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Objective:To evaluate the prevalence and distribution of ossification of ligamentum flavum (OLF) at the segments adjacent to the apex in patients with degenerative kyphosis.Methods:All of 74 patients with degenerative kyphosis from January 2018 to December 2021 were retrospective reviewed. All patients were taken anteroposterior and lateral radiographs, CT scan and magnetic resonance imaging (MRI) of the entire spine. Global kyphosis, the morphology of kyphosis and the occurrence of OLF at three segments adjacent to the kyphosis apex were recorded.Results:Of the 74 patients, 54 patients (73%) developed OLF in three segments adjacent to the kyphotic apex. The mean age of the 54 patients was 61.4±6.8 years, and the mean global kyphosis was 49.5°±21.2°. Among other 20 patients without OLF, the mean age was 56.1±7.5 years, and the mean kyphosis angle was 52.1°±19.1°. There was a statistically significant difference in ages ( t=2.92, P=0.005), but no statistically significant difference was observed regarding global kyphosis ( t=0.48, P=0.634). In these 74 patients, 9 patients had angular kyphosis, of which 8 (89%) developed OLF; of the 65 patients without angular kyphosis, 46 patients (71%) developed OLF. There was no significant difference between them (χ 2=1.32, P=0.251). Among the 54 patients diagnosed with OLF, 5 patients (9%) suffered ossification of the posterior longitudinal ligament (OPLL) and 20 patients (37%) suffered dural ossification; 43 patients (80%) developed OLF at proximal segments of apex, 6 patient (11%) developed OLF at distal segments of apex, and 5 patients (9%) developed OLF both at proximal and distal segments of apex. Thirty-two patients (59%) developed OLF at the first segment adjacent to the kyphotic apex, 27 patients (50%) developed OLF at the second segment, and 15 patients (28%) developed OLF at the third segment. Conclusion:Among patients with degenerative kyphosis, about 73% may development OLF within three segments adjacent to the kyphotic apex, and it mostly occurred within two segments adjacent to the apex proximally.
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@#A rare finding of a prostatic carcinoma metastasized in a ligamentum flavum at thoracic spine causing posterior column spinal cord compression. We reported a man with prostatic carcinoma presented with ataxic gait. Magnetic resonance imaging revealed an extradural cystic mass adjacent to the T4 intralaminar region indenting on the spinal cord. T4 posterior decompression via en bloc excision of the ligamentum flavum cyst and laminectomy was performed. Histopathology confirmed glandular tissue within the cyst wall which corresponds to prostatic adenocarcinoma cells. Two months post-operative, patient showed improvement in his muscle strength on left L2 myotome. The preoperative diagnosis is a challenge because of the ligamentum flavum cysts rarity in the thoracic spine and non-specific clinical signs and symptoms. To our best knowledge, this is the first report of metastatic adenocarcinoma of the prostate found as ligamentum flavum cysts.
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@#Introduction: Degenerative spondylolisthesis burdens the future economy. Elderly individuals with this condition suffer from back pain, limb paralysis, reduced activity, and diminished quality of life. Surgery offers relief but is risky and expensive. As healthcare improves, the aging population grows, and spondylolisthesis incidence rises. Early detection and risk factor management are vital for prevention. Therefore, this study aimed to evaluate the correlation of the risk factors for degenerative lumbar spondylolisthesis. Methods: A retrospective observational study was done in Dr Soetomo General Academic Hospital, Surabaya from January 2018 to December 2019. Forty-five subjects with degenerative spondylolisthesis diagnosed by MR Imaging enrolled in this study. Intervertebral disc, facet joint, multifidus muscle, and ligamentum flavum at level L1 until level L5 were examined using MR imaging. Correlation analysis was measured using the Spearman correlation test and risk factor analysis was measured using the logistic regression test. Results: There are significant correlations between intervertebral disc degeneration, facet joint osteoarthritis, multifidus muscle fatty infiltration, and thickening of ligamentum flavum with degenerative spondylolisthesis. The risk factors at levels L3-4 and L5-S1 are intervertebral disc degeneration and L4-5 is multifidus muscle fatty infiltration and facet joint osteoarthritis. Conclusion: This study confirmed the risk factors that correlated with degenerative lumbar spondylolisthesis.
