ligamentum flavum ossification, thoracic myelopathy,

1. Ossification of Ligamentum Flavum
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research Centre,
Indore, India

2. Why this case?
• Ossification of Ligamentum Flavum is a unusual cause
of neurogenic claudication in early stage of the disease.
• It may be the only presenting symptom.
• First reported by Polgar in 1920 on plain lateral x-ray of
spine.
• Thoracic myelopathy due to ossified LF was described
in 1964 by Yamaguchi and Isuruni.
• Myelopathy & radiculopathy in advance disease.
• Coexist with Ossification of Dura.
• Coexist with Lumbar Canal Stenosis.

3. Reading MRI Critically
• All MRI done for any segment of spine starts
with cervical spine.
• This is done for exact counting of level of
vertebrae.
• A record of lumberization/sacralization.
• Last floating Rib.
• Level of disc pathology.

4. Reading MRI Critically
• Although MRI of whole spine is done, reporting is
done for the segment of interest; Lumbar, Dorsal,
Cervical or SI joints.
• Incidental findings are about 8%.
• Many incidental findings in many part of the
spine goes unreported inadvertently .
• These incidental findings are vertebral
Hemangioma, Tarlov cyst, fibrolipoma, synovial
cyst, and sacral meningocele, some times OLF.

5. Case History
• A 45 Male, C/o vague backache with radiating
pain in both gluteal regions increased by
standing and walking.
• Typical neurogenic claudication with varying
distances.
• There was no obvious neurological or vascular
deficit.
• Planters were down going.

6. Investigations
• Routine investigations were normal.
• X-ray dorso – lumbar spine reported normal.
• MRI – classical picture of ossification of
ligamentum flavum.
• Axial CT confirms the diagnosis.

11. Case Two
• A 60 yrs. Male
• Gradually increasing paraperesis.
• Spastic &weak both lower limbs.
• Intact bladder bowel control.

17. OLF
• Ossification of the ligamentum flavum (OLF) is a
disease of ectopic bone formation within the
ligamentum flavum, which may result in mass effect
and neurological compromise.
• The low thoracic region is the most common region of
occurrence, and this is followed by the cervical, then
lumbar spine.
• 64% at D10 - D11, 21% at D11 - D12.
• The prevalence of OLF is higher in the Japanese (20%
above the age of 65 years) compared with other
nationalities and has a male preponderance.
• Commonly associated with dural ossification.

18. Etiology
• Unknown in most of the cases.
• Diffuse idiopathic skeletal hyperostosis (DISH),
• Ankylosing spondylosis,
• Hemochromatosis,
• Fluorosis,
• Calcium pyrophosphate dihydrate deposition
disease (CPPD),
• Trauma.

19. Patho - physiology
• Initially the ligament get hypertrophied, and
calcify before it get ossified.
• The process of ossification starts at the base
of the ligament with enchondral ossification of
the vascularised fibrocartilaginous tissues. It
starts from capsular side and gradually spread
anteriorly and medially compressing the spinal
card from posterio-lateral sides.

20. Clinically
• Two types of presentations:
– Most commonly present as gradual onset of
myelopathy with slow deterioration in
neurological status.
– Occasionaly present as acute paraplegia following
minor trauma.

21. Diagnosis
• OLF should be included in causes of thoracic
paraplegia.
• X-rays are not very classical.
• MRI – T2 weighted seggital plane shows
indentation on the thoracic card from behind
• CT – Axial plane shows typical ossification of
OLF.

22. Radiological signs of DO
• The radiologic signs of dural ossification (DO)as
depicted in the bone windows of CT were of 2
types:
• The "tram track sign," where there was a
hyperdense bony excrescence with a hypodense
center.
• The "comma sign," where there was evidence of
ossification of one-half of the circumference of the
duramater.
• Incidence of CSF leak is very high in cases of DO,
following surgical excision of OLF.

23. Types
• Type I, is located only laterally at the origin of the
ligamentum flavum at the articular processes.
• Type II, The extended type, extends from the lateral origin
of the ligamentum flavum to the interlaminar portion of
the ligamentum flavum.,
• Type III, The enlarged type protrudes into the canal
posterolaterally but is not fused in the midline.
• Type IV, The fused type, consists of bilateral ossified
ligaments that are fused at the midline with a groove at the
fusion in midline.
• Type V, the tuberous type, occurs when the fused ossified
ligamentum flavum forms a “tuberous” mass posteriorly in
the midline, which protrudes into the spinal canal.

24. Treatment
• Decompressive Laminectomy.
• Laminoplasty, retaining posterior elements.
• Laminectomy and fusion to prevent increase in
kyphotic deformity.
• Complications are high when it is associated with
ossification of dura.
• Commonest complication is CSF leak due to associated
dural calcification.
• This can cause meningitis, delayed wound healing,
incomplete neurological recovery or deterioration in
neurological status.

25. Review literature
• Omojola MF, Cardosa ER, Fox AJ et al : Thoracic myelopathy secondary to ossified
ligamentum flavum. J Neurosurg 1982; 56: 448-450.
• Miyasaka K. Kiyoshi, K. Ito T et al : Ossification of spinal ligaments causing thoracic
radiculomyelopathy. Radiology 1982; 143: 463-468.
• Jayakumar PN, Devi BI, Bhat DI, Das BS. Thoracic cord compression due to ossified
hypertrophied ligamentum flavum. Neurol India. 2002 Sep;50(3):286-9.
• Virani M, Parekh Harshed, Palande Deepak : Dorsal canal stenosis - A rare cause of
compressive dorsal myelopathy -Report of three cases. Neurol India 1990; 38: 305-
308.
• Mitra SR, Gurjan SG, Mitra KR: Degenerative disease of the thoracic spine in
Central India. Spinal Cord 34:333-337, 1996.
• Sushil P, Anant K: Ossified-calcified ligamentum flavum causing dorsal cord
compression with computed tomography-magnetic resonance imaging features.
Surg Neurol 41:441-442, 1994.
• Stollman A, Pinto R, Benjamin V et al : Radiological imaging of symptomatic
ligamentum flavum thickening with and without ossification. AJNR 1987; 8: 991-
994.
• Yazmaguchi M, Tamagake S, Fujita S : A case of the ossification of the ligamentum
flavum with spinal cord tumour symptoms (in Japanese) Seikeigeka (Orthop Surg)
1960; 11: 951-956.

26. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India, during last
32 years.
It is intended for use only by the students of orthopaedic
surgery.
Views and opinion expressed in this presentation are personal
opinion.
Depending upon the x-rays and clinical presentations viewers
can make their own opinion.
For any confusion please contact the sole author for
clarification.
Every body is allowed to copy or download and use the material
best suited to him.
The author is not responsible for any controversies arise out of
this presentation.
For any correction or suggestion please contact
naneria@yahoo.com