PMC9874224_01
Preoperative image examinations. (A-D) Magnetic resonance (MR) taken on 2 May 2019 detected a dorsal epidural compression at T10-11 interlaminar level. (A) midsagittal T1WI image; (B) midsagittal T2WI image, and transverse T2WI image at T10 (C) and T11 (D) levels. (E-G) Computed tomography (CT) taken on May 6 revealed intraspinal canal calcification deposits posterior to the spinal cord at the T10-11 level which had no continuity with the lamina. Midsagittal (E), coronal plane (F), and transverse CT image at T10 (F) and T11 levels (G) on bone window, respectively.
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F1
T10-11 level with intramedullary hypo-intense signals on T1-weighted images (T1WI) and hyperintense signals on T2-weighted images (T2WI) (Figure 1). The suspected diagnosis included ossification of LF (OLF), CLF, or subacute SSEH with incomplete paraplegia. Subsequent computed tomography (CT) taken on 6 May 2019 found the calcified protruding mass did not attach to the lamina (Figure 1).
Spontaneous spinal epidural hematoma (SSEH) in addition to calcification of the ligamentum flavum (CLF) compressing spinal cord at the T10-11 level was confirmed intraoperatively. (A) Following removal of CLF (1), necrotic deeper layer of ligamentum flavum (NLF) exhibiting purple-red color appeared (2), with stale blood clot in deep-red color squeezed out from opened small mouth of LF 2462. (B) SSEH was found to exist between NLF and dural sac. (C) Dural sac exposed after evacuation of SSEH. (D) Fluoroscopic image confirmed the location of anterior end of working canal.
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F2
Following removal of bilateral CLF and evacuation of SSEH, the dural sac expanded to its normal elliptical contour and free mobility of the dural sac was visualized endoscopically (Figure 2).
MR and CT re-examinations postoperatively. (A-C) CT taken on 15 May 2019 confirmed disappearance of CLF and fenestration at left T10-11 interlaminar space. (A) Midsagittal plane, bone window. (B, C) Axial plane, bone window. Arrow: T10 spinal process. (D, E) MRI taken on 26 December 2019 revealed complete recovery of dura sac. (D) Midsagittal T1WI image. (E) Midsagittal T2WI image.
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F3
CT re-examination on 15 May 2019 confirmed fenestration at left T10-11 interlaminar space with complete removal of CLF (Figure 3). MR re-examination on 26 December 2019 found complete expansion of the dura sac, while intramedullary hyperintensity on sagittal T2-weighted MR imaging sequences could still be detected (Figure 3E).
Follow-up postoperatively. (A) Dorsal flexion of left big toe could be detected in the surgery morning. (B) Right lower limb raising with right ankle at neutral position 1 day postoperatively. (C) The patient could walk freely for 5 m 7 days postoperatively. (D) Free walking 4 months later.
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F4
After 3 months, the patient gained complete recovery (Figure 4).