Research
We present a case of lower back pain with lumbar nerve compromise due to a ligamentum flavum haematoma which was successfully treated surgically. A 62-year-old man was evaluated for lower back pain with associated leg pain and early signs of cauda equina syndrome. MRI of the lumbar spine demonstrated a contrast-enhancing mass adjacent to the lamina of L3 which was causing severe canal stenosis. Surgical excision of the lesion was recommended. The patient underwent an L3 laminectomy with excision of the epidural lesion. Histopathology showed it to be a haematoma of the ligamentum flavum with no untoward features. The patient recovered without complication.
1Department of Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia,2Department of Pathology, Prince of Wales Hospital,Sydney, New South Wales,Australia
Summary
BACKGROUND
A 62-year-old man was referred for evaluation of back pain and worsening leg pain, which included neurogenic claudication and radicular pain in the left L3 distribution. The duration of his symptoms was approximately 2 months. There was erectile dysfunction and recent changes to his bowel habit. The patient noted that he had suffered a vertebral fracture (L2) after a fall several years previously, but could not identify any trauma at the time his symp- toms began. He reported no history of fever and no difficulty with urination. Significant medical history was hypertension and lower limb deep venous thrombosis, for which he was treated with warfarin for 6 months during the preceding year. There was no history of malignancy.
On examination, there was full power in all lower limb myotomes. There was a patchy decrease in sensation to the left lower limb. Reflexes were symmetric, and his gait was unremarkable.
INVESTIGATIONS
A CT scan of the lumbar spine showed an extra- dural lesion at L3 with adjacent ligamentum flavum hypertrophy and significant canal stenosis. There was an old compression fracture noted at the super- ior end plate of L2. MRI confirmed the presence of a solitary, well-defined lesion measuring
26×15×12 mm (craniocaudal × transverse × anteroposterior) adjacent to the lamina of L3 with intermediate intensity on T1-weighted and T2-weighted images. There was significant enhancement with gadolinium-based contrast ( figure 1). These findings were suggestive of an extradural tumour.
CT of the chest, abdomen and pelvis was per- formed. No evidence of malignancy was observed.
DIFFERENTIAL DIAGNOSIS
The traditional differential diagnosis of a spinal mass divides lesions into three groups according to their location. Intradural intramedullary masses arise within the spinal cord itself. Intradural extra- medullary masses arise outside of the spinal cord but within the thecal sac. Extradural (or epidural) masses arise outside the thecal sac, for example, in vertebral bone.
Our patient had an extradural mass which showed marked contrast enhancement. Coupled with the history of progressive symptoms, the leading differentials were a metastatic lesion, extra- dural meningioma or other extradural primary tumour. A facet joint cyst, with or without haemor- rhagic complication, was also considered, although the radiological findings were atypical.
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