Orthopedics

Case Reports 

Lumbar Ligamentum Flavum Hematoma Treated With Endoscopy

Tetsuro Ohba, MD, PhD; Shigeto Ebata, MD, PhD; Takashi Ando, MD, PhD; Jiro Ichikawa, MD, PhD; Devin Clinton, MD, PhD; Hirotaka Haro, MD, PhD

Abstract

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,…

Abstract

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.

Correspondence should be addressed to: Tetsuro Ohba, MD, PhD, Department of Orthopedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409–3898, Japan (tooba@yamanashi.ac.jp).
Posted Online: July 07, 2011

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.

Case Report

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.

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

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, revealing the absence of a synovial cyst or tumor within the spinal canal.

The endoscope then was angled to allow visualization as the base of the spinous process was undercut before proceeding to the contra-lateral side of the spinal canal. During this process, the ligamentum flavum was resected and was observed to have a brown adherent mass that required careful dissection to separate it from the thecal sac. After the ligamentum flavum was incised, the hematoma was found to be confined within the ligamentum flavum (Figure ).

Intraoperative photographs of the ligamentum flavum in situ show a dark brownish mass adherent to the dural sac (A, B). Photograph of the resected ligamentum flavum shows a cystic lesion filled with blood (C).

Figure 2:. Intraoperative photographs of the ligamentum flavum in situ show a dark brownish mass adherent to the dural sac (A, B). Photograph of the resected ligamentum flavum shows a cystic lesion filled with blood (C).

Histopathologic examination of the surgical specimen revealed hemorrhage surrounded by granulomatous tissue in the degenerated ligamentum flavum. Quality mucus did not exist among the Elastica van Gieson and hematoxylin-eosin stains (Figure ).

Photomicrographs show an old hemorrhage in the ligamentum flavum under Elastica van Gieson stain (original magnification ×40 on the left and ×100 on the right) (A) and hematoxylin-eosin stain (original magnification ×40 on the left and ×100 on the right) (B).

Figure 3:. Photomicrographs show an old hemorrhage in the ligamentum flavum under Elastica van Gieson stain (original magnification ×40 on the left and ×100 on the right) (A) and hematoxylin-eosin stain (original magnification ×40 on the left and ×100 on the right) (B).

Postoperatively, the patient experienced immediate resolution of his pain and improvement in his walking and standing endurance. His bladder function returned to normal by the end of the second postoperative day. Intraoperative blood loss was minimal (20 mL), and the patient remained hospitalized for 10 days. At his 6-month follow-up examination, the patient was pain free.

Discussion

Intraspinal cystic lesions of the lumbar spine can cause low back pain and gait disturbance. The differential diagnosis of these cystic lesions includes synovial facet joint cysts, ganglions, epidural tumors, and hematoma in the ligamentum flavum. Among these alternative diagnoses, synovial facet joint cysts are the most common cause of symptomatic compression.

A recent comparison of several studies describing the treatment of these cysts suggests equivalent outcomes between microendoscopic decompressive laminotomy and the standard open approach. 1 Moreover, endoscopic approaches have the added benefits of decreased blood loss, shorter hospital stay, and decreased narcotic use; these benefits have made endoscopy our preferred method for decompressing a synovial cyst or single-level lumbar stenosis. Endoscopy enabled us to adequately decompress this patient, after which we were able to identify the pathology as a hematoma in the ligamentum flavum.

A review of the English literature yielded 29 cases of hematoma of the lumbar ligamentum flavum 1–20 (). The patients in this dataset were elderly, with a mean age of 62.2 years (range, 30–80 years). 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). However, the literature review did not identify any case of lumbar ligamentum flavum hematoma treated endoscopically.

Reported Cases of Surgically Treated Lumbar Ligamentum Flavum Hematoma

Table. Reported Cases of Surgically Treated Lumbar Ligamentum Flavum Hematoma

In our patient, an endoscope was used to perform a unilateral partial hemilaminectomy, providing excellent visualization for bilateral decompression and removal of the ligamentum flavum hematoma. Our experience suggests the quality of visualization afforded by endoscopy may equip surgeons with the ability to address multiple pathologies causing neural compression, including hematoma of the lumbar ligamentum flavum.

