the various complications resulting from spinal surgery, unexpected neurological deterioration is the most undesired. There are reports of missed compressive lesions of the spinal cord at the cervical or thoracic level in lumbar degenerative disease.
Methods
There were 145 consecutive patients with symptomatic lumbar degenerative disease evaluated. Before the lumbar surgery, image data were obtained. The following parameters at the cervical and thoracic levels were analyzed: compressive lesions from the anterior parts; compressive lesions from the anterior and posterior parts; ossification of the ligamentum flavum; ossification of the posterior longitudinal ligament; and spinal cord tumor.
Results
Compressive lesions from the anterior parts were observed in 34 cases (23.4%). Compressive lesions from the anterior and posterior parts were observed in 34 cases (23.4%). Lesions of ossification of the ligamentum flavum were observed in 45 cases (31.0%). Lesions of ossification of the posterior longitudinal ligament were observed in 15 cases (10.3%). Spinal cord tumor was not observed.
Conclusions
A survey of compressive lesions at the cervical or thoracic level in lumbar degenerative disease is important in preventing unexpected neurological deterioration after the lumbar surgery.
doi:10.4184/asj.2014.8.1.19
PMCID: PMC3939365  PMID: 24596601
Cervical spine; Thoracic spine; Neurological deterioration; Lumbar surgery
9.  Lumbar Spinal Stenosis Due to a Large Calcified Mass in the Ligamentum Flavum 
Asian Spine Journal  2013;7(3):236-241.
We describe a rare case of lumbar spinal stenosis due to a large calcified mass in the ligamentum flavum. This patient presented with a 12-month history of severe right leg pain and intermittent claudication. A computed tomography scan was performed, revealing a large calcified mass on the ligamentum flavum at the right-hand side of the lumbar spinal canal. We performed a laminotomy at the L4/5 level with resection of the calcified mass from the ligamentum flavum. The findings of various analyses suggested that the calcified mass consisted mostly of Ca3(PO4)2 and calcium phosphate intermixed with protein and water. The calcified mass in the ligamentum flavum was causing lumbar spinal stenosis. Surgical decompression by resection of the mass was effective in this patient. The calcified material was composed mainly of elements derived from calcium phosphate. Degenerative changes in the ligamentum flavum of the lumbar spine may have been involved in the production of this calcified mass.
doi:10.4184/asj.2013.7.3.236
PMCID: PMC3779778  PMID: 24066222
Spinal stenosis; Calcification; Ligamentum flavum; Calcium phosphate
10.  Ligamentum flavum cyst in the lumbar spine: a case report and review of the literature 
Degenerative changes in the lumbar spine can be followed by cystic changes. Most reported intraspinal cysts are ganglion or synovial cysts. Ligamentum flavum pseudocyst, as a cystic lesion in the lumbar spine, is a rare and unusual cause of neurologic signs and symptoms and is usually seen in elderly persons (due to degenerative changes). They are preferentially located in the lower lumbar region, while cervical localization is rare. Complete removal of the cyst leads to excellent results and seems to preclude recurrence. We report the case of a right-sided ligamentum flavum cyst occurring at L3–L4 level in a 70-year-old woman, which was surgically removed with excellent postoperative results and complete resolution of symptoms. In addition, we discuss and review reports in the literature.
doi:10.1007/s10195-010-0094-y
PMCID: PMC2896575  PMID: 20582448
Ligamentum flavum cyst; Pseudocyst; Radiculopathy; Lumbar spine
11.  Ligamentum flavum cyst in the lumbar spine: a case report and review of the literature 
Degenerative changes in the lumbar spine can be followed by cystic changes. Most reported intraspinal cysts are ganglion or synovial cysts. Ligamentum flavum pseudocyst, as a cystic lesion in the lumbar spine, is a rare and unusual cause of neurologic signs and symptoms and is usually seen in elderly persons (due to degenerative changes). They are preferentially located in the lower lumbar region, while cervical localization is rare. Complete removal of the cyst leads to excellent results and seems to preclude recurrence. We report the case of a right-sided ligamentum flavum cyst occurring at L3–L4 level in a 70-year-old woman, which was surgically removed with excellent postoperative results and complete resolution of symptoms. In addition, we discuss and review reports in the literature.
