Symptomatic hematoma of lumbar facet joint: joint apoplexy of the spine?

Full-endoscopic Spine Surgery for the Treatment of Lumbar Ligamentous Flavum Hematoma

Lumbar ligamentous flavum hematoma (LFH) is a relatively rare pathology, and it is difficult to differentiate it from other cystic lesions. Full-endoscopic spine surgery (FESS), an excellent approach for clear and magnified operative visual field since it allows saline irrigation and minimizes destruction of surrounding tissues, has been applied to the treatment. This study aims to present a case series of patients with lumbar LFH treated by FESS.This case series consists of 17 lumbar LFH cases treated by FESS between May 2018 and November 2021 at a single institution. Patient background and operative data were collected from their medical records. The numerical rating scale (NRS), Oswestry Disability Index (ODI), and European Quality of Life-5 Dimensions (EQ-5D) were recorded preoperatively and postoperatively.Elderly men tend to suffer from lumbar LFH at the L4/5 vertebral level. Discontinuity with facet joint was confirmed under endoscopic visualization in all 17 cases. Blood clots were also observed in all cases under endoscope. The mean operative time was 68.6 min without complication. The patients were discharged at average 1.4 days after FESS with significant improvement of NRS score (P < 0.001). ODI and EQ-5D scores 2-year postoperatively statistically improved (P < 0.001), and there was no recurrence during followup period.The operative outcomes of lumbar LFH treated by FESS were satisfactory. FESS excels not only in the diagnosis but also in the treatment of lumbar LFH.

Ligamentum Flavum Hematoma Accompanied by Intraspinal and Extraspinal Hematomas: A Case Report

Studies on ligamentum flavum hematoma (LFH) have been gradually increasing; however, no study has reported an LFH spreading to the intraspinal and extraspinal spaces. The purpose of this report is to discuss this rare condition and report that extraspinal hematoma can be formed by LFH. The authors present the case of a 78-year-old man presented with right L5 radiculopathy caused by a space-occupying lesion with intraspinal and extraspinal expansions at the L4-L5 vertebral levels demonstrated on MRI. We tentatively diagnosed these lesions as intraspinal and extraspinal hematomas originating from the ligamentum flavum based on the chronological changes seen on MRI and computed tomography-based needle biopsy. After the extirpation of these lesions, the symptoms were relieved. Three months later, the patient could walk without a cane. From the intraoperative findings and pathological examination, we concluded that the extraspinal hematoma in paravertebral muscle was caused by an LFH of unknown etiology. This case report describes the difficulty in diagnosing LFH accompanied by an extraspinal hematoma with wide-spreading expansion and highlights the usefulness of repetitive MRI over time in capturing chronological changes of the hematoma. As far as we know, this is the first study on an LFH accompanied by an extraspinal hematoma in the multifidus.

Spontaneous Spinal Epidural Hematoma with Lumbar Facet Joint Destruction Mimicking Pigmented Villonodular Synovitis

BACKGROUND

Spontaneous spinal epidural hematoma (SSEH) is a spinal emergency that requires early diagnosis and decompression surgery. Here, we report a case of SSEH that was difficult to differentiate from pigmented villonodular synovitis (PVS) because of combined facet joint destruction and that required gross total resection, a procedure not typically indicated for SSEH.

CASE DESCRIPTION

A 58-year-old woman complained of sudden-onset walk disturbance after backache without any traumatic episode. Physical examination revealed motor paralysis in the leg. Moreover, extensive destruction of the L4/5 right facet joint and an epidural mass continuing from the facet was observed. The epidural mass showed heterogeneous intensity in magnetic resonance imaging, suggesting different stages of bleeding. These hemorrhagic changes combined with the facet joint destruction suggested PVS, and preoperative and intraoperative pathologic examinations could not rule out PVS. After surgical treatment of PVS, the lesion in the articular process was resected and decompression was performed. The pathologic diagnosis was hematoma with bone necrosis in the articular process, without neoplastic finding suggesting PVS.

CONCLUSIONS

SSEH could be combined with facet joint destruction composed of bone necrosis. Awareness of SSEH with facet joint destruction can facilitate early diagnosis and appropriate surgical treatment.

