Ligament Flavum Research Articles

Single-stage combined decompression for patients with tandem ossification in the cervical and thoracic spine

Retrospective study of clinical outcomes of single-staged combined cervical and thoracic decompression for patients with tandem ossification (TO). To describe primary clinical outcomes of this procedure. TO is introduced to described a double ossification lesion of the posterior longitudinal ligament (OPLL) or the ligament flavum (OLF) at the cervical, thoracic and lumbar spine. In clinical practice, cervical OPLL combined with thoracic OPLL or/and OLF are the most common types of TO. However, little is known about the clinical outcomes of surgical treatment and there is no consensus on the optimal treatment to this combined disorder. Between January 2005 and December 2008, 15 patients of this complicated phenomenon were treated by single-staged combined cervical and thoracic decompression in conditions where patients' general condition allowed and individuals agreed on. Surgical intervention, perioperative complications, and clinical outcomes were reviewed in these 15 TO patients who were followed up for more than 2 years (range 2-5 years). Clinical symptoms were evaluated using the JOA scoring system and activity of daily life was evaluated by Nurick classification before surgery, at 6 months postoperatively, and at final follow-up. Patient satisfaction was determined at final follow-up. The mean blood loss was 1,553.3 ± 735.7 ml (range 700-2,900 ml) and the mean operation time was 280.7 ± 53.6 min (range 220-370 min). The important intraoperative and postoperative complications recorded in medical documents included CSF leakage, hematoma, C5 palsy and neurological deterioration. The JOA score was significantly higher 6 months after surgery (8.1 ± 1.8 points vs. 11.0 ± 1.6 points, p < 0.0001), and there was no significant change between 6 months after surgery and final follow-up (11.0 ± 1.6 points vs. 11.3 ± 2.1, p = 0.5894). The mean Nurick classification significantly improved from grade 3.6 ± 0.7 before surgery to grade 2.5 ± 0.9 at 6 months after surgery (p < 0.001), and well maintained as grade 2.3 ± 1.0 at final follow-up (p = 0.3343). Three patients had satisfaction scores of 3 points, 5 had scores of 2 or 1 point, and 2 had score of 0 point. Pearson correlation analysis showed a significant positive correlation between satisfaction score and JOA score (r = 0.6493, p = 0.0093), and a significant negative correlation between satisfaction score and Nurick classification (r = -0.5941, p = 0.0195). Besides, perioperative complications and progression of tandem ossification which needed revision surgery had significant adverse effect on patients' satisfaction. The results showed that single-staged combined decompression could provide comparable clinical outcomes, and patients' satisfaction was significantly related with postoperative neurological function. In addition, satisfaction score could be decreased by perioperative complications and progression of tandem ossification. Thus, this aggressive surgical strategy should be used more carefully with emphasis on preoperative communication with patients.

Ligament flavum hematoma in the lumbar spine: a case of showing rapid progress of neurological symptoms

Ligament flavum hematoma in the lumbar spine: a case of showing rapid progress of neurological symptoms

Association Study of Fibroblast Growth Factor 2 and Fibroblast Growth Factor Receptors Gene Polymorphism in Korean Ossification of the Posterior Longitudinal Ligament Patients

ObjectiveThe aim of this study was to determine whether single nucleotide polymorphisms (SNPs) of fibroblast growth factor (FGF) 2 gene and fibroblast growth factor receptor (FGFR) genes are associated with ossification of the posterior longitudinal ligament (OPLL).MethodsA total of 157 patients with OPLL and 222 controls were recruited for a case control association study investigating the relationship between SNPs of FGF2, FGFR1, FGFR2 and OPLL. To identify the association among polymorphisms of FGF2 gene, FGFR1, FGFR2 genes and OPLL, the authors genotyped 9 SNPs of the genes (FGF2 : rs1476217, rs308395, rs308397, and rs3747676; FGFR1 : rs13317 and rs2467531; FGFR2 : rs755793, rs1047100, and rs3135831) using direct sequencing method. SNPs data were analyzed using the SNPStats, SNPAnalyzer, Haploview, and Helixtree programs.ResultsOf the SNPs, a SNP (rs13317) in FGFR1 was significantly associated with the susceptibility of OPLL in the codominant (odds ratio=1.35, 95% confidence interval=1.01-1.81, p=0.048) and recessive model (odds ratio=2.00, 95% confidence interval=1.11-3.59, p=0.020). The analysis adjusted for associated condition showed that the SNP of rs1476217 (p=0.03), rs3747676 (p=0.01) polymorphisms in the FGF2 were associated with diffuse idiopathic skeletal hyperostosis (DISH) and rs1476217 (p=0.01) in the FGF2 was associated with ossification of the ligament flavum (OLF).ConclusionThe results of the present study revealed that an FGFR1 SNP was significantly associated with OPLL and that a SNP in FGF2 was associated with conditions that were comorbid with OPLL (DISH and OLF).

