Calcification Of Ligamentum Flavum Research Articles

Cervical Ossification of Ligamentum Flavum: Elaborating anUnderappreciated but Occasional ContributortoMyeloradiculopathy in Aging PopulationBased onSynthesis of Individual Participant Data.

PurposeCervical ossification of ligamentum flavum (COLF) is a rare clinical entity which can occasionally contribute to severe myeloradiculopathy. Many orthopedists are unfamiliar with or underestimate this pathology. Therefore, a comprehensive research is obligatory to reappraise the epidemiological, radiological, clinical and histopathological characteristics of COLF-myeloradiculopathy based on synthesis of individual patient data.MethodsFollowing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, EMBASE, Scopus and Web of Science databases were searched for studies discussing COLF-myeloradiculopathy from the inception to December 2020.ResultsA total of 94 cases from 54 studies were identified. The annual publications demonstrated a steady increase, and most reports were from Japan and China. The mean age was 58.76±13.39 years and nearly 60% of cases occurred in the 55–64 and 65–74 years age group. The male-female ratio was 1.4:1. Most cases belonged to East Asian population (60.64%). COLF predominately appeared in the lower cervical and cervicothoracic spine (76.60%) and mainly affected C4-5 (23.29%) and C5-6 (21.23%). Single-segment type ossification accounted for 62.76 and 45.45% of ossification lesions distributed bilaterally. The majority of COLF (81.1%) were spontaneous, and motor disturbance (76.4%), spinal ataxia (62.5%) and sensory disturbance (58.9%) were the most common manifestations. Histopathologically, it’s a metaplastic process of endochondral ossification with the formation of mature lamellar bone which was distinguished from calcification of ligamentum flavum. About 21.28% of concurrent COLF and COPLL cases were identified as a separated group, with unique characteristics.ConclusionCOLF is an underappreciated but potentially growing pathogeny of myeloradiculopathy in aging population, though its distinct epidemiological, radiological, clinical and histopathological features are not fully supported by current evidence. However, our findings will provide several referential data for future researches to shed light on COLF.

Treatment of cervical spodylotic radiculopathy with posterior intervertebral foraminal discectomy via Delta channel

To explore the clinical efficacy and safety of posterior intervertebral foraminal discectomy via Delta channel for cervical spondylotic radiculopathy in the early phase. From September 2017 to July 2018, 10 patients with cervical spondylotic radiculopathy underwent posterior intervertebral foraminal discectomy via Delta channel. There were 6 males and 4 females, aged from 30 to 62 years old with an average of (41.5±4.3) years old. All of them had unilateral symptoms caused by cervical nerve root compression, including 2 cases of C4,5, 5 cases of C5,6 and 3 cases of C6,7. CT and MRI examination of all the patients did not show ossification of posterior longitudinal ligament or calcification of ligamentum flavum, and no cervical spine instability was present in dynamic radiographs. The clinical outcome was poor after more than 6 weeks of systematic non-surgical treatment. The VAS score, JOA score, NDI score, the cervical spine physiological curvature, and the height and stability of the compressed cervical vertebrae were measured before operation and at the latest follow-up. All patients successfully completed the surgeries without any spinal cord, nerve root or major blood vessel injury. The operation time was 70 to 120 min with an average of 90 min. Intraoperative blood loss ranged from 30 to 90 ml with an average of 40 ml. All the 10 patients were followed up for 6 to 14 months with an average of 9 months. Postoperative nerve root pain got relievd and nerve function was improved in all patients. VAS score decreased from 7.15±2.01 before surgery to 1.59±0.83 at the latest follow-up;JOA score increased from 12.57±1.24 before surgery to 16.42±0.58 at the latest follow-up;NDI score increased from 41.82±4.71 before surgery to 9.59±3.52 at the latest follow-up. All the results above presented significant difference between latest follow-up and preoperative (P< 0.05). The D value of cervical physiological curvature increased from (8.21±0.84) mm before surgery to(10.89±0.96) mm at the latest follow-up, and the difference was also statistically significant (P<0.05). The height of the diseased vertebrae was (5.62± 0.59) mm before surgery and (5.60±0.57) mm at the latest follow-up, with no statistically significant difference(P>0.05). At the latest follow-up, no cervical instability was observed on dynamic radiographs. Treatment of cervical spondylotic radiculopathy by posterior intervertebral foraminal discectomy via Delta channel can obtain a satisfactory clinical outcome without affecting the stability of cervical vertebra. The surgery is safe, reliable and worthy of clinical application.

