Myxomatous degeneration of the ligamentum flavum of the lumbar spine

STUDY DESIGN: Report of two cases of acute lumbar nerve root compression caused by myxomatous degeneration of the ligamentum flavum. OBJECTIVE: To report a rare cause of acute lumbar nerve root compression. SETTING: Orthopaedic department, Osaka, Japan. SUMMARY OF BACKGROUND DATA: Two patients, both 50-year-old men presenting with signs and symptoms suggestive of acute lumbar nerve root compression were found to have a ligamentum flavum mass. The masses were removed and the patients regained normal function postoperatively. METHODS: To reveal the nature of the mass, histopathological studies were made. Continuous sections were prepared from the removed mass lesions. The sections were stained with hematoxylin and eosin, van Gieson's stain, azan stain, periodic acid Schiff reaction, Alcian blue stain and von Kossa's stain. RESULTS: Histological examination revealed myxomatous degeneration of the ligamentum flavum. No elastic fibers were found at the degeneration site. Diffuse mucopolysaccharide deposition was found at the degeneration site, however, no cyst was found. Collagen fibers were not increased. Hypertrophy or ossification of the ligamentum flavum was not recognized in the sections. At a follow-up examination over 2 years later, the patients were free of symptoms and the findings of a neurological examination were normal. CONCLUSION: Two cases of myxomatous degeneration of the ligamentum flavum of the lumbar spine were reported, which have seldom been described as the cause of acute lumbar nerve root compression.     

合并腰椎疾患的下胸椎黄韧带骨化临床诊治

目的探讨合并腰椎疾患的下胸椎黄韧带骨化临床特点及诊治方法。方法下胸椎黄韧带骨化同时存在腰椎疾患的患者23例,诊断结合X线、椎管造影、CT、MRI检查,体征以肌张力增高和深反射异常为特点;患者均采用病变节段全椎板减压手术治疗。结果23例均获随访,时间10-36个月,手术减压1-3节胸椎椎板,患者在末次随访时都有不同程度的神经功能改善。术后功能恢复优4例,良13例,可6例。术后到末次随访时无一例患者因腰椎疾病而再次接受手术。结论合并腰椎疾患的下胸椎黄韧带骨化需要注意将客观体征与多种影像学检查相结合,尽早诊断、早期手术。     

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.     

Acute hemorrhagic cyst of the ligamentum flavum

STUDY DESIGN: A case report and clinical discussion. OBJECTIVE: To describe a rare complication of a cyst of the ligamentum flavum, which bled spontaneously, provoking an acute lower limb monoparesis and lumbar sciatic pain. SUMMARY OF BACKGROUNDS DATA: Cysts of the ligamentum flavum have been rarely reported. Intraspinal degenerative cysts described in literature are usually juxta-articular (synovial and ganglion) cysts and have a similar radiologic appearance. They are preferentially located in the lumbar spine, while the cervical localization is unusual. Hemorrhage into the cyst is an uncommon complication and an extremely rare cause of nerve root compression. METHODS: A 59-year-old woman presented with sudden severe radicular lumbar deficit and pain secondary to acute hemorrhage into a ligamentum flavum cyst. Magnetic resonance imaging showed at L3-L4 level a lobulated slightly hyperintense mass with a ventral area of marked hyperintensity in T1 images, hypointense on T2 images. Signal within the lesion was suggestive of intralesional hemorrhage. RESULTS: Complete resection of the lesion was performed, resulting in immediate recovery. The cyst was quite rounded, brownish, and contained rest of both partially fresh and coagulated hematoma. Histologic examination revealed myxoid degeneration of the ligamentum flavum with an hemorrage in the cystic cavity without a synovial layer. CONCLUSIONS: This report identifies a rare case of radicular lumbar deficit and pain secondary to acute hemorrhage into a ligamentum flavum cyst. The pathogenesis and clinicopathologic characteristics of this lesion are described.     