doi:10.1007/s10195-010-0094-y
PMCID: PMC2896575  PMID: 20582448
Ligamentum flavum cyst; Pseudocyst; Radiculopathy; Lumbar spine
12.  Thoracic myelopathy caused by ossification of ligamentum flavum of which fluorosis as an etiology factor 
Purpose
To evaluate the clinical feature, operative method and prognosis of thoracic ossification of ligamentum flavum caused by skeletal fluorosis.
Methods
All the patients with thoracic OLF, who underwent surgical management in the authors' hospital from 1993–2003, were retrospectively studied. The diagnosis of skeletal fluorosis was made by the epidemic history, clinical symptoms, radiographic findings, and urinalysis. En bloc laminectomy decompression of the involved thoracic levels was performed in all cases. Cervical open door decompression or lumbar laminectomy decompression was performed if relevant stenosis existed. The neurological statuses were evaluated with the Japanese Orthopaedic Association (JOA) scoring system preoperatively and at the end point of follow up. Also, the recovery rate was calculated.
Results
23 cases have been enrolled in this study. Imaging study findings showed all the cases have ossification of ligamentum flavum together with ossification of many other ligaments and interosseous membranes, i.e. interosseous membranes of the forearm in 18 of 23 (78.3%), of the leg in 14 of 23 (60.1%) and of the ribs in 11 of 23 (47.8%). Urinalysis showed markedly increased urinary fluoride in 14 of 23 patients (60.9%). All the patients were followed up from 12 months to 9 years and 3 months, with an average of 4 years and 5 months. The JOA score increased significantly at the end of follow up (P = 0.0001). The recovery rate was 51.83 ± 32.36%. Multiple regression analysis revealed that the preoperative JOA score was an important predictor of surgical outcome (p = 0.0022, r = 0.60628). ANOVA analysis showed that patients with acute onset or too long duration had worse surgical result (P = 0.0003).
Conclusion
Fluorosis can cause ossification of thoracic ligamentum flavum, as well as other ligaments. En bloc laminectomy decompression was an effective method. Preoperative JOA score was the most important predictor of surgical outcome. Patients with acute onset or too long duration had worse surgical outcome.
doi:10.1186/1749-799X-1-10
PMCID: PMC1636628  PMID: 17150117
13.  Upper Thoracic Myelopathy Caused by Delayed Neck Extensor Weakness in Myotonic Dystrophy 
Annals of Rehabilitation Medicine  2012;36(4):569-572.
Myotonic dystrophy is the most common autosomal dominant myopathy in adults. Our patient, a 41 year-old female suffering from myotonic muscular dystrophy, developed upper thoracic myelopathy due to hypertrophy of the ligamentum flavum and the posterior longitudinal ligament. She had a typical hatchet face and ptosis with "head hanging forward" appearance caused by neck weakness. Motor weakness, sensory changes and severe pain below T4 level, along with urinary incontinence began 3 months ago. Genetic and electrodiagnostic studies revealed myotonic dystrophy type 1. Magnetic resonance imaging of the spine showed loss of cervical lordosis and spinal cord compression due to hypertrophied ligamentum flavum and posterior longitudinal ligament at T1 to T3 level. We concluded that her upper thoracic myelopathy was likely related to the thickness of the ligamentum flavum and posterior longitudinal ligament due to repetitive mechanical stress on her neck caused by neck muscle weakness with myotonic dystrophy.
doi:10.5535/arm.2012.36.4.569
PMCID: PMC3438427  PMID: 22977786
Myotonic dystrophy; Neck weakness; Thoracic myelopathy
14.  Serum Levels of TGF-β1, TIMP-1 and TIMP-2 in Patients with Lumbar Spinal Stenosis and Disc Herniation 
Asian Spine Journal  2007;1(1):8-11.