Obesity and calcification of the ligaments of the spine: a comprehensive CT analysis of the entire spine in a random trauma population

Background ContextObesity, which is currently surging to epidemic levels within the United States, has been linked to hyperostotic conditions like diffuse idiopathic skeletal hyperostosis (DISH) and ossification of the posterior longitudinal ligament (OPLL). Excess adipose tissue and insulin-resistance may cause a systemic increase in serum levels of proinflammatory cytokines and these signals can affect bone metabolism. Spinal ligaments and discs may have receptors for these signaling molecules. Anecdotal observations at this institution suggested that there is a clinically important subset of younger patients with obesity and multilevel stenosis in the presence of unusual calcification of the spinal ligaments that is distinct from DISH. PurposeTo determine if there is an association between truncal obesity and calcifications of the spine in nonelderly adults. Study Design/SettingThis is a retrospective analysis of 214 sequential trauma patients between the ages of 29 and 50. Patients’ age, sex, truncal obesity, history of hypertension, and diabetes were assessed for association with ligamentous calcification of the spine. Patient SampleSequential trauma patients were chosen from our institution's trauma database between 2006 and 2007. MethodsFull spine computed tomography (CT) imaging was examined for bone formation in the region of the anterior longitudinal ligament (ALL) and annulus, posterior longitudinal ligament (PLL) and annulus, and the ligamentum flavum (LF). Visceral and subcutaneous abdominal fat were also evaluated. The authors report no study funding sources or conflicts of interest. Outcome MeasuresCalcification of the ALL, PLL, and LF were assigned a score at each level and then combined for a total calcification score (TCS) for the entire spine. Obesity was estimated using a truncal body mass index (TBMI) by using a previously validated CT derived truncal total adiposity volume (TAV). ResultsALL calcification was associated with age, male gender, hypertension, and increased adiposity. PLL calcification was significantly associated with age and hypertension. LF calcification was only associated with increased obesity. ConclusionsIn our analysis of nonelderly patients, LF calcification was independently associated with truncal obesity. This implies obesity plays a greater role in calcification than could be accounted for by simply age-related degeneration or gender.

MyELOPATHIE PAR OSSIFICATION DU LIGAMENT JAUNE REVELEE PAR UN TRAUMATISME : A PROPOS D’UN CAS ET REVUE DE LA LITTERATURE

Ossification of ligamentum flavum may be asymptomatic or lead to thoracic myelopathy rarely it could be revealed by a spine trauma. The authors made a report on a 23 years old patient who presented a complete paraplegia secondary a car accident. Neuro imaging study (CT scan and MRI) demonstrated T10 T11 spinal cord contusion and in front a calcified and disrupted ligamentum flavum. Calcium, phosphorus and fluor blood were normal. T10 T11 laminectomy has been done. The outcome is good with rapid recovery. Thoracic myelopathy related on calcification of ligamentum flavum is usually a chronically ill condition; sometimes it could be asymptomatic until a trauma revealed it and it needs immediate management. Key words: ossification, compression, spine, traumati

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

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

The mineralogical origin of calcium pyrophosphate dihydrate and carbonate hydroxyapatite depositions in human ligamentum flavum

Calcification of ligamentum flavum (CLF) in cervical spine was characterized in terms of crystal morphology, mineral phases and chemical components. The cause of the disease, forming mechanism, as well as the developing process of the calcification were discussed combined with the pathological results. Micro-FTIR, Raman, scanning electron microscope (SEM), transmission electron microscope (TEM) and synchrotron radiation X-ray diffraction (XRD) were applied to two cases of CLF in cervical spine. The results showed that the calcification mainly presented four kinds of morphology, i.e., columnar, granular, flocculent and spherical. Columnar and granular calcification, which was constituted by single crystals with good crystalline shape and sharp boundary, was identified as triclinic-calcium pyrophosphate dihydrate (t-CPPD). Flocculent or spherical calcification, which was aggregated by nano-polycrystalline, was mainly composed by B-type carbonate hydroxyapatite. The results of micro-FTIR and Raman showed that CPPD and CHA unevenly distributed among the calcification aggregates, where the proportion of CHA decreased but CPPD increased from the center to the periphery. Based on the above analysis, we estimated that granular and columnar CPPD crystals were formed in the initial stage of calcification . In the later stage, the decomposition of CPPD and deposition of CHA occurred on the calcification aggregates, in which the former process provided the material source for CHA formation. During the deposition of CHA, nanocrystals firstly formed, followed by their aggregation into flocculent calcification, and finally forming spherical calcification.

