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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 1  |  Page : 125--126

Cervicomedullary compression secondary to proliferation of transverse atlantal ligament

Jun-Peng Ma1, Lu Ma1, Chao You1, Jian-Ping Liu2,  
1 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
2 Department of Pathology, West China Hospital, Sichuan University, Chengdu, China

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
China




How to cite this article:
Ma JP, Ma L, You C, Liu JP. Cervicomedullary compression secondary to proliferation of transverse atlantal ligament.Neurol India 2012;60:125-126


How to cite this URL:
Ma JP, Ma L, You C, Liu JP. Cervicomedullary compression secondary to proliferation of transverse atlantal ligament. Neurol India [serial online] 2012 [cited 2021 Jun 21 ];60:125-126
Available from: https://www.neurologyindia.com/text.asp?2012/60/1/125/93619


Full Text

Sir,

A 62-year-old man was admitted with progressive extremity weakness and sensory disturbances of one-year duration. Neurological examination revealed moderate weakness of all four extremities with a cervical sensory level. Deep tendon reflex were hyperactive with bilateral up going plantar response. Magnetic resonance imaging (MRI) revealed a retro-atlantoaxial extradural mass, homogenously isointense on T1-weighted sequence and relatively hypo-intense on T2-weighted sequence [Figure 1]. There was no evidence of calcification or spondylosis on computed tomography (CT) and plain radiographs [Figure 2]. Extensive laboratory workup including immunological studies showed no abnormality. C1-2 hemilaminectomy and partial occipital craniectomy were done to expose the lesion. During the operation, a ligament-like mass adherent to the vertebra and dura could clearly be visualized [Figure 3]a. Subtotal resection was performed. Intraoperative frozen histopathological examination confirmed the mass as ligamentous structure [Figure 3]b. Postoperative course was uneventful and there was a rapid improvement of neurologic function in the lower limbs. He was discharged on the seventh postoperative day and he recovered from the neurological deficits during two years' follow-up.{Figure 1}{Figure 2}{Figure 3}

Cervicomedullary compression from lesions arising from the transverse ligament of the atlas (TLA) is extremely rare. In this patient, the image founding of proliferative TLA have the following features and characteristics: [1],[2] (1) retro-atlantoaxial extradural mass with obvious anterior cervico-medullary compression; (2) homogeneously isointense to the neural tissue on T1-weighted sequence and relatively hypo-intense on T2-sequence; (3) No contrast enhancement; and (4) no evidence of calcification, bone erosion, bone destruction or spondylosis in cervical X radiograph and CT scan. Histologically, proliferative changes of ligament are observed in the fibrous matrix with no evidence of calcification and salt deposition in the proliferative ligament. The pathophysiology of this condition is totally different from that of calcium pyrophosphate crystal deposition (CPCD) of TLA, the most common reported lesion arising from the TLA. [3],[4] But the exact pathophysiology of this condition and whether proliferation of the TLA will evolve to other pathological changes, such as ossification and canceration, are unclear. [5] Surgery is the only way to treat cervicomedullary compression in this condition. As the proliferative ligament is non-invasive and slowly progressive, the aim of surgery should focus on decompression and protection of the cervicomedullary junction together with mainstreaming atlantoaxial stability. Both preoperative imaging and intraoperative frozen histopathological sections are essential for the definite diagnosis and deciding the scope of resection. As long as the ligamentous structures are confirmed, subtotal resection is sufficient for decompression. However, as the understanding of this disease is very limited, whether there is continued proliferation and increased atlantoaxial instability after surgery are still uncertain.

References

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2Rhoton AL. The Foramen Magnum. Neurosurgery 2000;Suppl 3;47:158-9.
3Sethi KS, Garg A, Sharma MC, Ahmad FU, Sharma BS. Cervicomedullary compression secondary to massive calcium pyrophosphate crystal deposition in the atlantoaxial joint with intradural extension and vertebral artery encasement. Surg Neurol 2007;67:200-3.
4Assaker R, Louis E, Boutry N, Bera-Louville A, Paul Lejeune J. Foramen magnum syndrome secondary to calcium pyrophosphate crystal deposition in the transverse ligament of the atlas. Spine (Phila Pa 1976) 2001;26:1396-400.
5Kondo S, Onari K, Watanabe K, Hasegawa T, Toguchi A, Mihara H. Hypertrophy of the posterior longitudinal ligament is a prodromal condition to ossification: A cervical myelopathy case report. Spine (Phila Pa 1976) 2001;26:110-4.