Influence of Hinge Position on the Effectiveness of Expansive Open-door Laminoplasty for Cervical Spondylotic Myelopathy

A prospective study. To assess the influence of different hinge positions on the clinical results of expansive open-door laminoplasty (EOLP) for cervical spondylotic myelopathy (CSM). EOLP is currently the most widely adopted surgical treatment for CSM, although many long-term clinical follow-up studies have reported that most patients recover satisfactorily after EOLP, there have been numerous reports regarding postoperative complications, such as stubborn axial symptoms and segmental motor paralysis. The hinge position in EOLP plays a decisive role in determining the openness of the door so that affect clinical outcomes, whereas no thorough studies on the hinge positions have been published. A total of 102 consecutive CSM patients who underwent EOLP from February 2006 to February 2007 were enrolled in this randomized controlled trial and assigned alternatively to 1 of 2 treatment groups. Using a random digits table, 57 patients with the hinge located at the inner margin of the lateral mass were classified as wide-open group, whereas 45 patients with the hinge positioned at the lamina margin served as narrow-open group. All patients were followed up over 24 months, clinical results including operation duration, intraoperative bleeding volume, Japanese Orthopaedic Association scores, axial symptoms assessment, and C5 palsy, and radiologic examinations like C2-C7 angle, cervical curvature index, and range of motion were analyzed statistically. In this study, there were no significant differences in terms of operation duration, intraoperative bleeding volume, neural function recovery rate, curvature index, and range of motion. The neural functions were satisfactorily improved after EOLP in both groups (Japanese Orthopaedic Association score developed from 7.2 ± 1.1 to 14.3 ± 1.2 and 8.1 ± 0.9 to 15.1 ± 1.6 with P = 0.01 and 0.02, respectively), whereas the severity of axial symptoms was significantly lower in narrow-open group than in wide-open group (P<0.01). The incidence of C5 palsy in wide-open group was higher than that in narrow-open group (5.3% vs. 0%), even though the difference did not reach statistical significance (1-tailed Fisher exact test, P = 0.17). Our results indicate that proper inward shift of the hinge can ensure effectiveness of surgical decompression, avoid an excessive backward shift of the spinal cord, reduce the incidence of C5 palsy, and alleviate the severity of axial symptoms. In addition, an inward shift should be cautious and contraindicated in patients with fluorosis cervical stenosis, ossification of posterior longitudinal ligament, and ossification of ligament flavum.

Postlaminectomy synovial cyst formation: A possible consequence of ligamentum flavum excision

Ligamentum flavum is generally resected with impunity when a laminectomy is performed; it is a strong ligament and its removal may not be inconsequential. We sought to examine the consequence of resection of ligamentum flavum as it pertains to the formation of synovial cysts. Following IRB approval, we retrospectively reviewed the charts of consecutive patients who underwent a laminectomy for any diagnosis during the years 2009-2010. Exclusions were made for patients undergoing resection of a synovial cyst, laminectomy done as part of a fusion, and microdiscectomy. A total of 201 laminectomies were performed. 10 instances of post-laminectomy synovial cyst occurred in only the lumbar spine. Synovial cysts occurred exclusively after surgery for stenosis (n = 10). Laminectomy and resection of the ligament flavum is a risk factor for the subsequent formation of a synovial cyst. Secondary synovial cyst formation should be suspected in individuals who develop radiculopathy after laminectomy for stenosis.

