Hematoma of the ligamentum flavum is a rare cause of neural compression, for which treatment has consisted of excising the
hematoma via open surgical approaches, including total laminectomy or bilateral partial laminectomy. This article presents
the first report of a microscope-assisted endoscopic decompression to resect a hematoma of the ligamentum flavum.
A 52-year-old man presented with back and leg pain, as well as difficulty initiating micturation. Magnetic resonance imaging
demonstrated an epidural mass at L5/S1 that was continuous with the facet joint. Visualization was obtained via an endoscope,
and a reddish tan-brown solid mass was found beneath the ligamentum flavum. Thorough decompression of the cauda equine and
nerve roots was undertaken. The patient’s radicular leg pain and bladder function improved soon after the decompression. Histological
examination of the ligamentum flavum revealed a consolidated hematoma with granulomatous change.
A review of the English literature revealed 29 cases of hematoma in the lumbar ligamentum flavum. Surgical decompression in
these patients was accomplished with a standard open approach through hemilaminectomy (n=11), total laminectomy (n=10), or
laminectomy followed by posterior fixation (n=3). The literature review did not identify any case of hematoma of the lumbar
ligamentum flavum that was treated endoscopically. We expect our case may expand the indications for the endoscope in spine
surgery.
Drs Ohba, Ebata, Ando, and Haro are from the Department of Orthopedic Surgery, University of Yamanashi, Japan; and Drs Ichikawa
and Clinton are from the Department of Orthopedics, Vanderbilt University, Nashville, Tennessee.
Drs Ohba, Ebata, Ando, Ichikawa, Clinton, and Haro have no relevant financial relationships to disclose.
Hematoma of the ligamentum flavum is a rare cause of neural compression, for which treatment has consisted of excising the
hematoma via open surgical approaches, including total laminectomy or bilateral partial laminectomy. Minimally invasive, muscle-sparing
decompressive spinal procedures are becoming increasingly important in the treatment of a wide variety of conditions as the
morbidity of standard surgical approaches has become more apparent. This article presents the first report of a microscope-assisted
endoscopic decompression to resect a hematoma of the ligamentum flavum.
A 52-year-old man presented with low back pain and radicular symptoms in the right leg of 5 months’ duration. The patient
reported the pain began after he had lifted heavy baggage. His description of the pain pattern was consistent with neurogenic
claudication, and his symptoms significantly affected his walking and standing endurance. One month prior to presentation,
he developed hesitancy with micturation. He had no history of major trauma, previous surgery, anticoagulant therapy, or a
coagulation disorder.
Neurological examination revealed right lower-extremity weakness (manual muscle testing 4/5), perineal numbness, and normal
deep tendon reflexes. Magnetic resonance imaging (MRI) demonstrated an epidural mass at L5/S1 in continuity with the facet
joint (Figure ). The lesion appeared as an area of high-signal intensity on both T1- and T2-weighted MRI, with characteristics suggestive
of hemorrhage. Postcontrast MRI was unremarkable.
Figure 1:. T1- (A), T2- (B), and T2-weighted gadolinium-diethylenetriaminepenta-acetic acid (C) MRIs demonstrate a mass lesion on the
dorsal side of the spinal canal at the L5/S1 levels. The lesion appears as an area of high-signal intensity on both the T1-weighted
and T2-weighted images. No obvious
The lesion was treated surgically using a unilateral microendoscopic approach with the goal of achieving bilateral decompression. The patient was placed in the prone position on a radiolucent table, and a 2-cm paramedian incision was made over the L5/S1 interspace. The METRx lumbar microendoscopic diskectomy system (Medtronic Sofamor Danek, Memphis, Tennessee) was positioned to gently dilate the lumbar musculature and expand the right lumbodorsal fascia. The inferior portion of the right L5 lamina was removed through the operating endoscope,…