Cervical Ligamentum Flavum Research Articles

Full endoscopic surgery for calcium pyrophosphate deposition disease (CPPD) in the cervical ligamentum flavum: report of two cervical myelopathy cases.

Calcium pyrophosphate deposition disease (CPPD), known as pseudogout, is characterized by the accumulation of calcium pyrophosphate crystals in musculoskeletal structures, primarily joints. While CPPD commonly affects various joints, involvement in the cervical spine leading to myelopathy is rare. Surgical intervention becomes necessary when conservative measures fail, but reports on full endoscopic surgeries are extremely rare. We present two successful cases where full endoscopic systems were used for CPPD removal in the cervical spine. The surgical technique involved a full endoscopic approach, adapting the previously reported technique for unilateral laminotomy bilateral decompression. Full-endoscopic removal of cervical CPPD inducing myelopathy were successfully removed with good clinical and radiologic outcomes. The scarcity of endoscopic cases for cervical ligamentum flavum CPPD is attributed to the condition's rarity. However, our successful cases advocate for endoscopic surgery as a potential primary treatment option for CPPD-induced cervical myelopathy, especially in elderly patients or those with previous cervical operation histories. This experience encourages the consideration of endoscopic surgery for managing cervical ligamentum flavum CPPD as a viable alternative.

The cervical ligamentum flavum area: A new sensitive morphological parameter for identifying the cervical spinal stenosis.

Thickening of the cervical ligamentum flavum (CLF) has been considered as a main cause of cervical spinal stenosis (CSS). A previous study reported that cervical ligamentum flavum thickness (CLFT) is correlated with CSS. However, the whole hypertrophy is different from focal thickness. Therefore, to analyze hypertrophy of the CLF, we created a new morphological parameter, called the cervical ligamentum flavum area (CLFA). We hypothesized that the CLFA is an important morphological parameter in the diagnosis of CSS. CLF samples were acquired from 83 patients with CSS, and from 84 controls who underwent cervical magnetic resonance imaging (C-MRI). T2-weighted axial C-MRI images were acquired. We measured the CLFA and CLFT at the C6-C7 intervertebral level on C-MRI using appropriate image analysis software. The CLFA was measured as the cross-sectional area of the entire CLF at the level of C6-C7 stenosis. The CLFT was measured by drawing a straight line along the ligament side towards the spinal canal at the C6-C7 level. Mean CLFA was 25.24 ± 6.43 mm2 in the control group and 45.34 ± 9.09 mm2 in the CSS group. The average CLFT was 1.48 ± 0.28 mm in the control group and 2.09 ± 0.35 mm in the CSS group. CSS patients had significantly higher CLFA (P < .01) and CLFT (P < .01). For the validity of both CLFA and CLFT as predictors of CSS, a receiver operating characteristic curve analysis revealed an optimal cutoff point for the CLFA was 31.66 mm2, a sensitivity of 92.8%, specificity of 88.4%, and an area under the curve of 0.97 (95% CI, 0.94-0.99). The optimal cut off-point of the CLFT was 1.79 mm, with a sensitivity of 83.5%, specificity of 84.5%, and an area under the curve of 0.92 (95% CI, 0.87-0.96). Both CLFT and CLFA were significantly related to CSS, but CLFA was the more sensitive measurement parameter. Therefore, to evaluate patients with CSS, treating physicians should test for CLFA.

Do Cervical Parameters Increase the Risk of Thoracic Spinal Stenosis in Patients with Cervical Spinal Stenosis?

The diagnosis and treatment of tandem stenosis have been widely discussed. However, studies on concurrent cervical and thoracic spinal stenosis are rare in the literature. This study was aimed to investigate the risk factors for thoracic spinal stenosis (TSS) in patients with cervical spinal stenosis (CSS). This retrospective cohort study assessed the risk factors for TSS in 162 patients who were diagnosed with CSS. Patients were divided into TSS (n=45) and non-TSS (n=117) groups. We retrospectively analyzed clinical characteristics and radiographic parameters, including age, gender, body mass index, ossification of the cervical posterior longitudinal ligament (OPLLc), hypertrophy of cervical ligamentum flavum (HLFc), cervical stenosis segments, and cervical sagittal parameters. Cervical sagittal parameters were measured on T2-weighted magnetic resonance imaging (MRI), including C2-7 Cobb angle (Cobb), cervical tilt (CT), T1 slope (T1S), thoracic inlet angle (TIA), C2-C7 sagittal vertical axis (C2-C7 SVA) and cervical curvature. Two groups showed significant differences in OPLLc, HLFc, cervical stenosis segments, and TIA. The receiver operating characteristic curves (ROC) demonstrated that the optimal threshold for TIA was 68.25. In multivariate logistic regression analysis, OPLLc (OR=4.403,95% CI=1.782-10.880,P=0.001), HLFc (OR=4.849,95% CI=1.995-11.782,P<0.001) and TIA>68.25 ° (OR=2.555,95%CI=1.044-6.251,p=0.040) were independent risk factors for TSS. Moreover, the multi-index ROC curve demonstrated that the area under the curve for predicted probability was 0.799 (p<0.001). Routine thoracic MRI assessment is strongly recommended in CSS patients with OPLLc, HLFc, and enlarged TIA to screen for neglected but vital thoracic disease.