中央型腰椎管狭窄症患者黄韧带组织生化成分变化的研究

目的:通过测定中央型腰椎管狭窄症患者腰椎黄韧带胶原蛋白和蛋白多糖含量变化,观察组织显微结构改变,探讨黄韧带组织生化成分改变与中央型腰椎管狭窄症发病的相关性方法:收集中央型腰椎管狭窄症患者的腰椎黄韧带65块作为退变组,正常腰椎黄韧带27块作为对照组,采用微量羟脯氨酸测定法和硫酸-咔唑法分别测定两组黄韧带中羟脯氨酸及糖醛酸吸光度,并计算胶原蛋白和蛋白多糖含量;游标卡尺测量黄韧带厚度;并行HE染色和Masson染色,显微镜下观察各组组织结构改变。结果:退变组黄韧带厚度、胶原蛋白及蛋白多糖含量均高于对照组,差异有显著性(P0.05);病理学观察退变黄韧带弹性纤维排列紊乱,数量减少,胶原纤维增生。结论:退变腰椎黄韧带中胶原蛋白和蛋白多糖含量增加,黄韧带生化成分改变可能引起黄韧带厚度增加,参与中央型腰椎管狭窄症的发生。     

胸椎黄韧带骨化与腰椎黄韧带退变的病理及基本代谢元素的比较研究

目的：探讨胸椎黄韧带骨化的病因。方法：对１４例胸椎黄韧带骨化（包括５例氟骨症）及１４例腰椎管狭窄症患者手术切除的黄韧带标本作病理研究；对患者血清及黄韧带采用雾化原子吸收法等方法测定钙、磷、镁、锌、铜、锰、钼、氟含量，取急性外伤性截瘫患者为对照。结果：（１）骨化黄韧带初期的病理改变与黄韧带退变性质类似；（２）除氟元素外，７种基本代谢元素在骨化与退变患者血清及黄韧带中含量均呈基本一致的变化规律；（３）非氟骨症骨化患者黄韧带中氟含量显著增高（Ｐ＜０．０１）。结论：本文证实胸椎黄韧带骨化发生于黄韧带退变的基础之上，但退变不直接导致骨化，元素氟是诱导退变黄韧带进一步骨化的重要诱因。     

退行性变黄韧带细胞的体外培养及初步鉴定

目的：探讨黄韧带退变的发生机理。方法：采用组织块培养法，体外培养正常黄韧带和退变性黄韧带细胞．并进行细胞化学、免疫细胞化学等方面研究。结果：黄韧带细胞可以在体外增殖和传代，退变性黄韧带细胞呈现出某些成骨细胞表型特征，而正常黄韧带细胞主要为成纤维细胞表型。结论：退变黄韧带中存在大量具备某些成骨细胞表型特征的细胞，其中包括软骨细胞，它们可能被骨形成蛋白等骨生长因子所调控。     

Ligamentum flavum hematoma in the lumbar spine

A previously healthy 45-year-old woman presented with ligamentum flavum hematoma manifesting as radicular leg pain. Neurological examination findings were consistent with L-5 root compression. An old hematoma inside the degenerated ligamentum flavum was drained. The cyst showed no connection to the facet joint. Complete resection of the mass was performed, resulting in excellent pain relief. The most common cystic lesion in the lumbar spine is synovial cyst associated with the facet joints, but ligamentum flavum hematoma should be included in the differential diagnosis. The preoperative diagnosis can be based on computed tomography and magnetic resonance imaging findings of degenerative thickening of the ligamentum flavum associated with a fluid component.     

Lumbar canal stenosis caused by amyloidosis of the yellow ligament]

