Ligamentum flavum hematoma: a case report and literature review

Hematoma de ligamento amarelo: relato de caso e revisão da literatura

Hematoma del ligamento amarillo: caso clínico y revisión de la literatura

CASE REPORT RELATO DE CASO

Ligamentum flavum hematoma: a case report and literature review

Hematoma de ligamento amarelo: relato de caso e revisão da literatura

Hematoma del ligamento amarillo: caso clínico y revisión de la literatura

Ericson Sfreddo^I; Marcelo Teodoro Ezequiel Guerra^II

^IPreceptor in Neurosurgery, Hospital Cristo Redentor, Porto Alegre, RS, Brazil

^IIProfessor of Orthopaedics and Traumatology, ULBRA, Porto Alegre, RS, Brazil

^{Correspondência}

ABSTRACT

The aim is to present a rare case of ligamentum flavum hematoma in the lumbar region, discuss its physiopathology and treatment and review the literature. A woman aged 68 presented with neurogenic claudication due to degenerative lumbar spondylolisthesis that evolved into a sudden worsening with cauda equina syndrome. The magnetic resonance imagining (MRI) showed signs of degeneration of the lumbar spine, with a narrow spinal canal from L2 to S1, anterolisthesis L4 L5 and an expansive lesion hyperintense on T1-weighted and hypointense on T2-weighted images considered compatible with hematoma in the topography of the yellow ligament in L1-L2. The patient underwent laminectomy and lumbar fixation. Her evolution was good in the postoperative period and at 18 months of follow-up hse walked alone, despite the pain that is controlled with simple medications. Even though rare, it seems that ligamentum flavum hematoma has a relationship with the degeneration and rupture of small vessels associated with micro trauma to the spine. Its physiopathology is not well defined and treatment is similar to other spine compression processes.

Keywords: Spine; Cauda Equina; Ligamentum flavum; Hematoma; Laminectomy; Spondylosis.

RESUMO

O objetivo é apresentar um caso raro de hematoma do ligamento amarelo na região lombar, discutir sua fisiopatologia e tratamento e revisar a literatura. Uma mulher de 68 anos apresentou-se com claudicação neurogênica devido à doença degenerativa lombar e espondilolistese que evoluiu para uma piora súbita com a síndrome da cauda equina. A imagem por ressonância magnética (IRM) mostrou sinais de degeneração da coluna lombar, com um canal vertebral estreito de L2 a S1, ântero-listese de L4 L5 e, posteriormente no nível da L1-L2, um processo expansivo arredondado e hiperintenso em T1 e com bordas hipointensas em T2 ponderada, compatível com hematoma na topografia do ligamento amarelo. A paciente foi submetida a laminectomia e fixação lombar. Sua evolução foi boa no período pós-operatório e, aos 18 meses de follow-up andou sozinha, apesar da dor que é controlada com medicamentos simples. Mesmo sendo raro, parece que o hematoma do ligamento amarelo tem uma relação com a degeneração e ruptura de pequenos vasos associadas a microtraumas na coluna vertebral. Sua fisiopatologia ainda não é bem definida e o tratamento é semelhante ao de outros processos de compressão da coluna vertebral.

Descritores: Coluna Vertebral; Cauda Equina; Ligamento Amarelo; Hematoma; Laminectomia; Espondilose.

RESUMEN

El objetivo es presentar un caso raro de un hematoma ligamento flavum en la región lumbar, discutir su fisiopatología y el tratamiento y revisión de la literatura. Una mujer de 68 años presentó claudicación neurogénica debido a la espondilolistesis lumbar degenerativa y que se convirtió en un repentino empeoramiento con el síndrome de cauda equina. Una imagen de resonancia magnética (RM) mostró signos de degeneración de la columna lumbar, con canal espinal estrecho de L2 a S1, anterolistesis L4 L5 y en la L1-L2, un proceso expansivo redondeado e hiperintenso en T1 y hipointenso en los bordes en T2, compatible con hematoma en la topografía del ligamento amarillo. La paciente fue sometida a laminectomía y fijación lumbar. Su evolución fue buena en el postoperatorio y, a los 18 meses de seguimiento caminaba sola, a pesar del dolor que se controla con medicamentos simples. Aunque raro, parece que el hematoma del ligamento amarillo tiene relación con la degeneración y la ruptura de pequeños vasos asociadas a micro-traumas en la columna vertebral. Su fisiopatología no está bien definida y el tratamiento es similar a otros procesos de compresión de la columna vertebral.

Descriptores: Columna Vertebral; Cauda Equina; Ligamento Amarillo; Hematoma; Laminectomía; Espondilosis.

INTRODUCTION

Ligamentum flavum hematoma (LFH) is a rare cause of radicular or spine compression. It usually occurs in mobile segments of the spine, and it seems to bear a relation with smaller traumas; however, this relation does not occur in some cases as indicated by some reports, as this one. From the pathologic standpoint, there is a degeneration of the ligament with the subsequent rupture of small winding vessels. The present report it is a case of a patient presenting with a rapid neurological deterioration because of a cauda equina syndrome which was due to an advanced degenerative disease; the patient underwent a laminectomy and fixation of lumbar instability. The pertinent literature is discussed and reviewed.