Calcium pyrophosphate dihydrate of the ligamentum flavum in the cervical spine - A review of the literature.

Calcium pyrophosphate dihydrate (CPPD) deposition, also known as pseudogout, in the cervical ligamentum flavum (CLF), is a rare disease which can cause spinal cord signaling changes leading to rapid deterioration in function. The natural history of cervical myelopathy as a result of CPPD deposition within the CLF is not well understood. Our objective is to describe the presentation, imaging findings, and treatment options of CPPD deposition or pseudogout of the cervical spine. Using PubMed, we analyzed studies published from 1978 to 2022. Key words used were "pseudogout," "CPPD deposit disease," "cervical yellow ligament," "CLF," and "cervical spine." We excluded "crowned dense syndrome" and "ossification of ligament flavum." Using a department database, we queried for patients treated for CPPD of the cervical spine. Twenty clinical studies on CPPD of the cervical spine with 69 patients aged between 15 and 92 years (mean = 72) were identified. Neck pain and numbness of the hands were the most common symptoms. Diabetes mellitus and hypertension were the most common comorbidities. Males and females were affected at equal rates. C4-C5 and C5-C6 were the most affected segments. Earlier surgical treatment produced better outcomes. A laminectomy and fusion or laminoplasty were the most common procedures performed with most patients experiencing some return of neurologic function. Although rare, CPPD deposit disease in the CLF should be readily considered as a differential diagnosis due to the continuously aging population. CPPD's progressively worsening nature makes an early diagnosis and treatment important in improving the patient's overall quality of life.

Best cutoff score of cervical-pedicle thickness as a morphological parameter for predicting cervical central stenosis.

There are various factors for the cause of cervical central stenosis (CCS), such as osteophyte, cervical-disc degeneration, and cervical ligamentum flavum hypertrophy. However, the pedicle of the cervical vertebra has not yet been analyzed for its relationship with CCS. We created a new morphologic parameter called the cervical-pedicle thickness (CPT) to assess the association between CCS and the cervical pedicle.We obtained morphological cases involving the CPT from 82 patients with CCS. There were also 84 in the normal group who underwent cervical spine magnetic resonance imaging (CS-MR) as part of routine health screening. We obtained the T2-weighted CS-MR axial images from group members, and assessed the CPT at the level of the C6 vertebra on CS-MR.The mean CPT was 3.46 ± 0.57 mm in the normal group, 4.97 ± 0.75 mm in the CCS group, which thus had a significantly higher CPT (P < .01) than did the normal group. For the prognostic value of the CPT as a predictor of CCS, ROC analysis indicated that the best cutoff score for the CPT was 4.18 mm, with 93.9% sensitivity, 92.9% specificity, and AUC 0.97.Greater CPT was highly associated with a possibility of CCS. This conclusion will be helpful for assessing the CCS patients.

Cervical spine ligamentum flavum gaps: MR characterisation and implications for interlaminar epidural injection therapy

BackgroundCervical epidural steroid injections are commonly performed to manage pain from cervical spine disease. Cadaveric studies have demonstrated incomplete ligamentum flavum fusion in the central interlaminar region with resultant midline...