Spinal lumbar stenosis: an update

Spinal lumbar stenosis is a disease that occurs mainly between the 5th and 7th decade of life and can be congenital or acquired. The latter has many etiologies, but a degenerative cause is the most common. Stenosis is a narrowing of the spinal canal diameter caused by many factors such as bulging discs, hypertrophy of flavum ligament, facet capsule thickening and osteophyte formation. The classical symptom of the disease is sciatic pain, that improves with lumbar flexion and worsens with ambulation. Neurological examination is often normal and the most useful imaging test is magnetic resonance imaging (MRI). Conservative management consists in non-steroidal anti-inflammatory drugs, muscle relaxants, physical therapy and epidural - radicular infiltrations. Spinal infiltrations have a proven efficacy for pain management. A good result of this therapy predicts a favorable outcome after surgery. Surgical treatment consists in decompression with or without lumbar fusion. The addition of an arthrodesis is recommended for degenerative spondylolisthesis, correction of deformities, recurrent spinal stenosis with instability, sagittal or coronal imbalance and adjacent segment disease.

The Angiogenic Capacity from Ligament Flavum Subsequent to Inflammation: A Critical Component of the Pathomechanism of Hypertrophy

Spinal canal stenosis, the most common spinal disorder in elderly patients, leads to lower back and leg pain, and paresis. Despite several attempts, the pathomechanism of ligament flavum(LF) hypertrophy has not yet been thoroughly clarified.

Magnetic resonance imaging of the lumbar spine with axial loading: A review of 120 cases

To evaluate the imaging findings of patients with clinical symptoms of lower back pain who underwent magnetic resonance imaging (MRI) of the lumbar spine with axial loading. We examined 120 patients by MRI, before and after axial loading, using a compression device that applied 50% of their body weight for a load time of 5min. The dural sac cross area (DSCA) was examined by two experienced radiologists before and after axial load, and their findings were compared. Degenerative abnormalities within and adjacent to the spinal canal were also analyzed. A reduction in DSCA greater than 15mm(2) after axial load was defined as significant, and was found in 81 patients (67.5%) and 138 disc spaces (38.3%). Reduction was most frequent at L4-L5 (n=55). For other disorders, a 9% increase in cases of bulging disc was seen during axial loading, and seven disc spaces showed protrusion/extrusion only after load. Facet joint synovial cysts, foraminal stenosis, and hypertrophy of the flavum ligaments showed almost no differences, pre- and post-load. For adequate evaluation of lumbar symptoms, examination should be performed with axial loading, especially in cases of suspected spinal stenosis.

Comparison of Magnetic Resonance Imaging and Computed Tomography-Myelography for Quantitative Evaluation of Lumbar Intracanalar Cross-Section

PurposeA comparison of MRI and computed tomography-myelography (CTM) for lumbar intracanalar dimensions. To compare the capability and reproducibility of MRI and CTM in measuring the cross-sectional morphology of intracanalar lesions of the lumbar spine.Materials and MethodsMRI and CTM of lumbar disc levels from 61 subjects with various lumbar spinal diseases were studied. Dural area, dural anteroposterior (AP) diameter, dural right-left diameter, and thickness of the ligamentum flavum were measured by two orthopedic surgeons. Each section was graded by degree of stenosis. Absolute value and intra- and inter-observer correlation coefficients (ICC) of these measurements and the associations between MRI and CTM values were determined.ResultsExcept for MRI determination of ligament flavum thickness, CTM and MRI and intra- and ICC suggested sufficient reproducibility. When measurements of dural area, dural AP diameter, and RL diameter were compared, values in CTM were significantly (p = 0.01-0.004) larger than those in MRI (CTM/MRI ratios, 119%, 111%, and 105%, respectively). As spinal stenosis became more severe, discrepancies between CTM and MRI in measurements of the dural sac became larger.ConclusionBoth CTM and MRI provided reproducible measurements of lumbar intracanalar dimensions. However, flavum thickness may be more accurately measured by CTM. Because the differences in the measurements between CTM and MRI are very slight and there is very little data to suggest that the precise degree of stenosis is related to symptoms or treatment outcome, the usefulness of the CTM over MRI needs to be confirmed in future studies.