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Objective:To investigate the changes of thickness and area of the ligamentum flavum after lateral lumbar interbody fusion (LLIF) for lumbar degenerative diseases.Methods:From 2019 to 2021, a total of 54 patients with lumbar degenerative diseases who underwent LLIF combined with percutaneous pedicle screw internal fixation were retrospectively analyzed. There were 9 males and 45 females, aged 59.46±6.91 years (range, 45-76 years), followed up for 14.69±6.87 months (range, 12-33 months). The disc height (DH), midsagittal canal diameter (CD), dural sac axial cross-sectional area (DCSA), ligamentum flavum area (LFA) and ligamentum flavum thickness (LFT) before and after surgery and at the last follow-up were evaluated and compared. Pearson correlation analysis was used to assess the relationship between the amount of change in the DCSA and LFA in the immediate postoperative period and at the last follow-up, as well as the correlation between the two and the amount of change in the DH. The data of patients at the last follow-up of 12 months after operation were extracted. Pearson correlation was used to evaluate the changes in DCSA and LFA at the last follow-up and the visual analogue scale (VAS) of low back pain and leg pain and Oswestry disability index (ODI) at 1 year after surgery.Results:All patients were followed up for 14.69±6.87 months (range, 12-33 months). The differences in DH ( F=354.93, P<0.001), sagittal CD ( F=44.78, P<0.001) and DCSA ( F=130.97, P<0.001) before, immediately after surgery and at the last follow-up were statistically significant. The DH, sagittal CD, and DCSA immediate after surgery and last follow-up were higher than those before surgery ( P<0.05). The differences in LFA ( F=51.59, P<0.001) and bilateral LFT ( F=53.49, P<0.001; F=50.53, P<0.001) before and after surgery and at the last follow-up were statistically significant, and both LFA and bilateral LFT at immediate after surgery and last follow-up were smaller than those before surgery ( P<0.05). Pearson correlation analysis showed that the change of DH immediately after surgery was moderately correlated with the change of DCSA ( r=0.57, P<0.001), and was strongly correlated with the change of LFA ( r=0.65, P<0.001). The change of DH at the last follow-up was moderately correlated with the change of DCSA ( r=0.43, P<0.001), and was weakly correlated with the change of LFA ( r=0.25, P=0.042). The differences in VAS-leg ( F=199.51, P<0.001), VAS-low back ( F=233.90, P<0.001), and ODI ( F=199.17, P<0.001) were statistically significant in patients before operation, 3 months after operation and 12 months after operation. There was no correlation between the changes of DCSA and LFA at the last follow-up and the changes of VAS and ODI at 1 year after operation ( P>0.05). Conclusion:LFA and LFT decrease and DCSA increase in patients with lumbar degenerative diseases after LLIF. LFA and LFT gradually decrease with time, and VAS and ODI are significantly improved compared with those before surgery. The DH loss caused by a certain degree of cage subsidence after surgery does not affect the clinical efficacy. There is no correlation between the improvement of DCSA and LFA and the improvement of clinical symptoms.
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Ligamentum flavum cysts in the spinal canal are rare space-occupying lesions.They usually occur in the middle-aged and people over 50 years old, without obvious sex or regional differences, and mostly involve the cervical, thoracic and lumbar vertebrae, especially the lumbar vertebrae(L4/5 and L5/S1). There are no characteristic manifestations for ligamentum flavum cysts.They can cause neurological symptoms due to compression of nerve roots or the dural sac.For example, patients with lumbar ligamentum flavum cysts may complain of symptoms of lumbar disc herniation-related sciatica, which can easily lead to misdiagnosis.Surgical excision of the cyst is the most effective method.Recently, one patient with this disease was admitted to our department.After surgical fenestration, the ligamentum flavum cyst in the lumbar canal was resected and its diagnosis was eventually confirmed histologically.After 17 months of follow-up, the patient recovered well.
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Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5- C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed â muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, whichmay be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.
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Humans , Male , Aged , Spinal Cord Compression/surgery , Spinal Cord Compression/complications , Ligamentum Flavum/physiopathology , Spinal Cord Compression/diagnostic imaging , Spinal Fusion/methods , Cervical Vertebrae , Treatment Outcome , Diskectomy/methods , Spondylosis , Laminectomy/methodsABSTRACT
ABSTRACT Objective: to validate a lumbar spine endoscopic flavectomy simulator using the construct method and to assess the acceptability of the simulator in medical education. Methods: thirty medical students and ten video-assisted surgery experienced orthopedists performed an endoscopic flavectomy procedure in the simulator. Time, look-downs, lost instruments, respect for the stipulated edge of the ligamentum flavum, regularity of the incision, GOALS checklist (Global Operative Assessment of Laparoscopic Skills), and responses to the Likert Scale adapted for this study were analyzed. Results: all variables differed between groups. Procedure time was shorter in the physician group (p < 0.001). Look-downs and instrument losses were seven times greater among students than physicians. Half of the students respected the designated incision limits, compared to 80% of the physicians. In the student group, about 30% of the incisions were regular, compared to 100% in the physician group (p < 0.001). The physicians performed better in all GOALS checklist domains. All the physicians and more than 96% of the students considered the activity enjoyable, and approximately 90% believed that the model was realistic and could contribute to medical education. Conclusions: the simulator could differentiate the groups' experience level, indicating construct validity, and both groups reported high acceptability.
