- Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
Correspondence Address:
Akshay Vasant Mohite, Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India.
DOI:10.25259/SNI_583_2024
Copyright: © 2024 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, 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: Akshay Vasant Mohite, Tushar Narayan Rathod, Deepika Jain, Bhushan Hadole, Rushikesh Shahade, Chitranshu Shrivastava. Double trouble: Concurrent ossification of ligamentum flavum with infective spondylodiscitis in the thoracic spine resulting in paraplegia: A case report. 04-Oct-2024;15:362
How to cite this URL: Akshay Vasant Mohite, Tushar Narayan Rathod, Deepika Jain, Bhushan Hadole, Rushikesh Shahade, Chitranshu Shrivastava. Double trouble: Concurrent ossification of ligamentum flavum with infective spondylodiscitis in the thoracic spine resulting in paraplegia: A case report. 04-Oct-2024;15:362. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=13130
Abstract
Background: Thoracic ossification of the ligamentum flavum (OLF) and tuberculous infective spondylodiscitis rarely combine to cause paraplegia. Here, a 48-year-old female with both thoracic OLF and tuberculous spondylodiscitis experienced the acute onset of paraplegia successfully managed with a T8–L1 laminectomy with fusion.
Case Description: A 48-year-old female presented with the acute onset of paraplegia attributed to magnetic resonance-documented thoracic OLF and infective spondylodiscitis. Imaging revealed spinal cord compression (i.e., occupying >50% of the spinal canal) from D8 to D10 level and infective spondylodiscitis at the D10–D11 level. Surgery included a D8–L1 laminectomy with instrumented fusion. Histology and cultures revealed the presence of tuberculosis, and anti-tubercular therapy was administered. Both surgery and continued antibiotic therapy contributed to neurological improvement.
Conclusion: Thoracic OLF combined with tuberculous spondylodiscitis may be effectively treated with decompression, fusion, and appropriate anti-tubercular therapy.
Keywords: Dorsal spine, Infective spondylodiscitis, Koch’s, Neurological deficit, Ossified ligamentum flavum (OLF), Paraplegia, Tuberculosis spine instability score (TSIS)
INTRODUCTION
A 48-year-old female presented with the acute onset of paraplegia due to both thoracic ossification of the yellow ligament (OYL: T8–T10) and tuberculous spondylodiscitis (T10–T11). The patient markedly improved following a decompressive laminectomy with instrumented fusion (T8–L1) and anti-tubercular therapy.
CASE PRESENTATION
A 48-year-old female presented with sudden onset of paraplegia over 1 month’s duration. X-rays showed reduced disc spaces, vertebral body heights, and an exaggerated kyphosis at the D10– D11 level. The magnetic resonance imaging revealed altered marrow signals in the D10 and D11 vertebral bodies and within the D10–D11 discs accompanied by prevertebral and paravertebral abscess formation with anterior epidural granulation tissue consistent with infective spondylodiscitis. There was also a low-intensity mass compressing the spinal cord posteriorly from D8 to D10 due to ossification of the yellow ligament flavum (OLF) [
Figure 1:
(a) Magnetic resonance imaging (MRI) T2 sagittal cut highlights altered marrow signals in D10 D11 vertebral bodies and D10–D11 discs accompanied by pre and paravertebral abscess at D10–D11 level. In addition, there is a low-intensity mass compressing the spinal cord posteriorly at D8–D9 and D9–D10 levels with corresponding cord signal changes. (b) MRI axial cut at D8–D9 level highlights a low intensity mass compressing the cord posteriorly with cord signal changes at the corresponding level. (c) MRI axial cut at D9–D10 level highlights a low intensity mass compressing the cord posteriorly with cord signal changes at the corresponding level. (d) MRI axial cut at D10–D11 level highlights the pre, paravertebral, and epidural abscess compressing the cord.