Tissue transglutaminase is involved in mechanical load–induced osteogenic differentiation of human ligamentum flavum cells

ABSTRACTMechanical load–induced osteogenic differentiation might be the key cellular event in the calcification and ossification of ligamentum flavum. The aim of this study was to investigate the influence of tissue transglutaminase (TGM2) on mechanical load–induced osteogenesis of ligamentum flavum cells. Human ligamentum flavum cells were obtained from 12 patients undergoing lumbar spine surgery. Osteogenic phenotypes of ligamentum flavum cells, such as alkaline phosphatase (ALP), Alizarin red-S stain, and gene expression of osteogenic makers were evaluated following the administration of mechanical load and BMP-2 treatment. The expression of TGM2 was evaluated by real-time PCR, Western blotting, and enzyme-linked immunosorbent assay (ELISA) analysis. Our results showed that mechanical load in combination with BMP-2 enhanced calcium deposition and ALP activity. Mechanical load significantly increased ALP and OC gene expression on day 3, whereas BMP-2 significantly increased ALP, OPN, and Runx2 on day 7. Mechanical load significantly induced TGM2 gene expression and enzyme activity in human ligamentum flavum cells. Exogenous TGM2 increased ALP and OC gene expression; while, inhibited TG activity significantly attenuated mechanical load–induced and TGM2-induced ALP activity. In summary, mechanical load–induced TGM2 expression and enzyme activity is involved in the progression of the calcification of ligamentum flavum.

A Case Report on Febrile Neck Pain: Cervical Calcification of Ligamentum Flavum

Calcification of ligamentum flavum (CLF) is an uncommon disorder. This condition is probably underestimated and most reported cases were Japanese patients. A pubmed search found only one Tunisian case report [1]. The most common presentation of CLF is subacute myelopathy due to spinal cord compression by the calcifications in the absence of precipitating factors. CLF in this case occurred in a Caucasian patient who presented misleading clinical symptoms.

Original Etiology of Acute and Febrile Neck Pain: Cervical Calcification of Ligamentum Flavum

Calcification of Ligamentum Flavum (CLF) is an uncommon disorder. We present a 56-year-old patient with an acute inflammatory, febrile neck pain and higher value of ESR mimicking spine infection. The imaging investigations conclude for the diagnosis of calcification of the ligamentum flavum. Our observation illustrate the difficulties to differentiate, clinically, infection and calcium pyrophosphate dihydrate deposition in the spine and emphasize the importance of the imaging step in the diagnosis approach. Finally, we draw attention to the efficacy of medical treatment in our case and we discuss the different therapies proposed in the literature.

Posterior epidural calcified mass of the cervical spine

A non-enhancing triangular calcified mass in the left posterior epidural space is seen on the CT scan and MRI (Fig. 1 arrows) demonstrating continuity with the main bony structure. The density of the external portion of the mass is compatible with that of compact bone, and the density of the internal portion is compatible with that of bone marrow. Radiological findings were typical of osteochondroma, and the patient had a long history of radiculopathy. The diagnosis was confirmed pathologically following the therapeutic excision of the mass. The differential diagnosis of osteochondroma among the posterior epidural space masses includes calcified meningioma, ossified ligamentum flavum (OLF), calcified ligamentum flavum (CLF), and calcified epidural haematoma. Calcified meningiomas show contrast enhancement and the symptoms develop more rapidly when compared to OLF, CLF, and osteochondroma. OLF and CLF are usually bilateral, in contrast to osteochondroma, are V-shaped, broad-based, and are generally found (90%) in Japanese patients. Osteochondroma is the most frequently encountered benign bone tumor but vertebral involvement is rare. There are two types

Biomechanical comparison of a two-level Maverick disc replacement with a hybrid one-level disc replacement and one-level anterior lumbar interbody fusion