RESUMO Objetivo: validar um simulador de flavectomia endoscópica da coluna lombar por meio do método de constructo e, analisar a aceitação do simulador no ensino médico. Métodos: trinta estudantes de medicina e dez ortopedistas com experiência em videocirurgia realizaram um procedimento de flavectomia endoscópica no simulador. Foram analisados tempo, look-downs, perdas de instrumentos, respeito ao limite estipulado no ligamento amarelo, contorno regular do corte, checklist GOALS (Global Operative Assessment of Laparaoscopic Skills) e respostas à Escala de Likert adaptada para este estudo. Resultados: todas as variáveis diferiram entre os grupos. O tempo do procedimento foi menor no grupo dos médicos (p < 0,001). Look-downs e perdas de instrumentos foram sete vezes superiores entre os alunos do que entre os médicos. Metade dos alunos respeitou os limites de incisão designados, em comparação a 80% dos médicos. No grupo dos alunos, cerca de 30% das incisões foram regulares, em comparação a 100% no grupo dos médicos (p < 0,001). Os médicos tiveram melhor desempenho em todos os domínios da checklist GOALS. Todos os médicos e 96% dos alunos consideraram a atividade prazerosa, e cerca de 90% consideraram que o modelo era realista e poderia contribuir para o ensino médico. Conclusões: o simulador foi capaz de diferenciar o nível de experiência dos grupos, indicando a validade do construto, e ambos os grupos relataram alta aceitação.
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Humans , Physicians , Students, Medical , Laparoscopy , Clinical CompetenceABSTRACT
Objective:To analyze the prevalence and distribution characteristics of diffuse idiopathic skeletal hyperostosis (DISH) in hospitalized patients with thoracic ossification of the ligamentum flavum (TOLF).Methods:The clinical records of 132 consecutive TOLF patients from January 2018 to June 2019 were retrospectively studied. DISH was identified by the preoperative X-ray and CT and its prevalence was calculated. The prevalence of patients with different genders, different age groups and different ossification types was compared. The segmental distribution of DISH and the distribution in the upper (T 1-T 4), middle (T 5-T 8), and lower thoracic spine (T 9-T 12) were analyzed. Ossification degree of DISH was evaluated based on the Meta scoring system. The demographic characteristics (age, gender, BMI, etc.) were compared between DISH and non-DISH group. Results:Forty-nine patients was diagnosed as DISH with the prevalence of 37.1% in all included cases. The prevalence was about twice as high in male (46.3%) than in female (23.1%) ( χ2=8.806, P=0.003). The prevalence in the age groups of <40, 40-49, 50-59, 60-69 and ≥70 years was 20.0%, 28.0%, 34.4%, 44.0%, and 66.7%, respectively. The prevalence in long-segment TOLF patients (45.1%) was significantly higher than that in short-segment TOLF patients (24.0%) ( χ2=5.937, P=0.015). DISH most frequently affected T 8,9 levels (91.8%). The total number and mean number of ossified segments were 365 and 7.4, respectively. Ossification lesions in the upper, middle, lower thoracic spine accounted for 26.03%, 40.54%, and 33.15%, respectively. Grade I, grade II, and grade III ossification accounted for 21.4%, 28.5% and 50.1%, respectively. The mean age of the DISH group was older than the non-DISH group ( t=2.024, P=0.045). The proportion of male patients in the DISH group was significantly higher than that in the non-DISH group ( χ2=8.806, P=0.003). The average height and weight in the DISH group were significantly greater than those in the non-DISH group ( t=2.564, P=0.012; t=2.191, P=0.030), whereas no significant differences in BMI and constituent ratio of concurrent diabetes, cardiac disease, hypertension between two groups were observed. Conclusion:The prevalence of DISH in patients with TOLF is 37.1%. Male, elderly and long-segment TOLF patients are associated with higher prevalence. DISH frequently occurs in the middle and lower thoracic spine, and T 8,9 is the common affected segment. Ossification lesions may develop with age. Demographic characteristics of DISH group differ, to some extent, from those of non-DISH group.
