- Aga Khan University Medical College, Karachi, Pakistan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
Amir H. Sohail
Department of Medicine, Aga Khan University, Karachi, Pakistan
DOI:10.4103/sni.sni_364_17Copyright: © 2018 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Amir H. Sohail, Muhammad A. A. Maan, Muhammad S. Khan, Qamar Masood. Isolated ligamentum flavum ossification in primary hypoparathyroidism. 10-Jan-2018;9:4
How to cite this URL: Amir H. Sohail, Muhammad A. A. Maan, Muhammad S. Khan, Qamar Masood. Isolated ligamentum flavum ossification in primary hypoparathyroidism. 10-Jan-2018;9:4. Available from: http://surgicalneurologyint.com/surgicalint-articles/isolated-ligamentum-flavum-ossification-in-primary-hypoparathyroidism/
Background:The ligamenta flava can undergo ossification and calcification resulting in myelopathy. Only seven cases of ligamentum flavum ossification in association with hypoparathyroidism have been reported, most of which had concurrent osseous changes in other spinal ligaments. Here, we report a patient with hypoparathyroidism who presented with ligamentum flavum ossification causing both cervical and thoracic myelopathy.
Case Description:A 43-year-old male presented with backache, urinary retention, and lower limb weakness for the last few days. Magnetic resonance imaging scan showed ossification of the ligamentum flavum in the cervical and thoracic regions, with severe spinal stenosis. Following spinal decompressive surgery, the patient made a complete recovery. Primary hypoparathyroidism was found to be the underlying cause for ligamentum flavum ossification.
Conclusion:Ossification of ligamentum flavum secondary to hypoparathyroidism should be considered as a possible cause of myelopathy in all patients presenting with symptoms of spinal cord compression.
Keywords: Hypoparathyroidism, ligamentum flavum, myelopathy, ossification, parathyroid hormone
Degenerative calcification/ossification of the ligamentum flavum (OLF) often affects the geriatric Asian population. Although it is most prominent in the Japanese, it is only rarely found in the Pakistani population.[
OLF, resulting in thoracic myelopathy, is most frequently attributed to hypoparathyroidism, as well as to other factors and conditions (e.g. vitamin D, parathyroid hormone (PTH), local tissue growth factors, insulin, hyperthyroidism, hemochromatosis) [
A 43-year-old Punjabi male presented with backache, lower extremity weakness, and urinary retention of several days duration. He had fallen from a height of three feet while working in the fields the previous week. The neurological examination was consistent with a severe spastic paraplegia; marked lower extremity weakness/paraparesis (1/5), bilateral diffuse hyperreflexia, and bilateral Babinski responses.
Magnetic resonance imaging (MRI) scan of the spine showed multilevel OLF with marked spinal cord compression at the C4-C5 and T10-T11 levels [Figures
The patient underwent laminectomies at the C4-C5, T3-T4, and T10-T11 levels. Intraoperatively, the patient sustained an acute myocardial infarction. Calcium and phosphorus studies were consistent with the diagnosis of primary hypoparathyroidism; low ionized calcium level (1.99 mg/dL), low calcium level (4.2 mg/dL), low corrected calcium (5.0 mg/dL), low magnesium (0.9 mg/dL), high phosphorus (7.7 mg/dL), and a low parathyroid hormone level (<3.0 pg/ml). The patient was treated with intravenous calcium gluconate and magnesium, and oral calcium, magnesium, and vitamin D.
The postoperative MRI scans documented adequate OLF removal at the C4-C5 and T10-T11 levels [
Patients with OLF can present with myelopathy due to cervical and/or thoracic cord compression [
The pathophysiology of OLF, most typically attributed to hypoparathyroidism, is incompletely understood.[
About 50% of patients with thoracic myelopathy due to OLF will improve.[
Ossification of ligamentum flavum is a possible cause of myelopathy in patients with symptoms of spinal cord compression. If OLF is present, laboratory investigations should include a workup for hypoparathyroidism. Most critically, when myelopathy is significant, prompt surgical decompression is warranted.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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