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.     

Ossification of the cervical ligamentum flavum

A case of a 61-year-old man with ossification of the cervical ligamentum flavum is reported. The ossification was located on the left side of C3-4. The symptoms improved with laminectomy and resection. Ossification of the ligamentum flavum usually occurs in the lower thoracic spine, and is rare in the cervical region. Including the present one, only eight cases have been reported to our knowledge. The clinical features and pathogenesis are discussed.     

Cyst of the ligamentum flavum--case report

An 86-year-old man presented with intermittent claudication caused by a cyst of the ligamentum flavum. Lumbar magnetic resonance imaging demonstrated an extradural cystic mass at the L5-S1 intervertebral space and canal stenosis at the L4-5 space. L-5 laminectomy and flavectomy at the L4-5 and L5-S1 spaces were performed, and the cystic mass was excised. The histological features were consistent with cyst of the ligamentum flavum. The histological diagnosis was ganglion cyst of the ligamentum flavum. After surgery, claudication completely disappeared and the patient made a good recovery.     

Ligamentum flavum hematoma in the cervical spine - case report

A 67-year-old man presented with a rare case of ligamentum flavum hematoma manifesting as progressive tetraplegia following cervical traction therapy. Magnetic resonance imaging of the cervical spine showed a posterior mass that was continuous with the ligamentum flavum at the C3-4 levels. Complete resection of the mass that contained brownish hemorrhage was performed, resulting in excellent symptom relief. We speculate that repeated trivial trauma to the degenerative ligamentum flavum was the main predisposing factor in the present case. Ligamentum flavum hematoma is a rare cause of spinal root or cord compression which typically occurs in the lower thoracic or lumbar spine, but may also appear in the cervical spine.     

Calcification of the cervical ligamentum flavum. Case report and review of the literature

Calcification of the cervical ligamentum flavum is a rare entity observed exclusively in Japanese people. We report a new case in a 65-year-old man from Tunisia who presented with symptoms of cervical myelopathy with mild tetra paresis, sensory abnormalities and dysuria. Magnetic resonance imaging (MRI) showed a posterior compression of the spinal cord at C3-C4. CT-scan showed a calcification of the ligamentum flavum at level C3-C4, compressing the left postero-lateral aspect of the spinal cord. C3-C4 laminectomy was performed with removal of abnormal ligamentum flavum tissue. The postoperative course was uneventful and all symptoms resolved. Calcification of the cervical ligamentum flavum is a rare entity; the diagnosis is easy but the pathogenesis remains unclear. Literature regarding this pathology is reviewed.     

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.     

Cervical synovial cysts: case report and review of the literature

The authors describe the case of a 58-year-old man with a 6-month history of severe myelopathy. CT scan and MRI of the spine revealed a cystic formation, measuring about 1 cm in diameter, at C7-T1 at a right posterolateral site at the level of the articular facet. At operation the mass appeared to originate from the ligamentum flavum at the level of the articular facet and was in contact with the dura mater. Once the mass had been removed, there was a significant amelioration of the patient’s symptoms. As previously suspected, histological aspect was synovial cyst. Cervical synovial cysts are extremely rare and, as far as we know, only 22 cases have so far been described in the literature. Diagnostic radiological investigations used were CT scan and MRI. At CT scan the most important diagnostic findings are a posterolateral juxtafacet location of the mass, egg-shell calcifications on the wall of the cyst, and air inside the cyst. At MRI the contents of the cyst are iso/hypointense on T1- and hyperintense on T2-weighted images. There may also be a hypointense rim on T2-weighted images, which enhances after i.v. administration of gadolinium. Surgical treatment consists of removal of the mass. Fixation of the vertebral segments involved is not always necessary. Received: 12 January 1998 Revised: 17 September 1998 Accepted: 19 October 1998     

Cervical cyst of the ligamentum flavum and C7-T1 subluxation: case report

A patient with progressive gait disturbance resulting from a cyst of the cervical ligamentum flavum associated with C7-T1 listhesis is reported. Surgical removal of the cyst improved the patients myelopathy. Intraspinal degenerative cysts are preferentially located in the lumbar region:unusual is the cervical localization. Differential diagnosis includes ligamentum flavum cyst, synovial and ganglion cysts. Association between degenerative intraspinal cysts and listhesis is discussed. To our knowledge, this is the first case of cyst of the ligamentum flavum associated with cervical subluxation.     