Symptomatic lumbar canal stenosis without bony stenosis has previously been described. We describe the pathological modifications of ligamentum flavum among such operated patients. Ten patients were prospectively included in this study. Their mean age was 74, ranges: from 52-90. Clinical manifestation was a radicular claudication (sciatic or crural). Neuroradiology confirmed in all cases the ligamentum flavum thickness as the main cause of the symptomatology. This feature was also confirmed operatively and complete resection of the ligamentum flavum was performed. Resolution of the radicular pain was obtained in all cases at last follow-up. Pathological examination of the ligamentum flavum displayed characteristic features of degenerative modifications and elastic fibers fragmentation caused by numerous amorphous deposits. The deposits were studied using red Congo staining, polarized light and immunostaining methods. Such technique showed evidence of amyloid origin of the deposits. Immunodetection was positive for the P component in the amyloid deposits and for beta-2-microglobulin in one case (chronic renal failure and hemodialysis). The deposits did not express antitransthyretin antibodies. In parallel, control ligamentum flavum were obtained from 10 operated patients affected by bony lumbar stenosis. Moderate degenerative features were observed but small amounts of amyloid deposits were found in only 3 of those cases, without thickening of the ligamentous structure. This study correlates the presence of thickened ligamentum flavum caused by amyloid deposition, with symptomatic non-osseous lumbar canal stenosis. Association with degenerative modifications of the spine in the studied cases is suggestive of a microtraumatic origin.     

Rare ligamentum flavum cyst causing incapacitating lumbar spinal stenosis: Experience with 3 Chinese patients

Three Chinese patients suffered from severe lumbar spinal stenosis with debilitating symptoms due to a rare condition of ligamentum flavum cysts in the midline of the lumbar spine. This disease is distinct from synovial cyst of the facet joints or ganglion cysts, both intraoperatively and histopathologically. Magnetic Resonance imaging features of the ligamentum flavum cyst are also demonstrated. We share our surgical experiences of identification of the ligamentum flavum cysts, decompression and excision for two of the patients with demonstrably good recovery. This disease should be considered in the differential diagnosis of an extradural instraspinal mass in patients with lumbar spinal stenosis.     

腰椎退变黄韧带中炎性细胞因子的表达

目的:观察腰椎退变黄韧带中炎性细胞因子的表达情况,探讨其在腰椎黄韧带退变过程中的作用。方法:收集腰椎退变性疾病患者在后路椎板切除减压治疗时取下的黄韧带标本40例(退变组),术前通过CT、MRI证实均有黄韧带肥厚;以10例脊柱外伤行后路手术治疗的青年患者的腰椎黄韧带作为对照(对照组)。将术中切除的黄韧带剔除骨、脂肪及筋膜等组织,修成约2cm×1.5cm×0.3cm,在10%福尔马林溶液中固定24～48h后取出,制备成石蜡切片,采用苏木精伊红(HE)染色,应用光学显微镜观察病理学改变,并用免疫组化技术观察黄韧带标本中白介素-1(IL-1)、IL-6和肿瘤坏死因子-ɑ(TNF-ɑ)的表达情况。结果:对照组黄韧带弹力纤维呈波浪状,排列规则,弹力纤维间可见少量的胶原纤维和散在的成纤维细胞(22.56±6.05个/HP);退变组黄韧带弹力纤维明显减少,胶原纤维增多,并且伴软骨细胞、成纤维细胞、毛细血管的增生,成纤维细胞计数为62.66±18.40个/HP,两组成纤维细胞计数差异有统计学意义(P<0.05)。退变黄韧带组织中IL-1、IL-6、TNF-α表达阳性率分别为75%、77.5%、82.5%,对照组黄韧带组织中的表达阳性率分别为40%、20%、40%,退变组明显高于对照组(P<0.05)。结论:IL-1、IL-6、TNF-ɑ在腰椎退变黄韧带中有较高的表达,这些炎性因子可能参与了腰椎黄韧带退变的过程。     

A post-traumatic ligamentum flavum progressive hematoma: a case report

STUDY DESIGN: A case report. OBJECTIVES: To understand a rare case of ligamentum flavum progressive hematoma. SUMMARY OF BACKGROUND DATA: Previously there were only two reports about ligamentum flavum hematoma. METHODS: A patient was surgically treated for ligamentum flavum hematoma causing progressive L5 radiculopathy. Clinical and neuroradiologic features were reported, and the literature was reviewed. RESULTS: The etiology of this case could not be defined except by minor back injury. In spite of conservative therapy, the symptoms were progressive for 7 months. Magnetic resonance imaging demonstrated the epidural mass lesion at L4-L5 that was continuous with the ligamentum flavum. The mass was hypointense in T1-weighted images and central hyperintense and marginal hypointense in T2-weighted images. The margin was well enhanced by Gd-DTPA administration. After removal of the mass lesion, the patient's symptoms completely resolved. Before surgery, accurate diagnosis was difficult even based on magnetic resonance imaging and was achieved after histologic examinations. CONCLUSIONS: Surgery could be a choice of the treatment modality to resolve symptoms in ligamentum flavum hematoma.     

