Thoracic myelopathy secondary to ossified ligamentum flavum

Focal ossification of the ligamentum flavum (OLF) forms one of the rare causes of thoracic myelopathy. The lower thoracic spine is most frequently affected and the patients present with initial posterior column disturbances followed by progressively increasing spastic paraparesis. The pathogenesis of OLF has not been conclusively established.

Five patients with thoracic myelopathy due to OLF underwent decompressive laminectomy and excision of the ligamentum flavum. Their MRI delineated a linear or beak like excrescence, uniformly hypo-intense on T1 and T2 weighted images, situated posterior to the thecal sac. A comparison between the preoperative neurological status and the status at follow-up was done using Harsh's myelopathic grading.

Decompressive laminectomy followed by the drilling of the OLF and its excision, occasionally along with the adherent outer layer of the dura, resulted in significant improvement in motor weakness and tingling sensations. However, at the last available follow-up, none of the patients had retained their ability to run briskly (grade I) and all of them had residual spasticity.

OLF may significantly contribute to a spatial reduction of the thoracic spinal canal resulting in paraparesis. The T2 weighted sagittal image of the magnetic resonance imaging (MRI) is the modality of choice for screening of the longitudinal extent of the OLF. A rapid neurological improvement occurs following decompressive laminectomy and excision of the OLF. However, the persistence of residual spasticity at follow-up may be due to irreversible changes within the cord by the significant thecal compression and the delay between the onset of initial symptoms and signs and surgical decompression.