References

  1. 1. Vernet O, Fankhauser H, Schnyder P, Deruaz JP. Cyst of the ligamentum flavum: report of six cases. Neurosurgery. 1991; 29(2):277–283. doi: 10.1227/00006123-199108000-00021 [CrossRef]
  2. 2. Sweasey TA, Coester HC, Rawal H, Blaivas M, McGillicuddy JE. Ligamentum flavum hematoma: report of two cases. J Neurosurg. 1992; 76(3):534–537. doi: 10.3171/jns.1992.76.3.0534 [CrossRef]
  3. 3. Baker JK, Hanson GW. Cyst of the ligamentum flavum. Spine (Phila Pa 1976). 1994; 19(9):1092–1904. doi: 10.1097/00007632-199405000-00019 [CrossRef]
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Reported Cases of Surgically Treated Lumbar Ligamentum Flavum Hematoma

Authors Patient Sex/Age, y Level Symptom Surgery Etiology HT a
Vernet et al 1 (1991) F/57 L4/5 LBP, S Total laminectomy NA
F/50 L4/5 LBP, S Hemilaminectomy NA
M/63 L3/4 LBP, S, MW Total laminectomy NA
F/52 L4/5 LBP, S Hemilaminectomy NA
M/72 L4/5 LBP, S, MW Hemilaminectomy NA
M/61 L4/5 S Hemilaminectomy NA
Sweasey et al 2 (1992) M/43 L4/5 LBP, S Hemilaminectomy Minor back injury +
M/60 L2/3 LBP, S, MW Total laminectomy Stepping up onto a box +
Baker & Hanson 3 (1994) F/58 L5/S1 S Hemilaminectomy NA
Cruz-Conde et al 4 (1995) M/67 L4/5 S Total laminectomy & PLF Minor back injury
Mahallati et al 5 (1999) M/30 L3/4 LBP, S Total laminectomy Cleaning a bathtub
Minamide et al 6 (1999) M/76 L3/4 S Total laminectomy Standing up from sitting position +
Hirakawa et al 7 (2000) M/50 L4/5 LBP, S, MW Hemilaminectomy & PLF Fell from a height of 1.5 m
Yuceer et al 8 (2000) M/67 L2/3 LBP, S Total laminectomy Repairing a chair +
Chi et al 9 (2004) M/64 L3/4 LBP, S NA Fell down some stairs +
Mizuno et al 10 (2005) F/45 L4/5 S, MW Hemilaminectomy Lifting a table
Yamaguchi et al 11 (2005) M/62 L3/4 LBP Hemilaminectomy Practicing martial arts
Albanese et al 12 (2006) F/70 L1/2 LBP, MW Total laminectomy NA
Keynan et al 13 (2006) F/75 L3/4 LBP, S, MW Total laminectomy & PLF NA
Shimada et al 14 (2006) F/83 L2/3, 3/4 S Total laminectomy Fell
Spuck et al 15 (2006) F/64 L2/3 LBP, S Hemilaminectomy Local injection
M/62 L4/5 LBP, S NA Sport exercise
Gazzeri et al 16 (2007) F/59 L3/4 LBP, S, MW Hemilaminectomy Lifting a heavy shopping bag
Kotil & Bilge 17 (2007) M/74 L4/5 LBP, S, MW NA Minor back injury
M/80 L4/5 LBP, S, MW NA Minor back injury
Kono et al 18 (2008) M/64 L4/5 S, MW NA NA +
Miyakoshi et al 19 (2008) M/71 L3/4, 4/5 LBP, S, MW Total laminectomy Physical exertion on a farm +
Takahashi et al 20 (2009) F/63 L3/4 LBP, S, MW Total laminectomy NA +
M/63 L5/S1 LBP, S, MW Hemilaminectomy NA +
Ohba et al (2011) b M/52 L5/S1 LBP, S, micturation disorder Endoscope Lifting heavy baggage

10.3928/01477447-20110526-27

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