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Objective:To analyze the influencing factors of thoracic ossification of ligamentum flavum (TOLF) and to construct a predictive model.Methods:The clinical data of 138 patients who underwent TOLF surgery during February 2016 to February 2019 in Fengjie County People′s Hospital were retrospectively analyzed. All patients were followed up 6 months after the operation to evaluate the prognosis. Patients whose efficacy evaluated as "fair" or "poor" were included in the poor prognosis group (35 patients), and those whose efficacy evaluated as "excellent" "or "good" were included in the good prognosis group (103 patients). The clinical data of the two groups of patients were collected, and the risk factors affecting the prognosis of patients undergoing TOLF surgery were analyzed by multivariate Logistic regression method. A prediction model was constructed and it′s effect was verified finally.Results:Multivariate Logistic regression analysis showed that complications of dural sac bone, T 2 -weighted intramedullary high signal, spinal canal area residual rate, postoperative cerebrospinal fluid leakage and course of disease were risk factors for poor prognosis of TOLF surgery ( P<0.05). Prediction model: P = 1/ (e
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BACKGROUND: Lumbar spinal stenosis is one of the key causes of gait disorder and low back pain in the older adults. Hypertrophy of the ligamentum flavum is the main pathological mechanism leading to lumbar spinal stenosis. Although there are numerous imaging and pathological studies on the ligamentum flavum, little is reported on cell apoptosis. OBJECTIVE: To detect the apoptotic rate and the expression of caspase-3, fas and p53 in the hypertrophic ligamentum flavum, providing experimental evidence for understanding the mechanism underlying degeneration of the ligamentum flavum. METHODS: In experimental group, 50 hypertrophic ligamentum flavum specimens (L2-S1) confirmed by MRI and postoperative measurement were obtained from 50 patients with lumbar spinal stenosis who underwent posterior decompression surgery. There were 22 males and 28 females, aged from 32 to 74 years old, with an average of 54.46 years old. In control group, 30 non-hypertrophic ligamentum flavum specimens (L2-S1) confirmed by MRI and postoperative measurement were obtained from 30 patients with lumbar disc herniation undergoing surgery and lumbar burst fractures. There were 19 males and 11 females, aged 19-67 years, with an average of 47.27 years old. The apoptotic rate in the ligamentum flavum was detected by TUNEL staining, and the expression of caspase-3, fas and p53 was detected by SP immunohistochemistry. The study protocol was approved by the Ethics Committee of the Sixth Affiliated Hospital of Xinjiang Medical University, with approval No. LFYLLSJ2016007. RESULTS AND CONCLUSION: TUNEL results showed that the average apoptotic rate of the experimental group was (37.80±3.04)%, which was significantly higher than that of the control group [(13.18±1.34)%; t=41.83, P < 0.001]. The immunohistochemical staining of SP revealed that the positive expression percentages of caspase-3, fas and p53 in the ligamentum flavum were all 100% in the experimental group, while the positive percentages were 13.3%, 16.7%, and 10% in the control group, respectively. There was a significant difference between the two groups (P < 0.001). These findings indicate that cell apoptosis in the hypertrophic ligamentum flavum is increased and has a certain correlation with the up-regulation of caspase-3, fas and p53.
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BACKGROUND: Pathological mechanism of ossification of the ligamentum flavum is unclear. There is no effective drug or non-surgical treatment in clinical practice. Current studies have found that osteopontin and autophagy play an important role in the process of osteogenesis, but their role in ossification of the ligamentum flavum has not been elucidated. OBJECTIVE: To seek for the potential target of drug therapy by exploring the mechanism of ossification of the ligamentum flavum. METHODS: (1) Surgical specimens of the ligamentum flavum were taken from patients with ossification of the ligamentum flavum, thoracic vertebrae or simple lumbar disc herniation undergoing posterior total laminectomy and decompression. These specimens were divided into two groups: An ossification group and a non-ossification group. Eight specimens from each group were collected. Osteopontin, osteocalcin and autophagy indexes Beclin-1, LC3 and P62 were stained by immunohistochemistry. (2) The ligamentum flavum cells were isolated and cultured by adherence method. The third generation cells were treated with osteopontin at different concentrations for different time to construct an in vitro model of ligamentum flavum ossification. (3) Autophagy inhibitor 3-methyladenine with different concentrations was used to intervene with non-ossified ligamentum flavum cells, followed by induction with 100 μg/L osteopontin. Western blot assay was used to detect the expression of alkaline phosphatase, osteocalcin. (4) Non-ossified ligamentum flavum cells were induced with 100 μg/L osteopontin, and the induction was terminated at 0, 15, 30, 60, and 120 minutes, respectively. The phosphorylation of ERK1/2, JNK and P38, which are important molecules in the MAPK signaling pathway, was detected by western blot. (5) Finally, after inhibition by ERK1/2 phosphorylation blocker U0126, the expression of alkaline phosphatase and osteocalcin was detected by western blot after induction with 100 μg/L steopontin. RESULTS AND CONCLUSION: (1) Immunohistochemical staining of osteopontin and osteocalcin in ossified and non-ossified ligamentum flavum was positive. In the ossified ligamentum flavum, Beclin-1 was positive, but LC3 and P62 were not. Beclin-1, LC3 and P62 were all positive in the non-ossified ligamentum flavum. (2) The expression of alkaline phosphatase and osteocalcin in the ossified ligamentum flavum cells was higher than that in the non-ossified ligamentum flavum cells. Osteopontin could induce ossification of the ligamentum flavum in a concentration- and time-dependent manner. (3) The degree of ossification was negatively correlated with the degree of autophagy, that is, the more obvious autophagy was, the weaker ossification was. (4) Osteopontin could phosphorylate the MAPK signaling pathway in a time-dependent manner. After inhibiting the phosphorylation of MAPK, osteopontin could still induce the ossification of ligamentum flavum cells. To conclude, in the process of ligamentum flavum ossification, the upstream and downstream relationships of ERK1/2, osteopontin, alkaline phosphatase and osteocalcin molecules in signaling pathway are ERK1/2→osteopontin→osteocalcin/alkaline phosphatase.