Microsurgical excision of hematoma of the lumbar ligamentum flavum

Hematoma of the lumbar ligamentum flavum is a very rare cause of sciatica. A 72-year-old man presented with left-sided sciatica and paresthesia of the lateral aspect of his left foot. From CT and MRI findings, he was diagnosed as having a hematoma embedded in the ligamentum flavum, which compressed the dura mater at the L5/S1 disc level. After an adequate surgical field was obtained with a microscope and a Casper retractor, the hematoma of the ligamentum flavum could be excised via a unilateral approach and satisfactory decompression of the cauda equina and nerve roots were obtained.     

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.     

Paraparesis in a black man brought on by ossification of the ligamentum flavum: case report and review of the literature

We present the second case of paraparesis secondary to ossification of the ligamentum flavum at the midthoracic region in a black man. Ossification of the ligamentum flavum is frequently described in the Japanese population where the presentation is often in the lower thoracic region. The patient is a 37-year-old black man who, over the 6 months before admission, noticed progressive paraparesis. CT myelogram revealed severe thoracic stenosis by an ossified ligamentum flavum from T4 to T7 with most severe involvement at the T5, T6, and T7 levels. The patient underwent multilevel laminectomies and medial facetectomies from T4 to T7. Over the past decade, ossification of the ligamentum flavum has been reported with increasing frequency in non-Asian patients. This is the third case report in a black man. In addition, ossification of the ligamentum flavum in this particular location is rarely reported. The increased use of advanced neuroimaging techniques in the evaluation of "back pain" may reveal that the prevalence of this condition is higher than expected in non-Asian populations. Improvement in neurologic symptoms secondary to decompressive laminectomies will depend on the degree and duration of spinal cord compression.     

Cervical ligamentum flavum ossification. Two case reports

A 58-year-old woman (Case 1) presented with disturbance of fine movement and gait. Magnetic resonance (MR) imaging and computed tomography (CT) demonstrated bilateral ossified ligamentum flava at the C3-4 and C4-5 levels and severe cervical canal stenosis. She underwent posterior decompression and despite strong adhesion to the dura mater, the ossified ligamentum flavum was removed without inducing liquorrhea. Her neurological symptoms improved postoperatively. A 63-year-old man (Case 2) was admitted with disturbance of fine movement and gait that had developed gradually. MR imaging and postmyelography CT demonstrated cervical canal stenosis via the ossified posterior longitudinal ligament at the C4-6 levels and ossified ligamentum flavum on the right at the C4-5 levels. He underwent right posterior decompression of C4-5. After right hemilaminectomy of C4-5, the ligamentum flavum was exposed. Neither the ligamentum flavum nor the ossification had adhered to the dura mater, so complete removal was successful and he recovered completely from his neurological symptoms. Diffuse-type ossified ligamentum flavum had adhesion to the dura mater, as in our Case 1, whereas focal-type ossified ligamentum flavum did not, as in our Case 2. This information is useful for treatment planning.     

Ganglion cyst of a lumbar facet joint in an adolescent—a case report

‘Lumbar facet joint synovial cyst’ is the recent terminology used to describe cysts within and outside the lumbar spinal canal. These include ganglion cysts, synovial cysts and cysts arising from the ligamentum flavum. Ganglion or synovial cysts typically arise from the joints and tendon sheaths of the appendicular skeleton but are uncommon in the spinal facet joints and rare in an adolescent. This case report illustrates a 14-year-old female patient of the senior author (JHP) with lumbar facet joint cyst who presented with lower back pain. Excisional biopsy was performed and the histology confirmed the diagnosis of a ganglion cyst.     

Cervical myelopathy from calcium pyrophosphate dihydrate crystal deposition: a case report

Calcification of the ligamentum flavum secondary to calcium pyrophosphate dihydrate (CPPD) deposition may be a rare cause of cervical myelopathy. We present a 56-year-old man with spinal stenosis secondary to CPPD disease and subacute cervical myelopathy following minor trauma. The patient had no history of CPPD disease. Posterior C4-C6 decompression and instrumented fusion were performed. Intraoperative findings were densely thickened ligamentum flavum and distortion of the cervical dura mater due to impingement. Histological sections of discs and ligamentum flavum specimens showed CPPD crystals. Postoperatively, neck pain and paresthesias improved immediately. At 2 weeks after spinal surgery, the patient experienced acute right knee swelling. Standard radiographs showed chondrocalcinosis of the knee menisci.     