Cyst of the ligamentum flavum: report of six cases.

Six cases of cyst of the ligamentum flavum with compression of a lumbar nerve root are reported. All patients exhibited recurrent back pain and sciatica. Investigation included computed tomography, myelography, or both. The correct diagnosis was reached before operation in only half the patients. High-resolution computed tomography performed in the four last patients outlined the cystic lesion with its low-density center. Surgical excision was performed in all patients. Microscopic examination showed a dense fibrous cyst arising from the ligamentum flavum. The lumen contained myxoid or necrotic material, but no epithelial lining. Cysts of the ligamentum flavum must be considered in the differential diagnosis of causes of sciatica. A firm radiological diagnosis may, at present, still require myelography combined with high-resolution computed tomography. Differentiation from synovial or ganglion cysts of the spine is discussed.     

Ligamentum flavum hematoma in the rigid thoracic spinal segments: case report

Ligamentum flavum hematoma, a rare cause of spinal nerve root and canal compression, typically occurs in the mobile lumbar spine segments. A thoracic ligamentum flavum hematoma is extremely rare--only one such case of a thoracolumbar (T11-12) lesion has been reported. The thoracolumbar region with its floating ribs, however, is structurally and biomechanically similar to the lumbar spine and its mobility is greater than the higher thoracic levels. To the best of their knowledge, the authors report the first case of a ligamentum flavum hematoma in the region of the rigid thoracic spinal segments with the contiguous rib cage. A symptomatic T9-10 ligamentum flavum hematoma is described in the case of a 66-year-old woman with compensatory thoracic lordosis secondary to the lumbar degenerative kyphosis. The hematoma was removed and the diagnosis was histologically confirmed. The authors speculate that thoracic lordosis might have contributed to the development of the hematoma because the ligamentum flavum and the facet joint were subjected to greater axial stress than in individuals with normal spinal alignment.     

胸椎黄韧带骨化的病理组织学研究

目的：探讨黄韧带骨化的病理变化特点和发生机理。方法：利用组织病理学、组织化学和影像学检查对比研究正常黄韧带和12例骨化黄韧带的病理形态学特点。结果：组织学上可见病变早期出现胶原纤维肿胀、融合,进一步发生软骨化生,最终出现钙化和骨化。在肿胀融合的胶原纤维和软同有化生处可见阿新蓝（pH2.5）阳性的粘液性物质,根据病理学检查特点,结合影像学表现可将黄韧带骨化分为结节型（增生性）、周围型和弥漫型3种类型。结论：韧带的退行性改变是黄韧带骨化的基本原因;胶原纤维的肿胀融合及其粘液样变性是黄韧带骨化的起始病变;黄韧带骨化的大体类型代表着同一病变发展的不同阶段。     

Ganglion cyst in the ligamentum flavum of the cervical spine causing myelopathy: report of two cases.

BACKGROUND: Ganglion cyst in the ligamentum flavum is commonly found in the lower lumbar region; occurrence in the cervical region is extremely rare. We report two cases of ganglion cyst in the cervical region and the clinical, pathological, and radiological findings. METHODS: The first patient was an 81-year-old man who was admitted to our hospital with gradually progressive gait disturbance and radiating pain in both arms and legs, which was dominant on the left side. The second patient was a 65-year-old man with progressive muscle weakness of the extremities who was admitted with radiating pain in the right arm. In both cases, the cervical spinal cord had been compressed by the cystic mass with degeneration of the ligamentum flavum (the former left, the latter right) at the level of C3-4. RESULTS: The extradural-intraspinal cystic masses, which were revealed by computed tomography (CT) and magnetic resonance imaging (MRI) to be situated antero-laterally to the cervical laminae, were removed surgically without difficulty. After surgery, the symptoms and neurologic signs improved in both cases. CONCLUSIONS: Ganglion cyst in the ligamentum flavum of the cervical spine is a very rare lesion causing radiculo-myelopathy. In both our cases, a correct diagnosis could be established preoperatively based on CT myelogram and MRI findings, and the results of surgery were excellent.     