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BACKGROUND: MRI has high sensitivity to thoracic myelopathy, which can assess the spinal cord injury by morphology and magnitude of cervical spinal cord compression. Additionally, it is a valuable tool for the prognosis evaluation of thoracic spinal stenosis. OBJECTIVE: To explore the value of quantitative MRI T2WI parameters in predicting surgical outcome of thoracic ossification of the ligamentum flavum, and to establish the prediction model of poor prognosis, so as to provide reference for prognosis evaluation. METHODS: From January 2010 to January 2019 at Cangzhou Central Hospital, clinical and imaging data of 87 cases of thoracic ossification of the ligamentum flavum treated by thoracic laminectomy were reviewed retrospectively. According to the JOA recovery rate at 6-month follow-up, the patients were divided into good recovery group (≥ 50%) and poor recovery group (< 50%). Age, sex, duration of disease, JOA score, Sato type of ossification, maximum spinal cord compression, cross-sectional area, distribution of hyperintense signal, signal intensity ratio, intramedullary signal size, local kyphosis, kyphosis correction, number of decompressed levels and incidence of cerebrospinal fluid were compared between two groups. Univariate analysis was used to analyze indicators with significant differences. Receiver operating characteristic curve was plotted to analyze prognosis. Areas under the curve and cut-off values were recorded. The independent predictors of poor recovery were estimated through multivariate logistic regression analysis and the prediction model was established. RESULTS AND CONCLUSION: (1) The duration of disease, JOA score, maximum spinal cord compression, cross-sectional area, signal intensity ratio and intramedullary signal size showed significant difference between good recovery and poor recovery groups (P < 0.05). (2) Receiver operating characteristic curve analysis showed that the area under the curve of the duration of disease, JOA score, maximum spinal cord compression, cross-sectional area, signal intensity ratio and intramedullary signal size was 0.670, 0.733, 0.647, 0.715, 0.753 and 0.765 respectively. The cut-off value was duration of 13 months, score 4, 29.8%, 0.25 cm2, 1.593 and 13.64 mm respectively. The duration of disease and maximum spinal cord compression had low discrimination power (the area under the curve < 0.7) in predicting poor recovery, whereas the JOA score, cross-sectional area, signal intensity ratio and intramedullary signal size had moderate discrimination power (the area under the curve 0.7-0.9). The area under the curve indicates good ability of signal intensity ratio and intramedullary signal size in combination (the area under the curve=0.791). (3) Logistic multivariate regression analysis showed that JOA score, cross-sectional area and combination of signal intensity ratio and intramedullary signal size were independent risk factors of poor recovery. A predicting model was built according to the result of the logistic regression analysis. It was shown that the area under the curve of this model was 0.890, which was significantly higher than that of the JOA score, cross-sectional area and combination of signal intensity ratio and intramedullary signal size (P < 0.05). (4) Combination of signal intensity ratio and intramedullary signal size had higher predictive ability than other MRI parameters. JOA score, together with quantitative MRI T2WI parameters may have a better predictive value for the risk of poor recovery in patients with thoracic ossification of the ligamentum flavum.
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Calcification of the ligamentum flavum (CLF), which is a rare disorder that can potentially cause myelopathy, occurs uncommonly in the thoracic spine. Here, we report a rare case of thoracic myelopathy caused by CLF in a 78-year-old man. Magnetic resonance imaging (MRI) showed posterior spinal cord compression by a hypo-signal intense mass, and computed tomography (CT) revealed CLF and vacuum disc phenomenon at T10/11. After undergoing posterior decompression and instrumented fusion (T9–T12), the patient’s gait difficulties improved. The pathogenesis of CLF is largely unknown; however, it involves accumulation of calcium pyrophosphate dehydrate crystals (CPPD), and CLF from CPPD deposition tends to occur within a thickened and hypertrophic ligament. CLF occurs predominantly in the cervical spine and less frequently in the lumbar spine, with few cases involving the thoraco-lumbar spine. The thoracic spine is characterized by hypomobility; however, the thoraco-lumbar spine has a mobile segment which may potentiate CLF formation. Decompression with fusion surgery can be useful for treating patients with thoraco-lumbar CLF.
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Abstract: Introduction: Changes in ligamentum flavum (LF) related to degeneration are secondary to either the aging process or mechanical instability. Previous studies have indicated that LF with aging shows elastic fiber loss and increased collagen content, loss of elasticity may cause LF to fold into the spinal canal, which may further narrow of the canal. Material and methods: A total of 67 patients operated with the surgical indications of lumbar spinal stenosis (LSS), lumbar disc herniation (LDH) and lumbar degenerative spondylolisthesis (LDS) were included. LF samples were obtained from patients who had LSS (39), LDH (22) and LDS (6). Specimens were examined with regard to chondroid metaplasia, calcification, fragmentation of collagen fibers, cystic degeneration, fibrillar appearence, and hypercellularity. Results: The most frequent histopathological changes were hyalinization and fragmentation of collagen fibers occur in 34%, neovascularization in 40.3% and irregular arrangement of elastic fibers is the most prevalent change with 56.7% of the total samples. There is a difference in the presence of certain changes in the LF according to the diagnosis, being statistically significant for fragmentation of collagen fibers (p = 0.045), cystic degeneration (p = 0.001), fibrillar appearance (p = 0.007) and hypercellularity (p = 0.005) all of these, being more prevalent in LDS group. LHD group presented fragmentation of collagen fibers in 45.5% (p = 0.045) and fibrillar appearance in 4.5% (p = 0.009). Conclusions: There is not evidence of cellular hyperthophy in the histhopatological analyses, thickening of the LF can be seen by bulking of LF followed by collapse of motion segment.