Successful treatment of lumbar ligamentum flavum hematoma using a spinal full-endoscopic system

Background

Percutaneous endoscopic lumbar discectomy (PELD) is a relatively less invasive treatment for lumbar disc herniation (LDH). This study investigated the usefulness of a full-endoscopic system for PELD in lumbar ligamentum flavum hematoma (LFH) treatment.

Methods

Between May 2017 and Jun 2018, a total of five patients with leg pain due to LFH underwent surgery using a full-endoscopic system for PELD. A percutaneous endoscopic translaminar approach (PETA) was performed right above the LFH. Pathological examination of the hematoma capsule was performed in all cases.

Results

The mean age of the patients was 64 years; there were 3 male and 2 female patients. Leg pain improved immediately after operation in all cases. Intraoperative findings and pathological examination revealed that the synovium at adjacent facet joints was not involved.

Conclusions

Full-endoscopic system is not only a safe and effective minimally invasive system for the treatment of lumbar LFH, but is also superior to acquire a correct diagnosis.

Hemorrhagic lumbar facet cysts accompanying a spinal subdural hematoma at the same level

CONTEXT

We present a rare and interesting case of hemorrhagic lumbar facet cysts accompanying a spinal subdural hematoma at the same level suggesting a possible mechanism by which spinal subdural hematomas can arise.

FINDINGS

A 71-year-old man presented with persistent sciatic pain and intermittent claudication. Magnetic resonance imaging demonstrated a multilocular mass lesion that showed high signal intensity in both T1- and T2-weighted images, and was located both inside and outside of the spinal canal. Computed tomographic myelography showed a cap-shaped block of the dural tube at L5 and computed tomography with L5-S facet arthrography demonstrated cystic masses. The patient was diagnosed with lumbar radiculopathy caused by hemorrhagic facet cysts, and then progressed to surgical treatment. Surgery revealed that the cysts contained blood clots, and intraoperative findings that the inside of the dural tube appeared blackish and that the dural tube was tensely ballooned after removal of the cysts led us to explorative durotomy. The durotomy demonstrated concentrated old blood pooling both in the dorsal and ventral subdural space, and these spaces were subsequently drained. After surgery, his sciatic pain and intermittent claudication resolved. There was no evidence of cyst mass recurrence at 2 years of follow-up.

CONCLUSION

We propose a newly described mechanism for the formation of spinal subdural hematomas. We recommend surgeons be alert to epidural lesions causing repeated acute compression of the dural tube, which can cause spinal subdural hematoma, and consider the possible coexistence of these lesions in diagnosis and strategic surgical decisions.

Histopathological findings of hemorrhagic ganglion cyst causing acute radicular pain: a case report

Although juxtafacet cysts of the lumbar spine are being reported with increasing frequency, hemorrhage from a ganglion cyst is rare, and the pathophysiologic mechanism of the hemorrhage from the cyst is still unclear. A 75-year-old male presented with sudden radicular leg pain caused by hemorrhage from the ganglion cyst. Computed tomography revealed bony erosion of vertebral body and multiple punched-out lesions on facets. Magnetic resonance imaging showed the neural structure was compressed by a sharply delineating mass. Capsule and old hematoma with elastic consistency that extended to the epidural space were removed through a paramedian transforaminal approach, which led to the resolution of the patient's symptoms. Histopathologically, chronic inflammation with neovascularization and myxoid degeneration were present in the capsule. Alcian blue staining demonstrated the mixture of mucin and hematoma. The probable pathogenesis of hemorrhage from the cyst was discussed from the unique histopathological findings of surgical specimen.

Hemorrhagic synovial cyst: the possible role of initial trauma and subsequent microtrauma in its pathogenesis: case report

BACKGROUND AND IMPORTANCE

Intraspinal synovial cysts are uncommon causes of back and radicular leg pain. Usually associated with degenerative spinal disease, these juxtafacet cysts are usually located in the lumbar spine and may rarely undergo intracystic hemorrhage. The pathogenesis of these cysts are unclear, and risk factors that may contribute to hemorrhagic complications are largely unknown.

CLINICAL PRESENTATION

A 68-year-old man presented to the clinic 4 months after a fall on ice with persistent back pain and lumbar radiculopathy. A week after the initial clinic consultation, the patient presented to the emergency room with increased pain and worsening weakness in the left foot. An emergent magnetic resonance image showed thecal sac compression secondary to a large, juxtafacet cyst that was hyperintense on T1-weighted and hypointense on T2-weighted images. Lumbar decompressive laminectomies were performed at L3 and L4 with cyst removal and stabilization.