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

BackgroundInvolvement in cervical ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease. Only few cases of this condition have been reported. We revealed eighteen cases of CPPD in cervical ligamentum flavum that diagnosed at a single medical center. In our case series, clinical characteristics and magnetic resonance imaging findings of patients are described.MethodsWe retrospectively reviewed the medical charts and imaging studies of the eighteen patients with pseudogout attack of the cervical ligamentum flavum. In addition, we discussed the differences between this disease and ossification of ligamentum flavum in image manifestations.ResultsThere were fourteen men and four women aged between 59 and 87 years. Diabetes mellitus and hypertension were the most common comorbidities. Myelopathy and neck pain were presented in most patients. C4–5 and C5–6 were attacked most frequently, and multiple- rather than single-level involvement could be observed in our series. “Acute on chronic phenomenon” was a specific magnetic resonance image finding in patients whose symptom durations were between 2 to 5 months. Compared to ossification of ligamentum flavum, calcium pyrophosphate dihydrate crystal deposition had different image signs, including morphology, side of the involved ligament, no continuity with the lamina, acute on chronic phenomenon, and presence of retro-odontoid mass.ConclusionsNodular calcifications in cervical ligamentum flavum raise highly suspicion for calcium pyrophosphate dihydrate deposition and must be diagnosed by histological examination and polarized light microscopy. This disease is different from ossification of ligamentum flavum, and it could be recognized by specific image features.

Treatment of a Patient with Ossification of Ligamentum Flavum of Cervical Spine and Literature Review

<i>Background</i>: The ossification of ligamentum flavum occurs frequently in the thoracic vertebra, and the incidence of ossification of cervical ligamentum flavum is relatively low. It is easy to cause misdiagnosis and mistreatment due to lack of understanding in clinical practice. <i>Object</i>: To understand the diagnosis and treatment of cervical ossification of ligamentum flavum through the treatment of one case. <i>Material</i>: A 65-year-old female patient was hospitalized due to "lumbar discomfort with numbness of both lower limbs for 1 year, and aggravation with numbness and weakness of both upper limbs for the last 3 months". Physical examination showed cervical flexion, extension and lateral flexion activities were limited, post extension limitations were obvious, limb muscle strength was grade 4, right knee tendon reflex was active, and bilateral Hoffman sign and right Babinski sign were positive. Cervical JOA score was 8 points. Magnetic resonance imaging of cervical spine showed that there were pressure objects protruding to the spinal canal between C3/4, C5/6, and C6/7 laminae. Sagittal MRI showed segmental or focal nodular space occupying and protruding into the spinal canal from the rear of the spinal canal. Cross sectional MRI showed nodular or "M" shaped occupying space. T1 weighted image was equal signal, and T2 weighted image showed low signal shadow, suggesting high-density ossification and severe spinal cord compression. The effective sagittal diameter was less than 8mm. <i>Method</i>: Hemilaminectomy was performed for a single segmental OLF of C3/4, and a total laminectomy was performed for bilateral and multi-segmental OLF of C5/6, 6/7. According to the range of intraoperative decompression, C5 and 6 posterior lateral mass screws and C7 pedicle screws were fixed. <i>Result</i>: After the operation, the patient indicated that his upper limbs were relaxed, the umbilical horizontal band disappeared, and the muscle strength of his limbs was stronger than that before the operation. She could move freely on the ground, and her holding was more flexible and powerful than before. The postoperative JOA score was 12 points. The postoperative pathological result was fibrous connective tissue and ossification. The follow-up JOA score was increased to 15 points 8 months after operation, and the improvement rate was 78%. The patient could completely take care of herself, and the treatment was satisfactory. <i>Conclusion</i>: Surgical resection of cervical olf and canal decompression is an effective method for the treatment of Cervical OLF and can achieve good clinical results.

Ossification of the cervical ligamentum flavum and case report with myelopathy.

Background:Ossification of the ligamentum flavum (OLF) occurs mostly in adult males, typically in the thoracolumbar spine where it may contribute to neurological deficits. Here we reviewed 68 cases of cervical OLF resulting in progressive quadriparesis.Methods:The literature on cervical OLF was reviewed between 1962 and 2018 along with the case of an 81-year-old male with progressive quadriparesis attributed to cervical OLF.Results:Most patients with cervical OLF are Asian, with Caucasians constituting the second most frequently impacted population.Conclusions:Cervical OLF is typically reported in the Asian, followed by the Caucasian population, and is most often found in the thoracolumbar spine. Here we presented an 81-year-old male with cervical OLF contributing to quadriparesis.