Tissue Transglutaminase Expression and Activity in Human Ligamentum Flavum Cells Derived From Thoracic Ossification of Ligamentum Flavum

The study was undertaken to compare the expression and activity of tissue transglutaminase (TG2) in human ligamentum flavum cells derived from ossification of the ligamentum flavum (OLF) and non-OLF patients. To determine whether TG2 is involved in the pathologic process of OLF. OLF is a disease characterized by heterotopic formation of new bone in the flavum ligament. Recently, TG2 is proved to directly promote skeletal matrix mineralization and play an important role in the ossification. TG2 activity is vital to the differentiation of osteoblasts and the formation of mineralization. But whether TG2 is involved in the pathologic process of OLF is unknown. We investigated the relations between TG2 expression and OLF. OLF and non-OLF cells were cultured and osteocalcin, bone morphogenetic protein-2(BMP-2) and TG2 mRNA expressions were assayed by reverse transcription polymerase chain reaction. Meanwhile, alkaline phosphatase activity and calcified nodules were compared between OLF and non-OLF cells. To detect TG2 expression, Western blot and immunohistochemical analysis were carried out, and TG2 activity was compared between OLF and non-OLF cells. Our experiments demonstrated that OLF cells showed osteoblast-like activity and increased mRNA expression of BMP-2. More interesting, compared with non-OLF cells, OLF cells showed elevated expression levels of TG2 mRNA and protein, as well as enzyme activity. TG2 expression and enzyme activity are upregulated in the OLF cells and TG2 may be involved in the pathologic process of OLF.

Microsurgical decompression of lumbar spinal stenosis

Lumbar spinal stenosis in most cases is due to progressive degeneration of the spine, resulting in thickening of facet joints and flaval ligament. Thus the diameter of the lumbar spinal canal is reduced to less than 12 mm in the AP direction. Typically complaints consist in neurogenic claudication. Patients usually experience improvement of pain when bending their back or walking up a hill. Diagnosis of lumbar spinal stenosis is confirmed by MRI. CT myelography may help detect where compression is most pronounced. Surgical treatment should be based on the clinical symptoms of the mostly elderly people and should be performed as microsurgical decompression or in cases of clinical instability as TLIF.

A case of ligament flavum hematoma in the cervical spine

A case of ligament flavum hematoma in the cervical spine

Intérêt de l’échographie en ALR pédiatrique

The use of ultrasonographic guidance for regional anaesthesia has known recently a big interest in children in recent years. The linear ultrasound probes with a 25 mm active surface area (or probes with 38 mm active surface area in older children), with high sound frequencies in the range 8–14 MHz, allow a good compromise between excellent resolution for superficial structure and good penetration depths. In children, the easiest ultrasound guided blocks are axillar blocks, femoral blocks, fascia iliaca compartment blocks, ilio-inguinal blocks and para-umbilical blocks, caudal blocks. They permit a safe and easy learning curve of these techniques. The main advantage of ultrasound guided regional anaesthesia is the visualization of different anatomical structures and the approximate localization of the tip of needle. The other advantages for ultrasound guided peripheral nerve blocks in children are: faster onset time of sensory and motor block, longer duration of sensory blockade, increase of blockade quality and reduction of local anesthetic injection. The use of ultrasonographic guidance for central block allows to visualize different structures as well as spine and his content. Spinous process, ligament flavum, dura mater, conus medullaris and cerebrospinal fluid are identifiable, and give some information on spine, epidural space and the depth between epidural space and skin. At last, in caudal block, ultrasounds permit to evaluate the anatomy of caudal epidural space, especially the relation of the sacral hiatus to the dural sac and the search of occult spinal dysraphism. Benefit of this technique is the visualization of targeted nerves or spaces and the spread of injected local anaesthetic.

Thoracic compressive myelopathy due to post-traumatic intradural migration of ossified yellow ligament: Case report

Focal ossification of the ligament flavum (OLF) is a rare cause of thoracic myelopathy. The lower thoracic spine is most frequently affected. It is increasingly being recognized as a cause of myeloradiculopathy with advent of computed tomographic (CT) and magnetic resonance (MR) imaging of spine. We report an instance of ossified ligamentum flavum infiltrating and penetrating segmental dura as a result of trauma causing compressive myelopathy in a middle-aged female.