Resumen: Introducción: Los cambios en el ligamento flavum (LF) relacionados con la degeneración son secundarios al proceso de envejecimiento o a la inestabilidad mecánica. Estudios anteriores han indicado que LF con envejecimiento muestra pérdida de fibras elásticas y aumento del contenido de colágeno, la pérdida de elasticidad puede hacer que el LF se pliegue en el canal espinal, disminuyendo su espacio. Material y métodos: Se incluyeron 67 pacientes operados de estenosis lumbar espinal (LSS), hernia de disco lumbar (LDH) y espondilolistesis degenerativa (LDS). Se obtuvieron muestras de LF de pacientes que tenían LSS (39), LDH (22) y LDS (6). Se examinaron especímenes con respecto a metaplasia condroide, calcificación, fragmentación de fibras de colágeno, degeneración quística, apariencia fibrilar e hipercelularidad. Resultados: Los cambios histopatológicos más frecuentes fueron la hialinización y la fragmentación de las fibras de colágeno (34%), neovascularización en 40.3%, y la disposición irregular de las fibras elásticas es el cambio más frecuente con 56.7% del total de muestras. Existe una diferencia en la presencia de cambios en el LF, de acuerdo con el diagnóstico, siendo estadísticamente significativo para la fragmentación de las fibras de colágeno (p = 0.045), la degeneración quística (p = 0.001), la apariencia fibrilar (p = 0.007) y la hipercelularidad (p = 0.005) todos ellos, siendo más frecuentes en el grupo LDS. El grupo LHD presentó fragmentación de las fibras de colágeno en 45.5% (p = 0.045) y la apariencia fibrilar en 4.5% (p = 0.009). Conclusiones: No hay evidencia de hipertrofia celular en los análisis histopatológicos, el engrosamiento del LF se puede ver por abultamiento del mismo, seguido de colapso del segmento de movimiento.
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Humans , Spinal Stenosis/surgery , Spondylolisthesis , Ligamentum Flavum , HerniaABSTRACT
Objective: To investigate the mechanism of p38 mitogen activated protein kinase (MAPK) signaling pathway in regulating the hyperplasia and hypertrophy of human lumbar ligamentum flavum via transforming growth factor β 1 (TGF-β 1)/connective tissue growth factor (CTGF). Methods: The lumbar ligamentum flavum tissue taken from patient with lumbar intervertebral disc herniation was isolated by collagenase-predigested explant cultures. The ligamentum flavum cells were treated with the extracellular regulated protein kinase pathway blocker PD98059, c-Jun N-terminal kinase pathway blocker SP600125, and p38 pathway blocker SB203580, and then the mRNA expressions of CTGF, collagen type Ⅰ, and collagen type Ⅲ were detected by real-time fluorescence quantitative PCR (qRT-PCR). The ligamentum flavum cells were divided into 4 groups, and transfected with small interfering RNA (siRNA), p38 siRNA, siRNA+3 ng/mL TGF-β 1, and p38 siRNA+3 ng/mL TGF-β 1 in groups A, B, C, and D, respectively. After 24 hours of transfection, immunofluorescence staining was performed to observe the expressions of p38 and phosphorylation p38 (p-p38); the relative mRNA expressions of CTGF, collagen type Ⅰ, and collagen type Ⅲ in each group were detected by qRT-PCR; the protein expression of CTGF in each group was detected by Western blot. Results: p38 pathway blocker SB203580 could significantly reduce the relative mRNA expressions of CTGF, collagen type Ⅰ, and collagen type Ⅲ ( P<0.05). After 24 hours of transfection, immunofluorescence staining showed positive staining with p38 and p-p38 expressions in groups A, C, and D and negative staining in group B. Compared with group A, the relative mRNA expressions of CTGF, collagen type Ⅰ, and collagen type Ⅲ and relative protein expression of CTGF in group B decreased significantly ( P<0.05), while those in groups C and D increased significantly ( P<0.05); and those indicators significantly increased in group C than in group D ( P<0.05). Conclusion: TGF-β 1/CTGF based on the p38 MAPK signaling pathway play an important role in the occurance and development of hypertrophy of human lumbar ligamentum flavum.