The natural history of spinal deformity in patients with Coffin-Lowry syndrome

PurposeLittle is known about the natural history of spinal deformities in Coffin-Lowry syndrome (CLS). Our goal was to evaluate the spinal deformity progression and clinical impact.MethodsIn this institutional review board-approved study, we performed a multinational retrospective review of six male CLS patients, aged 13 to 22 years at final follow-up, for a mean of 7.25 years (3 to 13).ResultsAll showed delayed skeletal maturity. Three had calcifications of their lower cervical ligamentum flavum, all experienced neural axis abnormalities, including lower extremity weakness, numbness and tingling and in one, quadriparesis. Only two were ambulatory at final follow-up.All had significant spinal abnormalities, including severe progressive thoracic lordosis, thoracolumbar kyphosis and scoliosis. All had undergone spinal fusion or were being evaluated for surgery.ConclusionCLS is a rare X-linked mutation in the RSK2 gene, affecting between 1/50 000 to 100 000 people. There are two reports in the literature of patients with calcifications of their ligamentum flavum. Both had neural axis abnormalities and one had acute onset quadriplegia. Analysis of their ligamentum flavum found abundant central calcifications. Despite our small cohort we found 50% had calcifications and 100% had neurologic consequences associated with those calcifications. There was a 100% rate of deformity progression.They all exhibited delay in skeletal maturity, which mandates longer follow-up and has implications for surgical planning.From our cohort and literature review, the natural history of CLS supports frequent patient evaluation and a lower threshold for correction of spinal deformities. Aiming to avoid spinal cord compression and improve or avoid neurological deterioration.Level of EvidenceIV - retrospective study

Treatment of Cervical Ligamentum Flavum Calcification with Single-Level Double-Door Laminoplasty

Treatment of Cervical Ligamentum Flavum Calcification with Single-Level Double-Door Laminoplasty

Anatomical analysis of human ligamentum flavum in the cervical spine: Special consideration to the attachments, coverage, and lateral extent

Posterior decompression surgeries of cervical spine such as laminoplasty and laminoforaminotomy are well established and increasing in aging population. The anatomical knowledge of cervical ligamentum flavum (LF) is critical to perform posterior spinal surgeries, however, few studies have evaluated it, especially the relation of LF and neural foramen. The whole spine was removed en bloc from 15 formalin-embalmed human cadavers and then divided into two segments along the pedicle bases. A total of 90 LFs from C2-C3 to C7-T1 were measured manually from the ventral side before being painted with iron powder containing contrast agent and scanned by computed tomography. We recorded dimensions, coverage of adjacent laminae, and the relationships between LF and neural foramen or facet joints. Three-dimensional CT data was used to evaluate manually limited areas and make reconstructed images. LF height gradually increased from C2-C3 to C7-T1, and gradually decreased from medial to lateral within each level. LF width and thickness were relatively constant from cranial to caudal. The laminar surface covered by LF gradually increased from 33% in para midline and 30% laterally at C2, and increased to 70% in para midline and 47% laterally at C6, this trend was not completed at C7. The empty zone of the laminar surface (without LF coverage) was located at the upper half of each lamina; this zone gradually decreased from cranial to caudal. The craniomedial side of the cervical facet joint was covered by a mean 4.6±0.7mm of LF, however, LF did not enter the cervical neural foramen. LF did not enter the neural foramen in cervical spine unlike lumbar spine. This information might be critical to avoid neurological deterioration after cervical laminoplasty or laminoforaminotomy. Surgeons would imagine the attachments and coverage of LF and its relation to posterior bony structures to perform safe posterior cervical surgeries.

The Evaluation and Observation of "Hidden" Hypertrophy of Cervical Ligamentum Flavum, Cervical Canal, and Related Factors Using Kinetic Magnetic Resonance Imaging.

Study Design Retrospective cohort study. Objective The objective was to measure the change of flavum ligament diameter during positional changes of the cervical spine using kinetic magnetic resonance imaging (MRI) and to examine the correlational diameter changes of the flavum ligament, disk bulging, and the spinal canal from extension to flexion positions. Methods One hundred eight-nine patients underwent kinetic MRI in neutral, extension, and flexion positions. The diameters of cervical ligamentum flavum, disk bulging, and cervical spinal canal and the disk degeneration grade and Cobb angles were measured from C2–C3 to C7–T1. Results In all, 1,134 cervical spinal segments from 189 patients were included. There was a 0.26 ± 0.85-mm average increase in the diameter of the ligamentum flavum from flexion to extension, and 62.70% of the segments had increased ligamentum flavum diameter from flexion to extension. For all segments of the 189 patients, the cervical spinal canal diameters had an average decrease at the disk level of 0.56 ± 1.21 mm from flexion to extension. For all segments with cervical spinal canal narrowing ≥1 mm from flexion to extension view, the ligamentum flavum diameters at C3–C4 to C5–C6 had significant increases compared with patients with spinal canal narrowing < 1 mm (p < 0.05). For patients with ligamentum flavum hypertrophy of ≥1 mm from the flexion to extension view, the cervical spinal canal diameters at C2–C3, C4–C5, and C5–C6 had significant decreases compared with patients with ligamentum flavum hypertrophy of <1 mm (p < 0.05). Conclusion The “hidden” hypertrophy of ligamentum flavum was significant at C4–C5 and C5–C6 and significantly contributes to the stenosis of cervical spinal canal in the extension position.

