학급 프로젝트 나 의 꿈 찾 기 
 포토 슬라이드 2 
 ligamentum flavum ossification , thoracic myelopathy , 
 It may be a incidental finding on a MRI , it can be a cause of neurogenic claudication , and thoracic compressive myelopathy common in aging asians specially Japanies . 
 Ossification of Ligamentum Flavum Vinod Naneria Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research Centre , Indore , India 
 Why this case ? • Ossification of Ligamentum Flavum is a unusual cause of neurogenic claudication in early stage of the disease . • It may be the only presenting symptom . • First reported by Polgar in 1920 on plain lateral x - ray of spine . • Thoracic myelopathy due to ossified LF was described in 1964 by Yamaguchi and Isuruni . • Myelopathy & radiculopathy in advance disease . • Coexist with Ossification of Dura . • Coexist with Lumbar Canal Stenosis . 
 Reading MRI Critically • All MRI done for any segment of spine starts with cervical spine . • This is done for exact counting of level of vertebrae . • A record of lumberization / sacralization . • Last floating Rib . • Level of disc pathology . 
 Case History • A 45 Male , C / o vague backache with radiating pain in both gluteal regions increased by standing and walking . • Typical neurogenic claudication with varying distances . • There was no obvious neurological or vascular deficit . • Planters were down going . 
 Investigations • Routine investigations were normal . • X - ray dorso – lumbar spine reported normal . • MRI – classical picture of ossification of ligamentum flavum . • Axial CT confirms the diagnosis . 
 Case Two • A 60 yrs . Male • Gradually increasing paraperesis . • Spastic & weak both lower limbs . • Intact bladder bowel control . 
 OLF • Ossification of the ligamentum flavum ( OLF ) is a disease of ectopic bone formation within the ligamentum flavum , which may result in mass effect and neurological compromise . • The low thoracic region is the most common region of occurrence , and this is followed by the cervical , then lumbar spine . • 64 % at D 10 - D 11 , 21 % at D 11 - D 12 . • The prevalence of OLF is higher in the Japanese ( 20 % above the age of 65 years ) compared with other nationalities and has a male preponderance . • Commonly associated with dural ossification . 
 Etiology • Unknown in most of the cases . • Diffuse idiopathic skeletal hyperostosis ( DISH ) , • Ankylosing spondylosis , • Hemochromatosis , • Fluorosis , • Calcium pyrophosphate dihydrate deposition disease ( CPPD ) , • Trauma . 
 Patho - physiology • Initially the ligament get hypertrophied , and calcify before it get ossified . • The process of ossification starts at the base of the ligament with enchondral ossification of the vascularised fibrocartilaginous tissues . It starts from capsular side and gradually spread anteriorly and medially compressing the spinal card from posterio - lateral sides . 
 Clinically • Two types of presentations : – Most commonly present as gradual onset of myelopathy with slow deterioration in neurological status . – Occasionaly present as acute paraplegia following minor trauma . 
 Diagnosis • OLF should be included in causes of thoracic paraplegia . • X - rays are not very classical . • MRI – T 2 weighted seggital plane shows indentation on the thoracic card from behind • CT – Axial plane shows typical ossification of OLF . 
 Radiological signs of DO • The radiologic signs of dural ossification ( DO ) as depicted in the bone windows of CT were of 2 types : • The " tram track sign , " where there was a hyperdense bony excrescence with a hypodense center . • The " comma sign , " where there was evidence of ossification of one - half of the circumference of the duramater . • Incidence of CSF leak is very high in cases of DO , following surgical excision of OLF . 
 Types • Type I , is located only laterally at the origin of the ligamentum flavum at the articular processes . • Type II , The extended type , extends from the lateral origin of the ligamentum flavum to the interlaminar portion of the ligamentum flavum . ,• Type III , The enlarged type protrudes into the canal posterolaterally but is not fused in the midline . • Type IV , The fused type , consists of bilateral ossified ligaments that are fused at the midline with a groove at the fusion in midline . • Type V , the tuberous type , occurs when the fused ossified ligamentum flavum forms a “ tuberous ” mass posteriorly in the midline , which protrudes into the spinal canal . 
 Treatment • Decompressive Laminectomy . • Laminoplasty , retaining posterior elements . • Laminectomy and fusion to prevent increase in kyphotic deformity . • Complications are high when it is associated with ossification of dura . • Commonest complication is CSF leak due to associated dural calcification . • This can cause meningitis , delayed wound healing , incomplete neurological recovery or deterioration in neurological status . 
 DISCLAIMERInformation contained and transmitted by this presentation isbased on personal experience and collection of cases atChoithram Hospital & Research centre , Indore , India , during last 32 years . It is intended for use only by the students of orthopaedicsurgery . Views and opinion expressed in this presentation are personalopinion . Depending upon the x - rays and clinical presentations viewerscan make their own opinion . For any confusion please contact the sole author forclarification . Every body is allowed to copy or download and use the materialbest suited to him . The author is not responsible for any controversies arise out ofthis presentation . For any correction or suggestion please contactnaneria @ yahoo . com 
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