Lumbar ligamentum flavum hematoma at L3–4 treated with full-endoscopic laminectomy: a case report

Introduction

A ligamentum flavum hematoma (LFH) of the lumbar spine is a rare cause of lumbar nerve root and/or cauda equina compression (1,2). LFH is typically treated surgically by excising the degenerated ligamentum flavum and removing the hematoma following microsurgical laminectomy and posterior fixation (3).

With technological advancements, spinal surgery using small working channels and endoscopic visualization has become possible. Full-endoscopic laminectomy (FEL) of the lumbar spine allows for efficient, safe, and minimally invasive treatment of lumbar canal stenosis (4,5). Herein, we report the case of a patient with LFH due to lumbar canal stenosis at L3–4 who underwent FEL. We present this case in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-171/rc).

Case presentation

A 70-year-old female with lower back pain and radicular pain in the anterior aspect of her right leg. There was no history of major trauma, lumbar surgery, or antiplatelet/anticoagulant therapy. Muscle strength was not decreased in either leg and tendon reflex findings were unremarkable. Magnetic resonance imaging (MRI) revealed right L4 nerve root compression due to a right LFH and lumbar canal stenosis at L3–4 (Figure 1A-1C). Computed tomography (CT) revealed no calcified lesions within the spinal canal at L3–4 (Figure 1D,1E). Conservative treatment with nonsteroidal anti-inflammatory drugs was initially administered; however, there was insufficient improvement, and a local anesthetic injection into the right L4 nerve root produced a transient improvement in the symptoms. Nevertheless, lower back and radicular pain gradually increased compared to the initial presentation, and the patient underwent FEL under general anesthesia under fluoroscopy.

Figure 1 Preoperative magnetic resonance and CT images. (A) Sagittal T2-weighted image, (B) axial T2-weighted image, and (C) three-dimensional phase-balanced steady-state acquisition rewound gradient echo image show right L4 nerve root compression due to a right LFH and lumbar canal stenosis at L3–4. Sagittal and axial views were taken at the level of the yellow line in each view. CT of the (D) sagittal and (E) axial view reveals no calcified lesion within the spinal canal at L3–4. Sagittal and axial views were taken at the level of the red line in each view. CT, computed tomography; LFH, ligamentum flavum hematoma.

An approximately 1.0-cm vertical incision was made at 1.0 cm to the right of the midline, followed by the placement of an outer cylinder (external and internal diameter of the outer cylinder 9.9 and 8.9 mm, respectively). The endoscope (endoscope size: 8.4 mm, working channel size: 5.2 mm) was inserted in the outer cylinder. Sufficient bone of the lamina and bilateral facet joint at L3–4 was removed using a diamond bit drill and a Kerrison rongeur for the treatment of coexisting spinal canal stenosis. Approximately 10–15% of the medial corresponding facet joint, 7.0 mm of the caudal L3 lamina and 4.0–5.0 mm of the rostral L4 lamina at L4 (approximately 4.0–5.0 mm) were removed. An intraoperative chronic hematoma draining from the ligamentum flavum on the right side was visible during removal of the ligamentum flavum using a Kerrison rongeur for L4 nerve root decompression (Figure 2, Video 1). This chronic hematoma was confirmed to be discontinuous to the facet joint. The procedure was completed after confirming that the compression of the right L4 nerve root had been released and the drain tube was placed in the wound.

Figure 2 Intraoperative endoscopic view showing chronic hematoma draining during removal of the ligamentum flavum using a Kerrison rongeur for L4 nerve root decompression.

Immediately after the procedure, the patient mentioned that lower back and radicular pain in the anterior aspect of her right leg had completely disappeared. Postoperative MRI and CT revealed an expanded lumbar canal at L3–4 and decompression of the right L4 nerve root (Figure 3A-3D). The patient was discharged without any perioperative complications. No recurrence was observed for at least 3 months postoperatively. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 3 Postoperative magnetic resonance and CT images. (A) Sagittal T2-weighted image, (B) axial T2-weighted image, (C) axial CT, and (D) posterior view three-dimensional CT scans show the expanding lumbar canal at L3–4 and decompression of the right L4 nerve root. Sagittal and axial views were taken at the level of the yellow line in each view. CT, computed tomography.

Discussion

LFH of the lumbar spine is a rare cause of lumbar nerve root and/or cauda equina compression (1,2). The neurological symptoms of LFH are similar to those of lumbar disc herniation, namely, neoplasm, infection, epidural hematoma, and facet cysts. Ozdemir et al. reported that many cases involved older males (>60 years old), and reports of cases with LFH tend to be more frequent in Asian countries, mostly in Japan (6). MRI is an efficient tool for diagnosis as it reveals the connection between the ligamentum flavum and the hematoma. Differential diagnosis includes extradural tumors and facet cysts, and 25–44% of patients with LFH are provisionally diagnosed with a tumor preoperatively (7).

The ligamentum flavum consists of elastic fibers and collagen. It is poorly vascularized and only a few small vessels pass through it. The pathogenesis of LFH is unclear; however, its etiology could be associated with a partial tear of the ligament and intraligamentous bleeding from angiogenesis caused by mechanical stress or shearing force in the degenerated ligamentum flavum (1,8,9). Moreover, transmission of increased intra-abdominal pressure following a partial tear of the ligament to very small, thin-walled blood vessels in the degenerated ligamentum flavum might lead to the rupture of these vessels (10).

A previous study reported that LFH is typically treated surgically by excising the degenerated ligamentum flavum and removing the hematoma following microsurgical laminectomy and posterior fixation (3).

With technological advancements, minimally invasive spinal surgery has become increasingly feasible. Techniques using a small working channel and endoscopic visualization allow for nerve root and dural sac decompression while preserving the stabilizing structures of the spine. Percutaneous endoscopic lumbar laminectomy is a popular treatment option for lumbar canal stenosis. This method ensures an efficient, safe, and minimally invasive treatment of lumbar canal stenosis (4,5). No statistically significant differences in clinical efficacy have been reported between percutaneous endoscopic lumbar laminectomy and posterior open microscopic laminectomy (4,5). Full-endoscopic spine surgery has numerous advantages over open microscopic laminectomy, including smaller skin incisions, reduced scarring and muscle damage, decreased risk of postoperative infection, and reduced blood loss.

There have been some documented cases of full-endoscopic spinal surgery used to treat lumbar LFH (11,12). Intraoperative visualization of hematoma release from the ligamentum flavum, confirmed by FEL, can be helpful in successful decompression of intracanal pressure.

Conclusions

FEL for LFH based on lumbar canal stenosis may be effective due to its ability to visualize hematomas within the ligamentum flavum and dural sac while allowing for minimally invasive nerve root decompression.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-171/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-171/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-171/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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