Ossified ligamentum flavum of the thoracic spine presenting as spontaneous intracranial hypotension: case report

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Ossification of the ligament flavum in the thoracic spine is an uncommon radiological finding in the Western population but can present with back pain, varying degrees of myelopathy, and even paraplegia on occasion. The authors here present the case of a 50-year-old woman with a history of progressive back pain and symptoms of spontaneous intracranial hypotension who was found to have an ossified ligamentum flavum of the thoracic spine resulting in a dural erosion cerebrospinal fluid leak. Surgery involved removal of the ossified ligament flavum at T10–11, facetectomy, ligation of the nerve root, and primary closure of the dura, which resulted in complete resolution of the patient’s symptoms. Radiological, clinical, and intraoperative findings are discussed to assist surgeons with an accurate diagnosis and treatment in the setting of this unusual presentation.

ABBREVIATIONS CSF = cerebrospinal fluid; OLF = ossification of the ligamentum flavum; SIH = spontaneous intracranial hypotension.

Article Information

Correspondence Mazda K. Turel: Rush University Medical Center, Chicago, IL. mazdaturel@gmail.com.

INCLUDE WHEN CITING Published online January 26, 2018; DOI: 10.3171/2017.8.SPINE17513.

Disclosures Dr. O’Toole is a consultant for Globus Medical Inc., RTI Surgical Inc., Amendia, Bioventus, and the Federal Drug Administration; has received royalties from Globus Medical Inc. and RTI Surgical Inc.; and has direct stock ownership in Theracell Inc.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial (A) and sagittal (B) T2-weighted MR images of the lumbar spine showing a stable L4–5 grade I listhesis. There is a circumferential epidural CSF collection (arrows) around T11–12, which tracks down to the anterior epidural space down to L-3 and L-4 with scalloping of the posterior vertebral bodies. Figure is available in color online only.

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    Axial (A) and sagittal (B) CT myelograms showing OLF at T10–11 (arrowheads) with an outpouching of the arachnoid (arrow) on the right and extravasation of contrast below that level. Figure is available in color online only.

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    Intraoperative photograph (A) obtained after completion of the T10–11 laminectomy and right facetectomy, showing arachnoid outpouching (arrow) through the dura from which CSF was leaking. Isolation of the right T-10 nerve root (arrow, B) after decompressing the pseudomeningocele. Ligation of the nerve root to better delineate the dural defect (arrow, C). Final suturing (D) of the dural defect caused by the ossified ligamentum flavum. Figure is available in color online only.

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    Six-week postoperative axial (A) and sagittal (B) T2-weighted MR images of the thoracolumbar spine showing a T10–11 laminectomy defect with the usual postoperative changes and complete resolution of the epidural CSF collection around T11–12. Figure is available in color online only.

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    Six-month postoperative axial (A) and sagittal (B) T2-weighted MR images of the thoracolumbar spine showing the continued evolution of postoperative changes at T10–11 and sustained complete resolution of the epidural CSF collection around T11–12 as well as around the upper and mid lumbar vertebrae. Figure is available in color online only.

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