Study Design
The serum levels of transforming growth factor-beta 1 (TGF-β1), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) and TIMP-2 were measured by enzyme-linked immunosorbent assay.
Purpose
To compare the serum levels of TGF-β1, TIMP-1 and TIMP-2 between patients with lumbar spinal stenosis and disc herniation.
Overview of Literature
It has been reported that increased concentrations of TGF-β1, TIMP-1 and TIMP-2 in the ligamentum flavum might be a possible pathogenesis for ligamentum flavum hypertrophy in spinal stenosis. However, it is not determined whether this phenomenon in spinal stenosis is a local or systemic problem.
Methods
The concentrations of TGF-β1, TIMP-1 and TIMP-2 were quantitatively analyzed by ELISA in the ligamentum flavum and serum of patients with lumbar spinal stenosis (n=16) and disc herniation (n=16). The thickness of ligamentum flavum was measured on axial T1-weigted magnetic resonance image. The biochemical and radiological results were compared for the two conditions.
Results
The thickness of the ligamentum flavum was larger in patients with spinal stenosis compared with that with disc herniation (p=0.001). The mean concentrations of TGF-β1, TIMP-1, and TIMP-2 in the ligamentum flavum were significantly higher in patients with spinal stenosis than those with disc herniation (all, p < 0.05). However, the difference in serum levels of TGF-β1 (p=0.464), TIMP-1 (p=0.146) and TIMP-2 (p=0.794) was not significant between the lumbar spinal stenosis and disc herniation patients.
Conclusions
Despite increased levels of TGF-β1, TIMP-1, and TIMP-2 in the ligamentum flavum of spinal stenosis patients compared to disc herniation patients, the serum levels of TGF-β1, TIMP-1 and TIMP-2 were very similar in both groups. These results indicate that the role of TGF-β1, TIMP-1 and TIMP-2 on hypertrophy of the ligamentum flavum in spinal stenosis patients is a local phenomenon, not systemic.
doi:10.4184/asj.2007.1.1.8
PMCID: PMC2857497  PMID: 20411146
Spinal stenosis; Hypertrophy of ligamentum flavum; TGF-β1; TIMPs; Local phenomenon
15.  Morphological changes of the ligamentum flavum as a cause of nerve root compression 
European Spine Journal  2004;14(3):277-286.
The ligamentum flavum is considered to be one of the important causes of radiculopathy in lumbar degenerative disease. Although there have been several reports anatomically examining the positional relationship between the ligamentum flavum and nerve root, there are few reports on ventral observation. The purpose of this study is to clarify the shape of the ligamentum flavum seen ventrally, and to obtain anatomic findings related to nerve root compression. The subjects were 18 adult embalmed cadavers, with an average age of 78 years at the time of death. The ventral shapes of the ligamentum flavum were observed. The relationships between the morphological change of the ligamentum flavum and nerve root compression or radiographic findings were statistically evaluated. Among the shapes of the ligamentum flavum, bulging of the ligament was most frequently observed. Proximal bulging indicates the type with the cranial portion bulging from the subarticular zone to the foraminal zone of the ligamentum flavum. In this type associated with a decrease in disc height, nerve root compression was frequently observed. Thus, we could more realistically grasp the relationship between bulging morphology of the ligamentum flavum and nerve root compression.
doi:10.1007/s00586-004-0782-5
PMCID: PMC3476746  PMID: 15583951
Lumbar spine; Ligamentum flavum; Anatomy; Nerve root compression; Disc height
16.  Cervical cyst of the ligamentum flavum and C7-T1 subluxation: case report 
European Spine Journal  2005;14(8):807-809.