CASE REPORT

A 68-year-old woman had a history of lumbar pain irradiated to the posterior surface of the thighs at rest; the pain was associated to progressive limping. More recently, the patient presented with an unbearable pain and a decrease in quality of life, despite pharmacological treatment. During hospitalization for treatment and investigation, she presented with high and sudden lumbar pain and loss of strength in lower limbs. The neurological exam showed crural paraparesis degree I and urinary incontinence, characterizing cauda equina syndrome. The patient underwent magnetic resonance imagining (MRI), which showed degenerative signs of the lumbar spine with a narrowed spine canal of L2 and S1, anterolisthesis of L4 upon L5 and, at the level of L1-L2, a posterior lesion hyperintense in T1-weighted and with hypointense in T2-weighted (Figure 1 and 2).

The patient underwent decompression of the cauda equina by laminectomy of L1 to L5 and posterolateral fixation with pedicular screws from L1 to S1 plus intertransversal graft from iliac. During surgery, it was observed that the interior of the lesion between L1-L2 had hemorrhagic content in different stages of absorption, which characterized several episodes of bleeding at different times (Figure 3).

Presently, the patient is at 18 months of follow up and, after several physiotherapy sessions, is gradually recovering strength. Today, she walks unassisted and makes eventual use of analgesic medication for lumbalgia.

DISCUSSION

Currently, a few cases of ligamentum flavum hematoma have been reported in the English literature indexed¹: one case in the cervical spine², 3 cases in the thoracic spine^3-5, and the remaining, as well as the present case, in the lumbar spine (Table 1). The most distinguishing characteristic is that most patients are male¹. Most cases presents a small trauma as the probable genesis of the hematoma; however, one of the 3 cases of Spuck et al.⁴ did not present a history of trauma or intensive physical exercises; it was related to the complication of a percutaneous procedure for relief of low lumbar pain. The case presented herein was related only to a severe lumbar disease, although the hematoma was located at a superior level when compared to the alterations.

The ligamentum flavum consists of elastic fibers and collagen. It is poorly vascularized, and few small vessels go through it⁶. The ligamentum flavum is an unlikely site of bleeding because of its poor vascularization and the constant tension forces to which the ligaments of the vertebral spine are submitted. An exception to this is to the presence of a severe degenerative process⁴. Minamide et al.⁷ suggests that bleeding is related to irregular vessels of thin walls in a ligament that is degenerated and hypertrophied. An increase in abdominal pressure after a small trauma would transmit the pressure to these thin-walled vessels, then the proliferated vessels may be susceptible to rupture, causing the hematoma. Miyakoshi et al.³ suggests that the poor alignment of the vertebral spine submits the ligamentum flavum to an excessive axial load at a given point and relates this fact to the genesis of the hematoma that occurred according to his report at the level of T9-T10. A small trauma and poor vascularization may be important predisposing factors that increase the risk of hematoma⁸; however, in the present case there was no injury of any kind, and the hematoma occurred far from where the greatest degenerative compromise was, which contradicts the present theory. Moreover, according to Yamaguchi et al.¹, if the genesis of the hematoma depends on the presence of lumbar degeneration and small injuries, why is it so rare?

At the lumbar levels, tolerance to compression seems to be higher than at other levels. As result, the gradual formation of the hematoma or granuloma may take weeks to become symptomatic¹. The differential diagnosis includes synovial cyst, ganglion cyst, spontaneous epidural hematoma, neoplasia, and other cystic lesions^7,9.

Magnetic resonance imagining is the method of choice for diagnosis. In T2-weighted the hematoma appears as a hyperintense cyst that is very similar to a juxtafacet cyst⁵. Images depend on the size, location and mainly age of the hematoma. In the acute stage, it appears hypointense in T2-weighted and isointense in T1-weighted. Between the third and seventh day, the meta-hemoglobin makes the image hyperintense in T1-weighted. In the next weeks, the hemolysis of eritrocytes results in the accumulation of extracellular meta-hemoglobin that appears hyperintense in T1-weighted and T-2 weighted^10-12.

The treatment of choice is laminectomy or partial laminectomy, when the objective is the removal of the expansive effect^{1-3,6,13,15,23}, interlaminectomy with the removal of the ligamentum flavum⁴ or associated to arthrodesis when there are the criteria for spine instability^6,8. In the case presented herein, we opted for laminectomy for the removal of the hematoma and fixation with pedicular screws for treatment of spine instability in the inferior levels, especially at L4-L5 with the extension of the fixation up to L2-L3 where the laminectomy was performed.

Albanese et al.¹⁴ reviewed the literature and found excellent follow up on all cases of epidural hemorrhage due to ligamentum flavum hematoma. The authors points out that early decompression is essential for improvement of symptoms, however reviews all cases of epidural hemorrhage, regardless of cause. Tamura et al.¹⁵ suggest that if a patient presents with a lesion and symptoms such as those described here, the lesion should be surgically removed as soon as possible.

Recebido em 29/05/2011

Aceito em 19/09/2011

Trabalho realizado no Moinhos de Vento Hospital, Porto Alegre, RS, Brazil.

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Publication Dates

• Publication in this collection
  22 May 2012
• Date of issue
  2012

History

• Received
  29 May 2011
• Accepted
  19 Sept 2011