Background context Multilevel lumbar disc disease (MLDD) is a common finding in many patients. Surgical solutions for MLDD include fusion or disc replacement. The hybrid model, combining fusion and disc replacement, is a potential alternative for patients who require surgical intervention at both L5–S1 and L4–L5. The indications for this hybrid model could be posterior element insufficiency, severe facet pathology, calcified ligamentum flavum, and subarticular disease confirming spinal stenosis at L5–S1 level, or previous fusion surgery at L5–S1 and new symptomatic pathology at L4–L5. Biomechanical data of the hybrid model with the Maverick disc and anterior fusion are not available in the literature. Purpose To compare the biomechanical properties of a two-level Maverick disc replacement at L4–L5, L5–S1, and a hybrid model consisting of an L4–L5 Maverick disc replacement with an L5–S1 anterior lumbar interbody fusion using multidirectional flexibility test. Study design An in vitro human cadaveric biomechanical study. Methods Six fresh human cadaveric lumbar specimens (L4–S1) were subjected to unconstrained load in axial torsion (AT), lateral bending (LB), flexion (F), extension (E), and flexion-extension (FE) using multidirectional flexibility test. Four surgical treatments—intact, one-level Maverick at L5–S1, two-level Maverick between L4 and S1, and the hybrid model (anterior fusion at L5–S1 and Maverick at L4–L5) were tested in sequential order. The range of motion of each treatment was calculated. Results The Maverick disc replacement slightly reduced intact motion in AT and LB at both levels. The total FE motion was similar to the intact motion. However, the E motion is significantly increased (approximately 50% higher) and F motion is significantly decreased (30%–50% lower). The anterior fusion using a cage and anterior plate significantly reduced spinal motion compared with the condition (p<.05). No significant differences were found between two-level Maverick disc prosthesis and the hybrid model in terms of all motion types at L4–L5 level (p>.05). Conclusion The Maverick disc preserved total motion but altered the motion pattern of the intact condition. This result is similar to unconstrained devices such as Charité. The motion at L4–L5 of the hybrid model is similar to that of two-level Maverick disc replacement. The fusion procedure using an anterior plate significantly reduced intact motion. Clinical studies are recommended to validate the efficacy of the hybrid model.

Cervico-brachial neuralgia caused by spontaneous resorption of ligamentum flavum calcification

Cervico-brachial neuralgia caused by spontaneous resorption of ligamentum flavum calcification

Thoracic myelopathy caused by calcified ligamentum flavum

Calcification of the ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease (CPPD). In CPPD deposition disease, spinal involvement is rare. Until now, thoracic spine CPPD causing thoracic cord compression has been reported in only sporadic cases. We report a new case of thoracic calcification of the ligamentum flavum. In our case, similar to the other reported cases, an affected middle-aged woman despite the clinical and MRI signs of myelopathy had an unexpected important and rapid improvement of the neurological picture. This condition should be considered in differential diagnosis of thoracic cord compression to offer the patient an early and useful surgical treatment.

Estenosis cervical sintomática por calcificación del ligamento amarillo tras traumatismo cervical leve

The calcification of ligamentum flavum (CLF) is a rare disease mainly affecting middle or advanced aged Japanese women. Several clinical and radiological features differentiate CLF from the ossification of the ligamentum flavum (OLF). We present a case of symptomatic cervical-dorsal stenosis presenting after mild cervical trauma in a patient with a remarkable CLF who underwent decompressive laminectomy. The literature regarding CLF is reviewed. A 65 year-old female suffered mild cervical trauma as a consequence of a car accident. A year later she referred progressive cervical and upper dorsal pain without any sensory or motor defect. Spinal magnetic resonance images showed a well-delineated posterior epidural mass, from C2 to T2, which compressed the spinal cord, without signal of myelopathy. She underwent bilateral laminectomy of the affected levels but no clear improvement occurred. The pathological study of the resected pieces showed a remarkable calcification of the ligamentum flavum. The CLF is a kind of dystrophic calcification of unknown pathogenesis but likely related to the spinal degenerative changes. It usually presents in Japanese females. A definite relation between CLF and cervical trauma has not been established so far, although the latter may possibly trigger the symptoms. Typically, CLF presents in women in the seventh decade, affects preferably the cervical region, it shows nodular or diffuse pattern in the computerized tomography, it is hypointense in TI and T2-weighted MR sequences and exhibits minimum enhancement after gadolinium administration. CLF differentiates from OLF easily by demonstrating the presence of mature bone formation in the latter. Clinically, CLF may present as radiculopathy or myelopathy. The treatment of choice in symptomatic patients is posterior decompression. Excellent results after laminectomy are reported. Future similar observations will be important from a medical-legal point of view if a relation between CLF and cervical trauma is established since CLF may potentially turn into a severe condition.

頚椎黄色靭帯石灰化症の手術例の検討

頚椎黄色靭帯石灰化症の手術例の検討

Acute Quadriparesis Caused by Calcification of the Entire Cervical Ligamentum Flavum in a White Female—Report of An Unusual Case And A Brief Review of the Literature