A patient with progressive gait disturbance resulting from a cyst of the cervical ligamentum flavum associated with C7-T1 listhesis is reported. Surgical removal of the cyst improved the patient’s myelopathy. Intraspinal degenerative cysts are preferentially located in the lumbar region:unusual is the cervical localization. Differential diagnosis includes ligamentum flavum cyst, synovial and ganglion cysts. Association between degenerative intraspinal cysts and listhesis is discussed. To our knowledge, this is the first case of cyst of the ligamentum flavum associated with cervical subluxation.
doi:10.1007/s00586-005-0913-7
PMCID: PMC3489245  PMID: 15981000
Cyst; Ligamentum flavum; Cervical spine; Subluxation
17.  Easily misdiagnosed delayed metastatic intraspinal extradural melanoma of the lumbar spine: A case report and review of the literature 
Oncology Letters  2013;5(6):1799-1802.
Metastatic melanoma of the spine usually occurs as vertebral metastatic melanoma or intramedullary spinal cord metastatic melanoma. The present study reports a case of easily misdiagnosed delayed metastatic intraspinal extradural melanoma of the lumbar spine. A 67-year-old female patient presented with lower back pain accompanied by progressive intermittent claudication. Magnetic resonance imaging (MRI) suggested compression of the lumbar spinal cord caused by an extradural mass. The mass showed T2-hypointensity, T1-hypointensity and slight enhancement following a gadolinium-contrast injection. The patient had been diagnosed with a vulvar melanoma 13 years previously and had also undergone a resection of this tumor. A current diagnosis of a lumbar stenosis resulting from hypertrophy of the ligamentum flavum was suspected. However during corrective surgery, a dark gray solid mass was observed. An L3 laminectomy and removal of the tumor was performed. The tumor was confirmed to be a malignant melanoma by histopathological investigation. The patient was treated with radiotherapy and immunotherapy. At the final 13-month follow-up, the patient showed no signs of recurrence. It may be concluded that an early diagnosis of metastatic melanoma was prevented by delayed metastasis, the location of the mass and its unusual appearance in MRI scans. In such cases, early surgical removal and an appropriate comprehensive treatment are critical for patient survival. These observations suggest that caution should be used in the diagnosis of similar cases.
doi:10.3892/ol.2013.1299
PMCID: PMC3700799  PMID: 23833644
metastatic melanoma; lumbar spine; extradural; delayed metastasis; lumbar stenosis; misdiagnosed
18.  Cervical myelopathy due to degenerative spondylolisthesis 
Upsala Journal of Medical Sciences  2011;116(2):129-132.
Objective
To investigate clinical-radiological features of cervical myelopathy due to degenerative spondylolisthesis (DSL).
Methods
A total of 448 patients were operated for cervical myelopathy at Nishitaga National Hospital between 2000 and 2003. Of these patients, DSL at the symptomatic disc level was observed in 22 (4.9%) patients. Clinical features were investigated by medical records, and radiological features were investigated by radiographs.
Results
Disc levels of DSL were C3/4 in 6 cases and C4/5 in 16 cases. Distance of anterior slippage was 2 to 5 mm (average 2.9 mm) in flexion position. Space available for the spinal cord (SAC) was 11 to 15 mm (average 12.8 mm) in flexion position and 11 to 18 mm (average14.6 mm) in extension position; 11 cases were reducible and 11 cases were irreducible in extension position. Myelograms demonstrated compression of spinal cord by the ligamentum flavum in extension position. Compression of spinal cord was not demonstrated in flexion position. C5-7 lordosis angle was lower than control. C5-7 range of motion (ROM) was reduced compared to controls. These alterations were statistically significant.
Conclusions
DSL occurs in the mid-cervical spine. Lower cervical spine demonstrated restricted ROM and lower lordosis angle. Pathogenesis of cervical myelopathy due to DSL is compression of spinal cord by the ligamentum flavum in extension position and not by reduced SAC in flexion position.
doi:10.3109/03009734.2011.551932
PMCID: PMC3078542  PMID: 21329487
Cervical spine; degenerative spondylolisthesis; myelopathy
19.  Ossification of the ligamentum flavum as cause of thoracic cord compression: Case report of a Latin American man and review of the literature 
Background:
Ossification of the ligamentum flavum is a widely described pathology in eastern Asia. Cases have been reported in northern Africa, the Middle-East, India, the Caribbean, Europe, and North America, but no cases from Latin America have been published in the literature. It affects mostly elderly men, with a possible association with obesity and type 2 diabetes.