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Objective: To investigate the effect of transforming growth factor β 1 (TGF-β 1) induced proliferation of ligamentum flavum cells and ligamentum flavum hypertrophy and its effect on connective tissue growth factor (CTGF) expression. Methods: The ligamentum flavum tissue in lumbar intervertebral disc herniation was extracted and the ligamentum flavum cells were isolated and cultured by collagenase pre-digestion method. Morphological observation, immunofluorescence staining observation, and MTT assay were used for cell identification. The 3rd generation ligamentum flavum cells were divided into 5 groups. The cells of groups A, B, C, and D were respectively sealed with 3 ng/mL TGF-β 1, 50 ng/mL CTGF, 3 ng/mL TGF-β 1+CTGF neutralizing antibody, and 50 ng/mL CTGF+CTGF neutralizing antibody. Serum free DMEM was added to group E as the control. MTT assay was used to detect the effects of TGF-β 1 and CTGF on the proliferation of ligamentum flavum cells. Western blot was used to detect the expression of CTGF protein. Real-time fluorescence quantitative PCR (qRT-PCR) was used to detect the expression of collagen type Ⅰ, collagen type Ⅲ, and CTGF genes. Results: The morphological diversity of cultured ligamentum flavum cells showed typical phenotype of ligamentum flavum fibroblasts; all cells expressed collagen type Ⅰ and vimentin, and some cells expressed collagen type Ⅲ; MTT identification showed that with the prolongation of culture time, the absorbance ( A) value of each generation of cells increased gradually, and the A value of the same generation of cells at each time point was significantly different ( P0.05). After cultured for 24 hours, MTT assay showed that the A value of cells in groups A and B was significantly higher than that of group E ( P0.05); after neutralizing antibody was added, the mRNA relative expression of collagen type Ⅰ and collagen type Ⅲ in group D was inhibited and was significantly lower than that in group B, but still significantly higher than that in group E ( P0.05). Conclusion: TGF-β 1 can promote CTGF, collagen typeⅠ, collagen type Ⅲ gene level and protein expression in ligamentum flavum cells, and TGF-β 1 can synergistically promote proliferation of ligamentum flavum cells through CTGF.
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Objective To investigate the imaging characteristics and pathogenic manifestations of thoracic ossification of the ligamentum flavum complicated with dural ossification.Methods CT and MRI imaging data of 62 segments from 29 patients with thoracic ossification of the ligamentum flavum (TOLF) treated with "en bloc resection of lamina and ossified mass" were retrospectively analyzed.There were 19 males and 10 females,aged 54.9±10.25 years (36-77 years),16 segments in 11 cases with dural ossification (DO) and 46 segments in 18 cases without DO.The ossified mass shape,the relationship between ossified mas and dura mater on cross section of CT bone window and MRI T2WI,and the ossified mass occupational rate (OR) of the spinal canal were investigated.Pathologic features of TOLF-DO from 2 patients were analyzed by H&E staining.Results The shape of ossified mass was as followed,in 16 segments with DO,7 segments (43.8％) by CT and 2 segments (12.5％) by MRI showing ossification layer on the dural sac side of ligamentum flavum;1 segment (6.3％) by CT and 2 segments (12.5％) by MRI showing typical Tram track sign.The relationship between ossified mass and dura mater was that 7 segments (43.8％) by CT and 7 segments (43.8％) by MRI with "C" sign and 7 segments (43.8％) by CT and 8 segments (50.0％) by MRI with "V" sign.The ossified mass OR was 60.5％± 13.0％ in the group with DO and 42.2％± 12.3％ in the group without DO.There was a significant difference between the two groups (t=5.192,P＜0.001).Among the 16 segments with DO,the ossified mass OR of 7 segments with "C" sign was 68.8％± 12.8％ and that of the other 9 segments without "C" sign was 54.39％±9.9％.There was significant difference between the two groups (t=2.45,P=-0.028).Histological examination showed that there were two pathological phenomena in the dura tissue adjacent to ossified mass.The one,there were fibrocartilage,cartilage and osteogenesis in the dura mater.The other,the unossified dura mater fused with the ossified mass but with clear histological demarcation,while the dura mater on the ventral side of the ossified ligamentum flavum atrophies or disappeared.Conclusion The occurrence of dural sac ossification is associated with the ossification of ligamentum flavum beginning at the side of the dural sac and the persistent thickening of the ossified mass.The pathological manifestations of DO are ossification of dural tissue or fusion of dural with ligamentum flavum ossification.
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STUDY DESIGN: Retrospective and comparative study. PURPOSE: We assessed surgical treatment outcomes in patients with thoracic myelopathy due to ossification of the ligamentum flavum (OLF), and OLF combined with ossification of the posterior longitudinal ligament (OPLL) or vertebral fracture (VF) at the same level. OVERVIEW OF LITERATURE: OLF and OPLL cause severe thoracic myelopathy. Osteoporotic VF commonly occurs at the thoracolumbar junction. There have been no investigations of thoracic myelopathy due to OLF and VF. METHODS: Forty patients were divided among three groups: the OLF group (n=23): myelopathy due to OLF, the OLF+OPLL group (n=12): myelopathy due to OLF and OPLL, and the OLF+VF group (n=5): myelopathy due to OLF and VF. We recorded OLF, OPLL, and VF sites and operative procedures. Each patient’s neurological status, according to the Japanese Orthopaedic Association (JOA) score, and walking ability were evaluated pre- and postoperatively. RESULTS: Patients in the OLF+OPLL group were significantly younger than those in the other two groups. The preoperative JOA score was significantly lower in the OLF+VF than OLF group. The final JOA score was significantly lower in the OLF+VF than OLF and OLF+OPLL groups. The JOA score recovery rate was significantly lower in the OLF+VF than OLF group. Final walking ability was significantly worse in the OLF+OPLL and OLF+VF groups than in the OLF group and significantly worse in the OLF+VF than OLF+OPLL group. CONCLUSIONS: Thoracic myelopathy due to OLF+VF occurs primarily in older females, who also exhibit worse preoperative and postoperative neurological status, and worse walking ability, than patients with thoracic myelopathy due to OLF or OLF+OPLL.
