Ligamentum flavum hematoma (LFH) is a rare cause of spinal nerve compression. This condition remains challenging to diagnose using MRI due to the changing intensity of the hematoma on imaging. The aim of this study was to describe the patient with LFH who had a succession of MRI scans carried out. We report on a 71-year-old woman with a mass at L4/5 and decompression surgery was performed for her left leg symptom. She had MRI carried out in a previous hospital and also had MRI again in our hospital. In a 2nd MRI of the same area, after a 2-week interval, a newly isointense mass was present within the anterior part of the previously identified lesion on T1-weighted image and the hyperintense area in the lesion was a little extended on T2-weighted imaging. Her symptoms were resolved immediately after decompression surgery. Following a review of previous cases, we suggest that consecutive MRI scanning may support the diagnostic process for LFH.
Various pathological changes of the ligamentum flavum have been identified, including hypertrophy, calcification, ossification, and cyst formation that may compress the spinal cord. Ligamentum flavum hematoma (LFH) is a rare cause of spinal nerve compression [
A 71-year-old woman was referred for evaluation of back pain and worsening left lower extremity pain, which included neurogenic claudication. She gave a history of a fall from standing height, with onset of low back pain. Around a month later, her left leg pain became a prominent feature, with a symptom duration of approximately five months at the time of injury. She did not experience lumbar epidural or intrathecal injections. She reported no history of fever and no difficulty passing urine. Significant medical history included mild hypertension, of note, and there was no history of malignancy and no history of use of anticoagulant drugs. Both platelet count and prothrombin time were in the normal range. On examination, there was full power and symmetrical reflexes in both lower extremities. Patchy reduction in sensation to the left lower limb was noted. She was given a left L5 nerve root block which was only effective for 3 days. The patient and/or her families were informed that data from the case would be submitted for publication and gave their consent.
A lumbar MRI without gadolinium (Gd) had been performed prior to evaluation (4 months after symptom onset) in a previous hospital (Figure
Magnetic resonance images showing a posterior epidural mass at L4/5 compressing the thecal sac and spinal cord and linking with the ligamentum flavum.
2nd magnetic resonance images (MRI) showing left posterior mass at the same area of the 1st MRI. (a) Sagittal T1-weighted axial MRI reveals that there was a newly isointense mass present within the anterior part of the previously identified lesion. (b) Sagittal T2-weighted axial MRI reveals that the intensity inside the mass was a little extended. (c, d) T1-weighted axial MRI at L4/5 reveals the well-defined extradural mass in the left posterior aspect of the thecal sac. (c) There was no significant enhancement with Gd-based contrast (d).
The patient underwent surgery for decompression of the spinal canal and resection of the lesion, which at this stage was presumed to be an epidural tumour. After L4/5 partial laminectomy, the solid blackish ligamentum flavum was visible and firmly adherent to the dural sac at L4/5 posteriorly (Figure
(a) The ligamentum flavum after L4/5 partial laminectomy. (b) The solid blackish, swelling ligament in left side.
A hematoma inside the removal ligament.
Our patient recovered rapidly after surgical removal of the lesion and the previously reported patients also recovered immediately after surgery. To our knowledge, 28 cases of lumbar LFH [
Reported cases of lumbar ligamentum flavum hematoma.
Authors | Patient gender | Age (year) | Level |
---|---|---|---|
Sweasey et al. [ |
M | 43 | L4/5 |
M | 60 | L2/3 | |
Baker and Hanson [ |
F | 58 | L5/S1 |
Cruz-Conde et al. [ |
M | 57 | L4/5 |
Mahallati et al. [ |
M | 30 | L3/4 |
Minamide et al. [ |
M | 76 | L3/4 |
Hirakawa et al. [ |
M | 50 | L4/5 |
Yuceer et al. [ |
M | 67 | L2/3 |
Chi et al. [ |
M | 64 | L3/4 |
Mizuno et al. [ |
F | 45 | L4/5 |
Yamaguchi et al. [ |
M | 62 | L4/5 |
Albanese et al. [ |
F | 70 | L1/2 |
Keynan et al. [ |
F | 75 | L3/4 |
Shimada et al. [ |
F | 83 | L2-4 |
Spuck et al. [ |
F | 64 | L2/3 |
M | 62 | L4/5 | |
Gazzeri et al. [ |
F | 59 | L3/4 |
Kotil and Bilge [ |
M | 74 | L4/5 |
M | 80 | L4/5 | |
Kono et al. [ |
M | 64 | L4/5 |
Miyakoshi et al. [ |
M | 71 | L3-5 |
Takahashi et al. [ |
F | 53 | L3/4 |
M | 61 | L5/S1 | |
Ohba et al. [ |
M | 52 | L5/S1 |
Ghent et al. [ |
M | 62 | L3/4 |
Liu et al. [ |
M | 76 | L4/5 |
Ozdemir et al. [ |
M | 63 | L2/3 |
Ishimoto et al. (2017) | F | 71 | L4/5 |
The mechanism of development of LFH has not yet been identified [
The biggest challenge faced by clinicians is the difficulty in the diagnosis of this condition, as differentiating LFH from epidural tumours using MR imaging is considered virtually impossible. Keynan et al. [
We propose that differences between the first and second MRI scans can help in diagnosing LFH. However, at the present it is not clear what the appropriate time period between the first and second MRI scans should be. Such an approach may not be possible if the patient had severe symptoms requiring emergency surgery. Nevertheless, this is the first study to highlight the potential importance of differences between the first and second MRI for LFH diagnosis. Carrying out MRI scans in succession may support the diagnostic process for LFH.
Our patient with lumbar LFH underwent decompression surgery and her symptoms immediately resolved. Following a review of previous cases, we suggest that consecutive MRI scanning may support the diagnostic process for LFH.
The authors declare that there is no conflict of interest regarding the publication of this paper.
The author would like to thank the staffs in the theatre of Wakayama Medical University Kihoku Hospital for their assistance in the patient operation.