Case Description:
A 38-year-old previously healthy Latin American male presented to the emergency room department with severe functional disability and a 3/5 paraparesis. Blood reports showed no abnormalities. Computed tomography and magnetic resonance imaging showed a ligamentum flavum ossification with myelopathy. The patient underwent a T3-T9 laminotomy. At hospital discharge, the patient remained with a 3/5 paraparesis, mild hypoesthesia in both lower limbs and bladder incontinence. Rectal sphincter was continent. At 6 months, he was able to walk with a cane, with no sphincter or sensory alterations.
Conclusions:
Ligamentum flavum ossification is rare. To our understanding, this is the first case reported in the Latin American population.
doi:10.4103/2152-7806.118489
PMCID: PMC3784953  PMID: 24083054
Dorsal stenosis; ligamentum flavum ossification; thoracic myelopathy
20.  Ossification process involving the human thoracic ligamentum flavum: role of transcription factors 
Arthritis Research & Therapy  2011;13(5):R144.
Introduction
Ossification of the ligamentum flavum (OLF) of the spine is associated with serious neurologic compromise, but the pathomechanism of this process remains unclear. The objective of this study was to investigate the pathomechanism of the ossification process, including the roles of various transcriptional factors in the ossification of human thoracic ligamentum flavum.
Methods
Sections of the thoracic ligamentum flavum were obtained from 31 patients with OLF who underwent posterior thoracic decompression, and from six control patients free of OLF. Cultured ligamentum flavum cells (n = 6, each) were examined with real-time reverse transcription-polymerase chain reaction (RT-PCR) analysis for Sry-type high-mobility group box 9 (Sox9), runt-related transcription factor 2 (Runx2), muscle segment homeobox 2 (Msx2), Osterix, distal-less homeobox 5 (Dlx5), and AP-1. The harvested sections were examined with hematoxylin-eosin, the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) method, and immunohistochemistry for the transcriptional factors.
Results
Compared with the control, the OLF showed disorganization of the elastic fiber bundles and abundant hypertrophic chondrocytes in the ossification front. TUNEL-positive chondrocytes were found near the ossified plaques. The mRNA expression levels of Sox9, Runx2, Msx2, and AP-1 in cultured cells from the ligamentum flavum of OLF patients were significantly different from those of the control. OLF samples were strongly immunoreactive to Sox9, Runx2, and Msx2 at proliferating chondrocytes in the fibrocartilage area. Hypertrophic chondrocytes were positive for Runx2, Osterix, Dlx5, and AP-1.
Conclusions
The ossification process in OLF seems to involve chondrocyte differentiation under the unique expression of transcriptional factors. Accumulation of hypertrophic chondrocytes was evident around the calcified area at the ossification front, and we suggest that the differentiation of these cells seems to be concerned with the ossification process.
doi:10.1186/ar3458
PMCID: PMC3308072  PMID: 21914169
21.  The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum 
European Spine Journal  2009;18(5):679-686.
Load and activity changes of the spine typically cause symptoms of nerve root compression in subjects with spinal stenosis. Protrusion of the intervertebral disc has been regarded as the main cause of the compression. The objective was to determine the changes in the size of the lumbar spinal canal and especially those caused by the ligamentum flavum and the disc during loaded MRI. For this purpose an interventional clinical study on consecutive patients was made. The lumbar spines in 24 supine patients were examined with MRI: first without any external load and then with an axial load corresponding to half the body weight. The effect of the load was determined through the cross-sectional areas of the spinal canal and the ligamentum flavum, the thickness of ligamentum flavum, the posterior bulge of the disc and the intervertebral angle. External load decreased the size of the spinal canal. Bulging of the ligamentum flavum contributed to between 50 and 85% of the spinal canal narrowing. It was concluded that the ligamentum flavum, not the disc had a dominating role for the load induced narrowing of the lumbar spinal canal, a finding that can improve the understanding of the patho-physiology in spinal stenosis.
