Abstract

Background: Lumbar ligamentum flavum hematomas (LFHs) are rare. However, when they occur and contribute to epidural cauda equina compression, timely surgical intervention is frequently warranted.

Case Description: A 69-year-old female presented with the left lower extremity sciatica and gait disturbance of 2 weeks’ duration that ultimately evolved into a paraparesis/cauda equina syndrome. When the lumbar MRI revealed left-sided L4-L5 epidural compression attributed to a hemorrhage into the hypertrophied ligamentum flavum (HLF), she successfully underwent a bilateral fenestration/decompressive procedure. Pathologically, neovascularization and rupture of the ventral layers of the degenerated and thickened HLF contributed to the LFH.

Conclusion: Arterial neovascularization (i.e., arterial feeding vessels from paramuscular/prelaminar lumbar branches) contributed to a left-sided L4-L5 LFH that resulted in epidural cauda equina compression in a 69-year-old female. Following surgical focal fenestration/decompression, the patient’s symptoms/signs resolved.

Keywords: Cauda equina syndrome, Decompressive surgery, Degenerative lumbar spine, Hypertrophied ligamentum flavum hematoma, Lumbar canal stenosis, Neovascularization, Prelaminar artery

INTRODUCTION

Lumbar ligamentum flavum hematomas (LFHs) are rare; we were only able to identify 28 such cases in the literature [ Table 1 ].[ 4 ] Patients typically exhibit focal hematomas within hypertrophied ligamentum flavum (HLF) that is likely due to neovascularization (i.e., arterial ingrowth from paramuscular/prelaminar lumbar branches). Here, a 69-year-old female with a subacute epidural LFH developed a progressive cauda equina syndrome that resolved following surgical L4-L5 fenestration/decompression.

Table 1:

Reported Twenty-eight cases of lumbar ligamentum flavum hematoma.[ 4]

CASE REPORT

A 69-year-old female presented with 2 weeks of progressive left lower extremity sciatica and paraparesis/partial cauda equina syndrome. The lumbar MR showed a left-sided L4-L5 epidural hematoma and LFH within the left HLF [ Figures 1a and b ]. In addition, the CT demonstrated bilateral degenerated/ thickened facet joints [ Figure 1c ]. She underwent a bilateral L4-L5 lumbar fenestration/decompression on the 15^th day following the original onset of symptoms [ Figure 2a ]. At surgery, the dorsal surface of the left ligamentum flavum was dark brown and hematoma was observed within the multiple layers of the HLF [ Figures 2b - d ]. Postoperatively, the patient’s symptoms/signs improved. The LFH pathology revealed neovascularization (i.e., arterial feeding vessels from paramuscular/prelaminar lumbar branches) and an epidural hematoma within the ventral layers of the HLF [ Figure 3 ].

Figure 1:

(a) Lumbar MRI T1WI showed high-intensity left-sided L4-L5 epidural mass/ligamentum flavum hematoma (LFH). (b) Lumbar MRI T2WI showed low-intensity LFH and high-intensity epidural mass on the left at L4-5. (c) CT at L4-5 showed thickened degenerated facet joints and lumbar canal stenosis.

Figure 2:

Midline fenestration at L4-5 level: intraoperative findings. (a) A left-sided L4-L5 hematoma (asterisk) within hypertrophied ligamentum flavum (HLF) (arrow). (b) Hematoma (asterisk) in dorsal layer of left HLF (arrow); image after removed of the right HLF. (c) Epidural hematoma (double asterisks) on the ventral side of HLF (double arrows). (d) Resection of the left HLF revealed an epidural hematoma (double asterisks).

Figure 3:

En bloc resection of the left ligamentum flavum hematoma. (a) Dorsal hematoma (asterisk) seen within the layers of the hypertrophied ligamentum flavum (HLF). (b) Epidural hematoma (double asterisks) on ventral side of HLF.

DISCUSSION

The histopathology of LFH has largely been attributed to ligamentum flavum degeneration with neovascularization.[ 3 , 6 , 10 ] Miyakoshi et al. reported a patient who presented with a two-level LFH.[ 7 ] Other cases of LFH have been associated with facet synovial and ganglion cysts.[ 1 , 2 , 8 ] In Kaneko et al.’s report, five patients with LFH were successfully treated with endoscopic spine surgery; pathological evaluations revealed granulation tissue in all cases, but no evidence of synovial cysts.[ 5 ]

Etiology of LFH

Mechanical stress and angiogenesis both contribute to the development/progression of HLF and LFH [ Figure 4a ]. The resultant hemorrhages are typically attributed to arterial neovascularization arising from the dorsal muscular branches of the multifidus muscles, the posterior vertebral canal artery (prelaminar artery), or collapse/degeneration/hypertrophy of new small blood vessels within the HLF[ 9 ] [ Figure 4b ]. Here, the LFH originated from the left-sided HLF [ Figure 4c ].

Figure 4:

Illustration of lumbar ligamentum flavum hematoma (LFH) causing cauda equina compression. (a) LFH with neovascularization/angiogenesis. (b) LFH (asterisk) due to collapse of new blood vessels. (c) Lumbar LFH (single asterisk) extending into epidural space (double asterisks).-

CONCLUSION

Hemorrhage into the lumbar left-sided HLF due to neovascularization resulted in L4-5 epidural compression that successfully resolved following a fenestration/ decompressive procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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