Long-term Follow-up Results and Radiographic Findings of Anterior Surgery With Cloward Trephination for Cervical Spondylotic Myelopathy

Serial retrospective long-term follow-up study. To assess the long-term results of anterior surgery with Cloward trephination and iliac strut grafting for cervical spondylotic myelopathy. Anterior surgery remains the most common surgical option and generally gives good results, although early and late deterioration after initial postoperative improvement has been noted. Although anterior decompression with trephination is a variant of the Cloward technique, little information is available concerning the long-term results after this procedure. One hundred sixty-eight consecutive patients treated with this technique by the same author from the years 1978 to 1992 were followed serially. One hundred and seven patients were followed for over 10 years (mean: 14.1 y) (follow-up rate: 71.8%). Clinical results were evaluated according to the Japanese Orthopedic Association system and the results at different postoperative intervals were analyzed. Thirty-six patients returned for the final follow-up. Plain radiographs were taken in neutral and flexion-extension positions and computed tomography scans were taken at fused segments and unfused levels. The mean recovery rate was 56.8% at final follow-up. Deterioration of 2 Japanese Orthopedic Association points or more was experienced in 44 patients at various postoperative periods and was more frequent at over 10 years follow-up. Kyphosis of fused segments was noted frequently on the radiographies of the 36 patients with a mean of 7.8 degrees. A straight or misaligned cervical spine was found in 28 (77.8%) patients and these deformities were more serious in multilevel fusions. Stenosis of the canal at fused segments was found in 15 (41.7%) patients owing to osteogenesis resulting from inadequate decompression or pseudoarthrosis. At unfused levels, the incidence of spondylolisthesis, bony bridge, disc hernia, and thickening or bulging of the ligament flavum was 19.4%, 27.8%, 33.3%, 19.4%, respectively, and these abnormalities almost always occurred at levels adjacent to the fusion. Radiographic abnormalities were pejorative for long-term clinical results. Anterior surgery with Cloward trephination provides generally acceptable long-term results with considerable incidences of deterioration and radiographic abnormalities. This underlines the need for thorough decompression and preservation of the subchondral endplate bone for solid fusion and maintenance of the cervical lordotic curvature.

Experimental study of reservation flaval ligament on prevention of peridural adhesion after operation on lumbar disc

Through an experiment in rabbits, to evaluate the role of reservation flaval ligament using different methods to prevent the epidural adhesion by observing the morphological changes and provide experiment evidences for clinic. 45 adult rabbits were divided into three groups: Group A (treated with no reservation of flaval ligament), Group B (treated with reserving half flaval ligament), and Group C (treated with reserving the complete flaval ligament). Every group has 15 rabbits. At the 2nd, 4th and 8th weeks, the samples were obtained for gross observation, histological examinations, and the images were analysed by computer. The data were processed using SPSS11.5. Gross Observation and Histological Examinations, at the 2nd, 4th and 8th postoperative week, there was significant difference between the group A, B and C (gross observation: F2w=4.660, F4w=8.591, F8w=31.858, P<0.05; histological examinations: F2w=5.190, F4w=9.561, F8w=34.658, P<0.05). Images analysis: the difference was very significant in the groups at 2nd, 4th and 8th weeks (F2w=30.783, F4w=47.350, F8w=25.544, P<0.01). With time passing, the ratio became larger and larger in the same group. Reserving the complete flaval ligament can significantly prevent the peridural adhesion from the back as a barrier, and can reduce the adhesion formed.

Degenerative lumbar intervertebral instability: what is it and how does imaging contribute?