doi:10.1007/s00586-009-0919-7
PMCID: PMC3234003  PMID: 19277726
Ligamentum flavum; Intervertebral disc; Spinal stenosis; Cauda equina; Loaded MRI
22.  Unilateral ossified ligamentum flavum in the high cervical spine causing myelopathy 
Indian Journal of Orthopaedics  2009;43(3):305-308.
High cervical ossified ligamentum flavum (OLF) is rare and may cause progressive quadriparesis and respiratory failure. Our two patients had unilateral OLF between C1 and C4 levels. MR showed a unilateral, triangular bony excrescence with low signal and a central, intermediate or high signal on all pulse sequences due to bone marrow within. There was Type I thecal compression (partial deficit of contrast media ring). The first patient had a linear and nodular OLF with calcification within tectorial membrane, C2–3 fusion and unilateral C2-facetal hypertrophy; and the second patient, a lateral, linear OLF with loss of lordosis and C3–6 spondylotic changes. A decompressive laminectomy using “posterior floating and enbloc resection” brought significant relief in myelopathy. Histopathology showed mature bony trabeculae, bone marrow and ligament tissue. The coexisting mobile cervical vertebral segment above and congenitally fused or spondylotic rigid segment below the level of LF may have led to abnormal strain patterns within resulting in its unilateral ossification. In dealing with cervical OLF, carefully preserving facets during laminectomy or laminoplasty helps in maintaining normal cervical spinal curvature.
doi:10.4103/0019-5413.49385
PMCID: PMC2762168  PMID: 19838355
Cervical spine; laminectomy; ossified ligamentum flavum; myelopathy
23.  Clinical analysis of thoracic ossified ligamentum flavum without ventral compressive lesion 
European Spine Journal  2010;20(2):216-223.
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, χ2 = 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.
doi:10.1007/s00586-010-1515-6
PMCID: PMC3030703  PMID: 20628768
Thoracic; Ossified ligamentum flavum; Compressive myelopathy; Axial type; Laminectomy
24.  Ossification of the Ligamentum Flavum 
Asian Spine Journal  2014;8(1):89-96.
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.
doi:10.4184/asj.2014.8.1.89
PMCID: PMC3939377  PMID: 24596612
Ossification of ligamentum flavum; Treatment; Prognostic factors
25.  Cervical synovial cysts: case report and review of the literature 
European Spine Journal  1999;8(3):232-237.
The authors describe the case of a 58-year-old man with a 6-month history of severe myelopathy. CT scan and MRI of the spine revealed a cystic formation, measuring about 1 cm in diameter, at C7-T1 at a right posterolateral site at the level of the articular facet. At operation the mass appeared to originate from the ligamentum flavum at the level of the articular facet and was in contact with the dura mater. Once the mass had been removed, there was a significant amelioration of the patient’s symptoms. As previously suspected, histological aspect was synovial cyst. Cervical synovial cysts are extremely rare and, as far as we know, only 22 cases have so far been described in the literature. Diagnostic radiological investigations used were CT scan and MRI. At CT scan the most important diagnostic findings are a posterolateral juxtafacet location of the mass, egg-shell calcifications on the wall of the cyst, and air inside the cyst. At MRI the contents of the cyst are iso/hypointense on T1- and hyperintense on T2-weighted images. There may also be a hypointense rim on T2-weighted images, which enhances after i.v. administration of gadolinium. Surgical treatment consists of removal of the mass. Fixation of the vertebral segments involved is not always necessary.
doi:10.1007/s005860050164
PMCID: PMC3611166  PMID: 10413351
Key words Synovial cyst; CT; MRI; Surgical treatment

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