1. Amin Jahanbakhshi M.D. , Guive Sharifi M.D. , Kaveh Ebrahim Zadeh M.D.
Loghman Hakim Hospital
Myelopathy Due to Thoracic OLF and Ankylosing of Multiple Vertebral Bodies
Amin Jahanbakhshi M.D. , Guive Sharifi M.D. , Kaveh Ebrahim Zadeh M.D.
Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Summary:
We present a complicated case of severe degenerative spine disease presented with upper motor neuron signs and symptoms . Apart from severe degenerative disc changes, loss of lumbar lordosis, marked osteophyte formation and interestingly multilevel severe ankylosing, myelopathic syndrome could be attributed to a thoracic canal stenosis caused by ossification of the ligamentum flavum (OLF). So, we directed the treatment against that one pathology and selected a conservatory management for the others.
Introduction:
Ossification of the ligamentum flavum is much more common in far eastern than in western patients. It is usually occurs in lower thoracic spine. The pathophysiology is not exactly known, but mechanical traumatic assaults as well as inflammatory mechanisms have been blamed. A progressive process of cartilaginous metaplasia, calcification and eventually ossification of the ligamentum flavum and the role of cytokines such as bone morphogenic protein (BMP) and transforming growth factor- β (TGF-β) have been proposed.
Case Presentation:
A 60-year-old man presented with symptoms and signs of thoracic myelopathy. He complained about back pain, gait disturbance since one year ago which was exacerbating in the recent 3 months. He had no sphincter dysfunction. Muscle forces were intact. lower extremity paresthesia and spasticity existed. Hyperreflexia was present in the lower limbs. Babinsky existed bilaterally.
Imaging: we see signs of severe degenerative spine disease, with loss of normal lumbar lordosis, decreased disc space height, marked osteophyte formation and interestingly multilevel severe ankylosing of the vertebral bodies. At 10th and 11th thoracic vertebral junction a big signal voided mass from posterior has marked pressure on the cord and obliterated the thoracic canal, a feature consisting with OLF.
Sagital T2-Weighted MRI: reversing lumbar lordosis, loss of disc height and disc degeneration, OLF at T11-T12 level
Treatment: Although we see many problems in this spine imaging, presence of a thoracic OLF, describes the patients symptoms clearly. Considering the severe and progressive nature of myelopathic symptoms, surgical decompression is clearly indicated.
The patient underwent a T10-T11 laminectomy and resection of OLF. An ossified fragment of the ligamentum flavum was attached so hardly to the dura and we dissected and detach it by floating technique.
Follow-up: Sensory and myelopathic symptoms improved quickly at the end of 3rd Post-operative month. The symptoms never recurred. The patient was advised to take appropriate exercises and avoid activities that may exacerbate the current severe degenerative spine disease. .
Conclusion:
In a large epidemiologic study in Japan, OLF, consisting 56% of the patients, has been the leading cause of thoracic myelopathy, followed by OPLL (11%), disc herniation (11%) and osteophytes (8%). It is important for a spine surgeon to know how to deal with such patients.
It is noteworthy that we confronted with a complex spine problem and pinpointed a single, most important, pathology . OLF may be tightly attached to dura. The best way of detachment is to drill it from one side while leave it attached at the other side, so that you can drill it safely. The last parts could be resected by floating technique.   
Axial T2-Weighted MRI: marked canal obliteration by OLF
A-P and Lateral Standing X-ray: extensive vertebral ankylosis
Acknowlegement:
The authors have no conflict of interest and no financial disclosure.
Contact Info:
Amin Jahanbakhshi M.D., Department of Neurosurgery, Loghman Hakim Hospital, South Kargar Ave., Tehran, Iran.
amin
Phone:
S.P.I.N.E Annual Meeting, Beirut, Lebanon