Case report. To describe an extremely unusual case of acute quadriparesis in a white female caused by calcification of the ligamentum flavum (LF) from C1 to T2, and to review briefly the pertinent literature. Diseases characterized by abnormal calcium deposition on the spinal ligaments have an unclear etiology. The overwhelming majority of these cases has been reported in people of Asian descent and has a predilection for the thoracic spine. Multilevel involvement of the cervical LF in white patients is exceptionally rare. To our knowledge, complete calcification of the entire cervical LF has not been previously reported in the literature. The history, physical examination, and radiographic studies of a 64-year-old white female with a history of scleroderma are described. The patient presented with neck pain and acute quadriparesis caused by spinal cord impingement by calcified cervical LF from C1 to T2. The patient underwent emergent C3-C7 laminectomy and C2-C7 posterior spinal fusion. Operative intervention resulted in marked neurologic improvement and relief from neck pain. Histopathologic examination of the calcified LF showed that the deposits consisted of hydroxyapatite crystals exclusively with no heterotopic bone. However, kyphosis did develop in the patient after laminectomy. To our knowledge, this unusual case of complete calcification of the entire cervical LF has not previously been described. Multilevel laminectomy and fusion can improve neurologic function but may result in kyphosis.

Regional difference in the appearance of apoptotic cell death in the ligamentum flavum of the human cervical spine

Ossification or calcification of the ligamentum flavum (LF) is relatively common in the middle and lower cervical, thoracic, and lumbar spine but extremely rare in the upper cervical region. This clinical fact suggests that there exist local factors promoting or preventing ossification or calcification of LF. However, little is known about the differences in the ultrastructure and cellular alterations of the LF between the different spinal levels, even in the cervical spine. With electron microscopy, we examined samples of LF collected surgically from the upper and lower cervical spine regions; we then studied the apoptotic appearance of ligament cells using a preferential labeling method. We found direct evidence of apoptosis of ligament cells in the LF. Apoptosis was more apparent in the upper region samples than in the lower region samples. The spaces around the normal fibroblasts were filled with thick collagen fibrils, but the collagen fibrils disappeared around the apoptotic bodies and thin fibrils were formed. The difference of the level of apoptosis may correlate to the ultrastructural difference of LF, and our data will benefit further investigations seeking to clarify the mechanism of various pathological conditions in the human LF.

Calcium pyrophosphate dihydrate and basic calcium phosphate crystal-induced arthropathies: update on pathogenesis, clinical features, and therapy.

Calcium-containing crystals are the most common class for the osteoarthritic joint. They are responsible for acute periarthritis and destructive arthropathies, and for tissue deposits mimicking tumor-like masses. These crystals encompassed mainly calcium pyrophosphate dihydrate and basic calcium phosphate crystals, with the latter being related to hydroxyapatite, carbonate-substituted apatite, and octacalcium phosphate. Calcification deposit mechanisms will be reviewed with respect to extracellular inorganic pyrophosphate dysregulation mainly caused by modulation of specific membrane channel disorders. Genetic defects have been extensively studied and identified mutation of specific genes such as ANKH and COL. Pathogenesis of crystal-induced inflammation is related to synovial tissue and direct cartilage activation. Besides classical knee or wrist pseudogout attacks or Milwaukee shoulder arthropathies, clinicians should be aware of other specific common presentations, such as erosive calcifications, spinal cord compression by intraspinal masses, ligamentum flavum calcification, or atypical calcified tophus. Promising clinical results for preventing calcium crystal deposits and cartilage degradation are lacking. Practical imaging tools are needed to monitor reduction of calcification of fibrocartilage and articular cartilage as markers of drug efficacy.

Ossification of the ligamentum flavum

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

Intraoperative Transligamentous Ultrasound in the Evaluation of Thoracic Intraspinal Disease

Intraoperative transligamentous ultrasonography was used in a variety of different thoracic surgical procedures for spinal cord compression secondary to neoplastic disease. The utility and practicality of intraoperative transligamentous ultrasonography for thoracic intraspinal disease was evaluated. Because intraoperative localization and evaluation of targeted levels in the thoracic spine using radiographs is often difficult or imprecise, alternative or complementary techniques may be helpful. Intraoperative transligamentous ultrasound, performed before laminectomy, via an interlaminar window, has not been widely used for thoracic intraspinal pathology. A standard 7.5-MHz hand-held probe, used in conjunction with a Codman OR 330 ultrasound machine, was used to evaluate the practicality of intraoperative transligamentous ultrasound in the thoracic spine. A clear sonographic window, permitting visualization of the spine and the intraspinal contents, can frequently be found. However, densely calcified ligamentum flavum or overlapping laminas do not allow effective insonation. Four illustrative cases are presented. Transligamentous ultrasound before laminectomy can be used for localization and evaluation of intraspinal disease in many patients. Overlapping laminas or calcified ligamentum flavum can impede adequate sonographic visualization, but in these cases adequate intraoperative transligamentous ultrasound evaluation is usually possible through a small laminotomy. Evaluation of intraspinal lesions and localization of the correct surgical level is facilitated by dynamic real time sonographic imaging.