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In patients with tumors and spinal cord lesions, inflammation and tissue infection can result in mass effect detection on imaging. As a result, surgical biopsy procedures are often performed on the lesions. We report a rare case in which the thickening ligamentum flavum (LF) appeared to be a tumor in the epidural space of the cervical spine based on imaging findings. A 52-year-old man visited our outpatient clinic with severe shoulder pain and radicular pain in his right arm that had developed gradually after a traffic accident two months earlier. Magnetic resonance imaging of the cervical spine revealed an extradural mass at the cervicothoracic junction level. Suspecting a tumor, spinal decompression surgery was performed and a biopsy of the mass was obtained. At the time of surgery, the LF was thick and compressed the spinal cord. After successful removal of the LF, the spinal cord appeared normal. Histopathological examination confirmed the mass as the LF. The patient was discharged without pain or weakness two weeks postoperatively. This case demonstrated that when the LF of the cervicothoracic junction is thickened, it may be misdiagnosed as a cervical spine tumor compressing the spinal cord.
Subject(s)
Female , Humans , Middle Aged , Accidents, Traffic , Ambulatory Care Facilities , Arm , Biopsy , Cervical Vertebrae , Decompression , Epidural Space , Inflammation , Ligamentum Flavum , Magnetic Resonance Imaging , Radiculopathy , Shoulder Pain , Spinal Cord , Spinal Cord Compression , SpineABSTRACT
Objective To investigate the safety and effect of zoning laminectomy for the ossification of thoracic ligamentum flavum.Methods From November 2011 to December 2014,34 patients (15 males,19 females;41-76 years old,average 55.0±8.1) with ossification of thoracic ligamentum flavum (OLF) were treated by zoning laminectomy.The course of disease ranged from 1 month to 123 months (average 16.5 months).According to the anatomical characteristics and the pathological ossification process of the thoracic ligamentum flavum,we proposed the concept of "zoning",which divided each segmental thoracic OLF into three zones:"safety zone","middle zone" and "risk zone".From the features of anatomy of LF and process of OLF development,we found there is no or less cerebrospinal fluid between spinal cord and the tip of each ossified nodular masses in severe OLF,any procedures using instruments in this area have the potential to cause irreversible spinal cord injury,we defined this area as "risk zone",the "null" area of each lamina and lateral and dorsal side of nodular masses as "safety zone",and the other area as "middle zone".From "safety zone" to "risk zone" the spinal canal decreased gradually,different zone needs different surgical strategy:This surgical procedure first removed the "null" area of superior and inferior lamina and dorsal side of each segmental OLF.Next,partially or totally resected the "middle zone",exploring the lateral side of nodular masses,and the "risk zone" was exposed and isolated.Finally,dissected the lateral side of nodular masses,and then the "risk zone" was floated and resected with a directly decompressing the spinal cord.Preoperative and postoperative modified Japanese Orthopedic Association (JOA) score and neurologic functional recovery ratio were used to evaluate the surgical outcomes.Results Of the total 83 decompressed OLF segments,5 (6.0％) located in the upper thoracic spine (T1-T4),8 (9.6％) in the midthoracic spine (T5-T8),and 70 (84.4％) in the lower thoracic spine (Tg-L 1).The followed up ranged from 4 to 40 months,with an average of 21.7±9.9 months.The mean JOA score increased significant from 5.3±2.0 preoperatively to 8.8±1.8 at the final follow-up (t=1 1.566,P=0.001).Postoperative average JOA neurologic functional recovery rates were 63.2％±24.7％,including excellent in 15 cases,good in 11 cases and fair in 8 cases.The excellent and good rate was 76.5％.Twelve cases had transient CSF leakage because of dural defect.The dural defect was only treated by tightly suturing the paraspinal muscles,the subcutaneous tissue,and the skin layers.The CSF leakage lasted for 6 to 8 days after operation.Two cases with wound infection were treated with debridement and antibiotics and healed completely.One case with thoracic spinal cord transient incomplete paralysis due to a post-operative epidural hematoma was treated with an emergency operation and got recovered neurological function.Conclusion Zoning laminectomy has the advantages of safe manipulation and thorough decompression,which is an effective choice for the surgical treatment of thoracic OLF.