Letter to the Editor (case Report)

Abstract

SIR, Deposition of calcium in the ligamentum flavum is an uncommon degenerative disorder characterized by hydroxyapatite and/or calcium pyrophosphate deposition inside the ligamentum flavum [1–6]. The present report describes a rare case of spontaneous resorption of calcific deposits in the cervical ligamentum flavum that was associated with acute cervico-brachial neuralgia. A 67-yr-old Caucasian woman was referred to our hospital for progressive intense left cervicalgia radiating into the left arm (C7 dermatoma). No precipitating factor was identified. At clinical examination, she was apyretic and had no sensory or motor deficit. She had a stiff cervical spine when bending or rotating to the left. The left triceps reflex was reduced. There were no central neurological signs. Blood analysis showed an isolated inflammatory response [erythrocyte sedimentation rate (ESR): 65 mm/h and C-reactive protein (CRP): 122mg/l], normal total erythrocyte and leucocyte counts and no further abnormalities on routine examination. Lumbar puncture showed an increase of total protein (1.09 g/l), 10 lymphocytes/mm and no germs on direct analysis. A symptomatic treatment with antiinflammatory (ketoprofene) and analgesic medication (tramadol) was started under the diagnosis of C7 cervico-brachial neuralgia due to spondylitis. An MRI made at day 3 (Fig. 1) showed two nodules in the ligamentum flavum in front of the left lamina C6 and C7, without other abnormalities. The C6 nodule was hypointense on T1and T2-weighted images. The nodule at C7 had a hypo-intense centre on T1and T2-weighted images, and a hyper-intense rim on T2, that enhanced profoundly after intravenous injection of gadolinium. This argued in favour of inflammation of the C7 nodule. A CT-scan (Fig. 1) made immediately after the MRI showed two calcifications that matched with the MRI nodules. The C7 calcification was less dense than the C6 calcification and had a cloud-like appearance, arguing in favour of demineralization due to progressive resorption. CT and MRI showed that the inflamed C7 calcification compressed the left nerve root C7, which appeared otherwise normal. Radiography of shoulders, wrists, knees and pelvis showed no other calcification. Additional blood analysis showed normal concentrations of urea, creatinine, calcium, phosphate, vitamin D and parathyroid hormone. Control CT-scan made 10 days after the start of the symptoms (Fig. 1) showed that the C7 calcification had almost completely disappeared. The C6 calcification was unchanged. After 2 weeks of treatment, the symptoms had disappeared with normalization of the inflammatory response (ESR: 28 mm/2 h and CRP: 6.2mg/l). Three months after symptom onset, the patient was asymptomatic and control CT-scan showed no changes. Calcific deposits in the ligamentum flavum occur predominantly in women over 65 yrs and prevail in Japan and the French Antilles [1–5, 7]. The cervical spine is usually affected [5]. Ligamentum flavum calcifications may be asymptomatic or may be responsible for chronic myelo-radiculopathy [4, 5, 7]. Acute worsening of chronic myelopathy has been reported [4]. The mean diagnostic delay varies between 7 [1] and 11 months [7]. Due to the paramedian posterior localization of the ligamentum flavum, calcification within the ligamentum may cause radicular symptoms. These are found in 20% of the cases [1, 7]. Fever and inflammatory laboratory markers have been reported during

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Cite this paper

@inproceedings{Saliou2007LetterTT, title={Letter to the Editor (case Report)}, author={G Saliou and Marie Th{\'e}audin and Franck Grados and Patricia Lehmann and Dik R. Rutgers and Jean No{\"{e}l Vall{\'e}e}, year={2007} }