Surgery
The patient underwent a decompressive laminectomy (T8–T10) with instrumented fusion from D8 to L1 levels (i.e., sparing D11). Transpedicular decompression was performed on the left at the D11 level; when the disc space was entered, caseous material with granulation tissue was removed and sent for microbiological and histopathological analysis. The disc space was curetted, and the morselized bone graft was packed anteriorly, along with the placement of a D10–D11 interbody cage [
Postoperative course
The patient slowly neurologically improved postoperatively, starting on postoperative day 3. Follow-up 1 year later showed she reached ASIA grade D, while her visual analog scale score improved from 5 (moderate pain) to 2 (mild pain), and her Oswestry Disability Index improved significantly, decreasing from 80% (bedridden) to 20% (minimal disability).
DISCUSSION
Spinal tuberculosis (TB), while concerning, often has a favorable prognosis with timely and adequate treatment. Anti-tuberculous medications are crucial, with surgery only needed for those with neurological impairments, though recovery varies, especially in severe cases.[
Our patient, over 3 months, developed severely progressive paraparesis attributed both to thoracic T8– T10 OLF and infective spondylodiscitis T10–T11; the patient underwent a T8–T10 laminectomy with a T8–L1 instrumented fusion. Intraoperative cultures/pathology revealed TB (Koch’s), and appropriate antibiotic therapy was initiated. Specifically, the patient was placed on four-drug anti-tubercular therapy (Isoniazid, rifampicin, pyrazinamide, and ethambutol) for 3 months, followed by a three-drug (Isoniazid, rifampicin, and ethambutol) regimen.[
Combination of OLF and tuberculous infective spondylodiscitis – It is rare that both OLF and infective spondylodiscitis, particularly of tubercular origin, occur simultaneously, as observed in this case. OYL most frequently occurs in the lower thoracic spine, being predominantly found at the T10–T11 level. This location may, in part, be attributed to the increased tensile force focused on this location.[
CONCLUSION
A 48-year-old female acutely presented with paraplegia attributed to a combination of thoracic OLF and tuberculous infective spondylodiscitis. Following a decompressive laminectomy (T8–T10) with instrumented fusion (D8–L1) and anti-tubercular therapy, the patient regained Asia Grade D function within 1 postoperative year.
Ethical approval
The Institutional Review Board approval is not required.
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.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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.
References
1. Ahn DK, Lee S, Moon SH, Boo KH, Chang BK, Lee JI. Ossification of the ligamentum flavum. Asian Spine J. 2014. 8: 89
2. Ahuja K, Kandwal P, Ifthekar S, Sudhakar PV, Nene A, Basu S. Development of tuberculosis spine instability score (TSIS): An evidence-based and expert consensus-based content validation study among spine surgeons. Spine. 2022. 47: 242-51
3. Chen DY, Lu XH, Yang LL. Ossification of ligamentum flavum related to thoracic kyphosis after tuberculosis: Case report and review of the literature. Spine. 2009. 34: E41-4
4. Erdani D, Topolovec M, Hero N, Brumat P. Ossification of ligamentum flavum related to progressive thoracic myelopathy and acute paraplegia in a Central-European male with a thoracic kyphoscoliosis. J Surg Case Rep. 2023. 2023: rjad070
5. Nagayama M, Yanagawa Y, Okuda T, Yonezawa I, Iba T, Kaneko K. A case of paraparesis with thoracic ossification of the posterior longitudinal ligament and the ligamentum flavum induced by falling down on the abdomen. Acute Med Surg. 2014. 1: 54-7
6. Rajasekaran S, Soundararajan DC, Shetty AP, Kanna RM. Spinal tuberculosis: Current concepts. Global Spine J. 2018. 8: 96S-108
7. Rathod TN, Sathe AH, Marathe NA. It’s never too late: Neurological outcome of delayed decompression in tuberculosis of spine. Global Spine J. 2021. 11: 716-21
8. Shah KS, Uchiyama CM. Thoracic ossification of the ligamentum flavum causing acute myelopathy in a patient with cervical ossification of the posterior longitudinal ligament: Illustrative case. J Neurosurg Case Lessons. 2021. 2: CASE2178
9. Yamada T, Shindo S, Yoshii T, Ushio S, Kusano K, Miyake N. Surgical outcomes of the thoracic ossification of ligamentum flavum: A retrospective analysis of 61 cases. BMC Musculoskelet Disord. 2021. 22: 7