腰椎管狭窄症的影像学诊断

目的：探讨腰椎管狭窄症的X线、CT及MRI诊断价值。方法：分析130例临床诊断和影像学检查征象典型的腰椎管狭窄症的病例资料。男83例,女47例;年龄27～75岁,平均43.5岁。所有病例均行CT检查,其中23例行X线检查,57例行MRI扫描。结果：腰椎管狭窄位于L3,4水平25例,L4,5水平48例,L5S1水平57例。CT显示椎体后缘、椎板、下关节突骨质增生46例,椎板上下关节突肥大7例,黄韧带钙化、骨化13例,椎体向前滑脱5例,侧隐窝狭窄24例,椎间孔狭窄35例。MRI显示椎间盘突出伴黄韧带肥厚23例,黄韧带对称性肥厚18例,广泛多节段增生肥厚9例,局限性黄韧带肥厚7例。结论：继发性腰椎管狭窄症的最常见原因是退变。传统X线检查有很大的局限性,CT和MRI具有多方位成像和分辨率高的优点,但在韧带骨化上MRI难于显示,而CT能很好的显示韧带钙化与骨化及骨质改变,腰椎管狭窄症检查应该首选CT。     

Characterization of cultured human ligamentum flavum cells in lumbar spine stenosis.

To investigate the pathogenesis of the degenerative changes of the ligamentum flavum occurring in lumbar spine stenosis, yellow ligament cells from patients with lumbar spine stenosis were cultured for the first time and subjected to biochemical, histochemical and immunohistochemical study. Stenotic ligamentum flavum (SLF) cells were seen to express high levels of alkaline phosphatase (ALP) activity and to produce a matrix rich in type I and III collagen, fibronectin and osteonectin. The matrix mineralized only following beta-glycerophosphate (betaGP) and ascorbic acid supplementation. Stimulation with human parathyroid hormone (PTH) increased intracellular cAMP concentration. These findings indicate that there was significant evidence of osteoblast-like activity in these cells. SLF cells also stained for S100 protein, type II and type X collagen, and co-localized type II collagen and ALP labelling, reflecting the presence of hypertrophic chondrocyte-like cells. Cultures from control patients showed neither osteoblastic nor chondrocytic features: they expressed type I and type III collagen and fibronectin, but did not stain for osteonectin, nor were bone-like calcifications observed in presence or absence of betaGP. Normal ligamentum flavum (NLF) cells did not synthesized S100 protein or type II or type X collagen, and showed a weaker response to PTH stimulation. Our data demonstrated the presence of hypertrophic chondrocytes with an osteoblast-like activity in the ligamentum flavum of patients with spinal stenosis suggesting that they could have a role in the pathophysiology of the heterotopic ossification of ligamentum flavum (OLF) in lumbar spine stenosis.     

The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum

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.     

Management of cervical and lumbar stenosis]

Spinal stenosis is most common in elderly patients and is defined as narrowing of the spinal canal and (or) lateral nerve root canals. The underlying processes leading to spinal stenosis are degenerative changes in facet joints and intervertebral discs and buckling of the ligamentum flavum. Spinal stenosis can occur in both the cervical and the lumbar spine. Cervical stenosis mayleat to the development of radiculopathy and (or) myelopathy. The majority of patients respond to nonoperative management. Degenerative lumbar spinal stenosis presents with back and (or) leg paints of valuing severity and duration. Nonoperative treatment associated with lumbar spinal stenosis consists of restituting and avoiding those maneuvers that reproduce pain. Surgical treatment of cervical and lumbar stenosis includes decompressive lamine ctomy, often fusion and instrumentation.