IntroductionAlthough low back pain (LBP) is the most commonrheumatologic symptom that leads to consultation with ageneral practitioner, the identification of a specific symp-tomatic cause remains elusive in the majority of patientswith mechanical LBP. Degenerative lumbar intervertebralinstability as a cause of chronic LBP is an important factorin determining indications for spinal surgery.The concept of lumbar instability remains a subject ofconsiderable debate. In spite of many efforts, a widelyaccepted definition of the condition has not been clearlyestablished. The best diagnostic methods and the mostefficacious treatment approaches are controversial, and therelationship between radiologic evidence of instability andsymptom production is not always clear cut.This perspective discusses the role of imaging as apotential unifier of varied clinical labels and therapeuticoptions.PathomechanismsA workable definition of instability is based on a loss ofmotion segment stiffness, such that force application to thatsegment produces greater displacement than would be seenin a normal state [1, 2]. In a biomechanical sense, stiffnessis defined as the ratio of the load applied to a structure andthe resulting motion. Stability to the lumbar spine isprovided by the restraining structures working in conjunc-tion (i.e., disks, joints, ligaments, and muscles) [3].Degenerative processes, leading to laxity of restrainingstructures, result in altered equilibrium and instability [2–6]. The degenerative processes of the lumbar spinegenerally initiate from the intervertebral disk with progres-sive biochemical and structural changes leading to amodification in its physical properties of elasticity andmechanical resistance and eventual collapse of the inter-vertebral disk.Three clinically relevant consequences of acquiredcollapse of the intervertebral disk are: (a) pathologicchanges in the vertebral bodies, with osteophyte develop-ment; (b) anterior bulging of the flaval ligaments andposterior bulging of the posterior longitudinal ligament,with consequential narrowing of the central spinal canal;and (c) posterior bulging of redundant posterior disksurface, with narrowing of the central spinal canal and ofthe inferior recesses of the neural foramina. Moreover,weakening of the disk structure permits the adjacentvertebrae to slide back and forth over each other, resultingin laxity of the ligamentous network binding the vertebrae

Classification and management of the tandem ossification of the posterior longitudinal ligament and flaval ligament

To provide appropriate guidelines for treatment of tandem ossification of the posterior longitudinal ligament (OPLL) and flaval ligament (OFL). Data sources Published articles about OPLL and OFL were selected using Medline and Embase electronic databases. Study selection An English literature search from January 1980 to December 2006 was conducted. Because many reported cases were incorporated in OFL studies, the key words for search were OFL or OFL and OPLL. The first step revealed 93 studies of which 13 reports of tandem OPLL and OFL (tandem ossification) were selected. All studies were case series or case report and advocated that the primary therapy for tandem ossification should be operative. The clinical outcomes of surgery were evaluated in most reports, predominantly using the JOA scores. Gender is the only factor which has prognostic value. A higher proportion of women was found in the failure group. A two-stage classification of tandem ossification was developed to relate diagnosis to outcome. All patients with suspected ossification of the spinal ligaments should undergo routine MRI screening of the whole spine. The correlation of the classification with surgical treatments needs further studies to validate its usefulness.

Lumbar Intraspinal Extradural Ganglion Cysts

The lumbar intraspinal epidural ganglion cyst has been a rare cause of the low back pain or leg pain. Ganglion cysts and synovial cysts compose the juxtafacet cysts. Extensive studies have been performed about the synovial cysts, however, very little has been known about the ganglion cyst. Current report is about two ganglion cysts associated with implicative findings in young male patients. We discuss about the underlying pathology of the ganglion cyst based on intraoperative evidences, associated disc herniation at the same location or severe degeneration of the ligament flavum that the cyst originated from in young patients.

Radiographic Parameters of Segmental Instability in Lumbar Spine Using Kinetic MRI

To investigate the effectiveness of radiographic parameters on segmental instability in the lumbar spine using Kinetic magnetic resonance imaging (MRI). Segmental motion, defined as excessive (more than 3 mm) translational motion from flexion to extension, was investigated in 309 subjects (927 segments) using Kinetic MRI. Radiographic parameters which can help indicate segmental instability include disc degeneration (DD), facet joint osteoarthritis (FJO), and ligament flavum hypertrophy (LFH). These three radiographic parameters were simultaneously evaluated, and the combinations corresponding to significant segmental instability at each level were determined. The overall incidence of segmental instability was 10.5% at L3-L4, 16.5% at L4-L5, and 7.3% at L5-S1. DD and LFH at L3-L4 and FJO and LFH at L4-L5 were individually associated with segmental instability (p<0.05). At L4-L5, the following combinations had a higher incidence of segmental instability (p<0.05) when compared to other segments : (1) Grade IV DD with grade 3 FJO, (2) Grade 2 or 3 FJO with the presence of LFH, and (3) Grade IV DD with the presence of LFH. At L5-S1, the group with Grade III disc and Grade 3 FJO had a higher incidence of segmental instability than the group with Grade I or II DD and Grade 1 FJO. This study showed that the presences of either Grade IV DD or grade 3 FJO with LFH at L4-L5 were good indicators for segmental instability. Therefore, using these parameters simultaneously in patients with segmental instability would be useful for determining candidacy for surgical treatment.