CONCLUSION

We present the eighth reported case of a hemorrhagic juxtafacet cyst secondary to physical trauma, the second in which the patient's symptoms acutely worsened several months after the initial insult without new trauma. We also present summary statistics of the 31 cases of hemorrhagic juxtafacet cysts reported in the literature and propose a putative mechanism that may account for the development and progression of symptoms in some patients.

Spontaneous hemorrhage into a lumbar synovial cyst

Lumbar synovial cysts frequently present with back pain, chronic radiculopathy and/or progressive symptoms of spinal canal compromise. These cysts generally appear in the context of degenerative lumbar spinal disease. Few cases of spontaneous hemorrhage into synovial cysts have been reported in the literature.

Spontaneous ligamentum flavum hematoma in the rigid thoracic spine : a case report and review of the literature

Ligamentum flavum hematoma is a rare condition. Twenty cases including present case have been reported in English-language literature. Among them, only one case reported in pure thoracic spine. A 72-year-old man presented with thoracic myelopathy without precedent cause. Magnetic resonance images revealed a posterior semicircular mass which was located in T7 and T8 level compressing the spinal cord dorsally. T7-8 total laminectomy and extirpation of the mass was performed. One month later following surgery, the patient fully recovered to normal state. Pathologic result was confirmed as ligamentum flavum hematoma. Ligamentum flavum hematoma of rigid thoracic spine is a very rare disease entity. Most reported cases were confined to mobile cervical and lumbar spine. Surgeons should be aware that there seems to be another different pathogenesis other than previously reported cases of mobile cervical and lumbar spine.

Kyste lombaire hémorragique juxta-articulaire

We report the case of a hemorrhagic lumbar juxta facet cyst (L2-L3), revealed by a chronic right lumbocruralgia, in a 77-year-old woman treated by anticoagulants for cardiac arrhythmia. Computerized tomography and magnetic resonance imaging suggested the diagnosis of benign tumor. During surgical removal of the whole lesion, a hemorrhagic synovial cyst was evoked. The operation dramatically relieved the symptoms. The diagnosis was confirmed by the histopathological analysis confronted with the clinical and the radiological findings. This uncommon observation allows the discussion of the pathogenic mechanism and of the differential diagnosis.

Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy

BACKGROUND CONTEXT

Acute onset of radicular symptoms has been reported following hemorrhage into lumbar synovial cysts after trauma or in cases of spinal instability. No previous cases have been linked to anticoagulation therapy.

PURPOSE

To present a case of symptomatic hemorrhagic lumbar synovial cyst occurring after anticoagulation therapy.

STUDY DESIGN

A case report and review of the literature.

METHODS

A patient presented with low back and radicular pain secondary to a large synovial facet cyst. Magnetic resonance imaging revealed a large facet cyst compressing the thecal sac and L3 exiting nerve root.

RESULTS

The synovial cyst was excised during a lumbar decompression and fusion. Gross blood was present in the cyst.

CONCLUSIONS

This is the first reported case of symptomatic hemorrhagic lumbar facet cyst associated with anticoagulation therapy.

Ligamentum flavum hematoma in the rigid thoracic spinal segments

✓ Ligamentum flavum hematoma, a rare cause of spinal nerve root and canal compression, typically occurs in the mobile lumbar spine segments. A thoracic ligamentum flavum hematoma is extremely rare—only one such case of a thoracolumbar (T11–12) lesion has been reported. The thoracolumbar region with its floating ribs, however, is structurally and biomechanically similar to the lumbar spine and its mobility is greater than the higher thoracic levels. To the best of their knowledge, the authors report the first case of a ligamentum flavum hematoma in the region of the rigid thoracic spinal segments with the contiguous rib cage. A symptomatic T9–10 ligamentum flavum hematoma is described in the case of a 66-year-old woman with compensatory thoracic lordosis secondary to the lumbar degenerative kyphosis. The hematoma was removed and the diagnosis was histologically confirmed. The authors speculate that thoracic lordosis might have contributed to the development of the hematoma because the ligamentum flavum and the facet joint were subjected to greater axial stress than in individuals with normal spinal alignment.