Calcification of ligamentum flavum is a rare disease that was found to occur almost exclusively in Japanese population. However the disease is now being increasingly recognized as a cause of thoracic myeloradiculopathy in Indian Population. We report a case of thoracic myelopathy at multiple levels due to ossified and hypertrophied ligamentum flavum

Jaisuresh, K

Sundaravadivelu, V

Vinod kumar, P

English

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Thoracic myelopathy due to ossified hypertrophied ligamentum flavum

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Jaisuresh et al  
Calicut Medical Journal 2007;5(5):e1 
 
Page 1 (Page number not for indexing purposes) 
Radiology images 
Thoracic myelopathy due to ossified hypertrophied ligamentum 
flavum 
Jaisuresh K*, $, Vinodh Kumar P*, Sundaravadivelu V** 
*Postgraduate Resident, Department of Internal Medicine, Madras Medical College, Chennai,**Professor, Institute of Internal 
Medicine, Madras Medical College, Chennai. $ Corresponding Author. E-mail: drjaisuresh@gmail.com  
 
 
ABSTRACT 
 
Calcification of ligamentum flavum is a rare disease that was 
found to occur almost exclusively in Japanese population. 
However the disease is now being increasingly recognized as a 
cause of thoracic myeloradiculopathy in Indian Population. We 
report a case of thoracic myelopathy at multiple levels due to 
Ossified and hypertrophied ligamentum flavum. 
 
Key words: ligamentum flavum hypertrophy, myelopathy. 
 
 
CASE SUMMARY: 
 
43yr old male presented with three months history of numbness 
and progressive spastic weakness of both lower limbs. His 
neurological examination revealed spastic paraparesis with 
exaggerated knee and ankle jerks and positive Babinski sign in 
both lower limbs. Sensory system examination revealed decrease 
in all modalities of sensation below T12 level. His bladder function 
and anal tone were normal. Biochemical   investigations including 
serum calcium (9.1;normal: 8.6-10.3mg/dl), phosphate (3.9mg/dl; 
2.5-4.5mg/dl), parathyroid hormone (24pg/ml; normal: 12-
72pg/ml), alkaline phosphatase (58IU/L; Normal: 38-126IU/L), 
fluoride (0.4 ppm) were with in normal range.X.rays of Spine and 
chest did not show any abnormality. CT (Figure 1) and MRI 
(Figure 2) revealed narrowing of Spinal canal and thoracic cord 
compression at multiple levels due to ossification and hypertrophy 
of ligamentum flavum. 
DISCUSSION: 
 
The ligamentum flavum (LF) is a yellow elastic ligament 
extending from second cervical vertebra to the first piece of 
sacrum. The ligament is in the dorsal portion of the spinal canal, 
attaching the laminae and extending to the capsules of the facet 
joints and the posterior aspects of the neural foramina1.Thoracic 
myelopathy due to ossified LF was described in 1964 by 
Yamaguchi and Isuruni.The pathogenesis of ossified ligaments is 
not clear. Etiology2 of ossification of LF include trauma, diffuse 
idiopathic skeletal hyperostosis (DISH), ankylosing spondylosis, 
hemochromatosis, fluorosis and disorders of calcium and 
Phosphorous. However etiology remains unknown in most of the 
cases. Of the 15 Cases reported by jayakumar3 et al etiology has 
remained obscure in 12 patients. The proposed mechanisms4 
include mechanical stress of the lower thoracic spine and the 
thoracolombar junction, causing yellow ligament degeneration, 
ossification along the superficial layer of the hypertrophied yellow 
ligaments, an increased number and size of collagen fibers, as well 
as premature osteons or osteoblasts. 
 
 
 
 
Figure 1:Thoracic CT scan –axial view showing “V” shaped hyper 
density in the   dorsal aspect of spinal canal. This is characteristic 
of ossification of ligamentum flavum. 
 
 
The ligamentum flavum can contribute by hypertrophy or 
ossification to spinal stenosis, most often in the lower thoracic or 
lumbar spine, affecting the cord or cauda equina5.The condition 
may be asymptomatic, however, in patients with a stenotic spinal 
canal or with large calcifications, it may cause compression of the 
spinal cord. Numbness in the lower limbs is the most common 
initial symptom of thoracic myelopathy. All patients have motor 
weakness in lower extremities and difficulty in walking. Root pain 
and stiffness are not usually seen. Bladder disturbance is seen only 
in late stages. 
 
        CT remains the investigation of choice to demonstrate 
ossification. Spinal MRI shows hypertrophy of ligamentum flavum 
causing spinal cord compression. Lateral radiograph can show 
ossified ligaments in some patients. Thoracic cord compression at 
multiple levels is very rare. 2 of the 15 patients reported by 
Jaisuresh et al  
Calicut Medical Journal 2007;5(5):e1 
 
Page 2 (Page number not for indexing purposes) 
Jayakumar et al showed spinal cord compression at two different 
levels. Our patient had cord compression at five different levels 
(T3-T4, T6-T7, T8-T9, T9-T10, T10-T11 Levels). 
 
 
Figure 2: Saggital T2 weighted MRI of thoracic spine showing 
thoracic canal stenosis at multiple levels. Ossified ligamentum 
flavum is seen as hypointensities in the dorsal aspect spinal canal. 
 
REFERENCES: 
 
1. RosenbaumRB, Ciaverella DP.Disorders of Bones, Joints, 
Ligaments and Meninges.In: Bradley WG, Daroff RB, 
Fenichel GM, Jankovic J, editors. Neurology in clinical 
practice.4th ed. Philadelphia: ButterworthHeinemann; 
2004.p.2204. 
 
2. Kruse JJ, Awasthi D, Harris M, Waguespack A, Riccardi J. 
Ossification of the Ligamentum Flavum as a Cause of 
Myelopathy in North America: Report of Three 
Cases.J.spinal disorders 2000; 13(1): 22-5. 
 
3. Jayakumar PN, Devi BI, Bhat DI, Das BS. Thoracic cord 
compression due to Ossified hypertrophied ligamentum 
flavum. Neurology India 2002; 50:286-9. 
 
4. Kocer A,Gozke E, Tasali N. Thoracic myelopathy due to 
enlarged Ossified ligaments (Japanese disease) in a Turkish 
female patient. Journal of Neurological Sciences (Turkish) 
2005; 22(1): 69-73. 
 
5. Gil-salu JL, Lopez-escobar M, Gomez-cardenas E, 
Rodriquez-pena F, Repeto-lopez JA, Lopez-Lopez J et al. 
Calcification of thoracic yellow ligament as a cause of 
myelopathy. Rev Neurol 2002 Apr 16-30; 34(8): 750-3. 
 


Calcification of thoracic yellow ligament as a cause of myelopathy. Rev Neurol

Ciaverella DP.Disorders of Bones, Joints, Ligaments and Meninges.In:

Ossification of the Ligamentum Flavum as a Cause of Myelopathy in North America: Report of Three Cases.J.spinal disorders

Thoracic cord compression due to Ossified hypertrophied ligamentum flavum. Neurology India

Thoracic myelopathy due to enlarged Ossified ligaments (Japanese disease) in a Turkish female patient.

Thoracic myelopathy due to ossified hypertrophied ligamentum flavum

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