Case of cervical monostotic fibrous dysplasia with a large cyst

We report a rare cervical monostotic fibrous dysplasia with a large cyst in the C2 region in a 55-year-old man complaining of headache. MRI revealed an expanding bony tumor at the C2 spinous process. Gd-DTPA MRI showed slight enhancement around a cystic mass. We performed C2 laminectomy and removed the tumor. It was comprised of soft tissue in the C2 spinous process and right lamina and contained a large septated cyst filled with xanthochromic fluid. Histopathology confirmed fibrous dysplasia with typical woven bony trabeculae. His postoperative course was uneventful and outpatient follow-up detected no deficits. Cervical fibrous dysplasia with a distinct cyst is a rare entity and few cases have been reported in the literature. Such cysts are considered to reflect a tumor regression process. Diagnosis based on MRI and CT study alone is difficult. We suggest that these lesions be surgically resected.     

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.     

Ossification of the thoracic ligamentum flavum presenting with intercostal neuralgia. Case report]

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.     

Spontaneous haematoma of ligamentum flavum. Case report and literature review

Spontaneous infarction of the ligamentum flavum is a very rare cause of mielo-radicular compression. In the literature only four cases are reported, all characterized by a clinical history of slowly progressive mielo-radiculopathy and good outcome after surgical treatment. A 70 year-old female patient presented with a four months clinical history of spontaneous, sub-continuous, progressive lumbar pain with bilateral irradiation to the L4-L5 dermatomers, right leg monoparesis and hypoaesthesia affecting tactile, thermal and pain sensivity, urinary incontinence and constipation. CT scan and MRI evidenced an extradural ovalar lesion in correspondence of the L1-L2 levels, that exerted compression over the dural sac, dislocating it anteriorly. The patient underwent a L1-L2 laminectomy and the lesion was totally resected. Rapid improvement of the patient's symptomatology has been noticed in the postoperative period, with complete recovery during the following month. Histologic examinations demonstrated that the mass was a haematoma of the ligamentum flavum. It's our opinion, that a picture of ligamentum flavum haematoma should be taken into account in differential diagnosis of posterior mielo-radicular compression. The progressive growth of the haematoma may explain the long clinical history of these patients and surgical treatment, even if delayed, permits an excel-lent clinical outcome.     

Two-level ligamentum flavum hematoma in the lumbar spine. Case report

Ligamentum flavum hematoma is a rare cause of spinal root or cord compression that usually occurs at a single level. No case of multiple-level ligamentum flavum hematoma has previously been reported. We report an extremely rare case of double, contiguous ligamentum flavum hematomas in the lumbar spine. A 71-year-old man with hypertension and degenerative lumbar scoliosis presented with pain and muscle weakness in the left lower extremity after physical exertion. Magnetic resonance imaging of the lumbar spine showed severe spinal stenosis caused by two-level ligamentum flavum hematoma (L3-L4 and L4-L5). Both hematomas were completely removed and the diagnosis was histologically confirmed. Symptoms completely resolved after surgery. Despite being extremely rare, ligamentum flavum hematoma with involvement of multiple levels may be observed.     

Entirely suprasellar symptomatic Rathke's cleft cyst

Two rare cases of entirely suprasellar Rathke's cleft cyst were reported. Case 1. A 62-year-old man was admitted to our hospital on the 14th of January, 1988, complaining of headache and diplopia. A plain skull x-ray showed the sella turcica was normal. CT scan and MRI demonstrated a lesion mass located entirely in the suprasellar cistern. Right frontotemporal craniotomy was performed, and the cyst wall was resected subtotally. Microscopic sections of cyst wall showed ciliated single layer with focal stratified epithelium. Case 2. A 51-year-old man was hospitalized complaining of visual impairment in the left eye. Endocrinological examination showed no abnormalities. CT and MRI demonstrated a lesion mass located entirely in the suprasellar region. Right frontotemporal craniotomy was performed. The mass was opened and a large amount of yellowish fluid was released. Histologically, the specimens were simple ciliated cuboidal epithelium. Postoperative courses of these patients were uneventful. The findings on CT and MRI of the cases located entirely in the suprasellar region were varied. The histopathogenesis and embryological pathogenesis of Rathke's cleft cyst in the literature, particularly the entirely suprasellar type, were discussed.