English

English

Rare Skeletal Complications in the Setting of Primary Hyperparathyroidism.

Parathyroid carcinoma represents an extremely rare neoplasm with diverse clinical manifestations which vary from asymptomatic patients to severe complications of hypercalcemia or parathyrotoxicosis while skeletal involvement is rather common. Herein we aimed at presenting a unique case of a young patient with rare aggressive skeletal complications of parathyroid cancer that initially were misdiagnosed. Ossification of the cervical ligamentum flavum and skull tumor illustrates erosive bonny lesions of hyperparathyroidism that in association with previous medical history of recurrent nephrolithiasis and biochemical findings guide the diagnosis. We suggest that increased awareness and holistic approach are needed in order to recognize and further investigate signs and symptoms of hyperparathyroidism.

Ligamentum flavum hematomas of the cervical and thoracic spine

ObjectiveTo report extremely rare cases of ligamentum flavum hematomas in the cervical and thoracic spine. Only six cases of thoracic ligamentum flavum hematomas and three cases of cervical ligamentum flavum hematomas have been reported so far. MethodsTwo patients presented with tetraparesis and one patient presented with radicular pain and paresthesias in the T3 dermatome. MRI was performed in two patients, which showed a posterior intraspinal mass, continuous with the ligamentum flavum. The mass was moderately hypointense on T2-weighted images and hyperintense on T1-weighted images with no contrast enhancement. The third patient underwent cervical myelography because of a cardiac pacemaker. The myelography showed an intraspinal posterior mass with compression of the dural sac at C3/C4. ResultsAll patients underwent a hemilaminectomy to resect the ligamentum flavum hematoma and recovered completely afterwords, and did not experience a recurrence during follow-up of at least 2 years. ConclusionThis case series shows rare cases of ligamentum flavum hematomas in the cervical and thoracic spine. Surgery achieved complete recovery of the preoperative symptoms in all patients within days.

Multiple-level ossification of the ligamentum flavum in the cervical spine combined with calcification of the cervical ligamentum flavum and posterior atlanto-axial membrane

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. 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. 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.

Spinal cord compression by hematoma in the cervical ligamentum flavum: a case report

There have been some reports describing hematoma in the thoracic and lumbar ligamentum flavum, but there have been only three reports of hematoma in the cervical ligamentum flavum. We describe another case of the ligamentum flavum hematoma in the cervical spine with a different feature of occurrence that required surgical treatment. Case report. Patient with ligamentum flavum hematoma in the cervical spine. Preoperative magnetic resonance imaging and pathologic finding from operative specimen confirmed the diagnosis. A 69-year-old man insidiously presented with pain in his left upper arm and difficulty in left shoulder abduction. Neurologic examination demonstrated a cervical myelopathy with diffuse muscle weakness of left upper extremity and sensory disturbance. Imaging studies revealed a mass of high intense on T1-weighted images and isointense on T2-weighted images posterior to the dura at C4 lower end level. The patient underwent C4-C5 hemilaminectomy and the removal of the mass. The mass existed within the ligamentum flavum and was connected toward the pedicle like the beads of a rosary. Histopathologic examination of the surgical specimen showed that the hematoma was present within the ligamentum flavum and contained macrophages that had phagocytosed red blood cells and hemosiderin. After surgery, the patients' symptoms immediately improved, and no recurrence was observed at 2 years postoperatively. We reported a very rare case of hematoma in the ligamentum flavum of the cervical spine that required surgery. Because the patient was without the history of trauma, it was suggested that the use of antiplatelet drugs was responsible for the occurrence of the disease.

A cervical ligamentum flavum cyst in an 82-year-old woman presenting with spinal cord compression: a case report and review of the literature

IntroductionWe 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 presentationAn 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.ConclusionCervical 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.

Surgical Treatment for Calcification of the Cervical Ligamentum Flavum

Surgical Treatment for Calcification of the Cervical Ligamentum Flavum