Additionally it protects the spinal cord from impingement by folding, which would occur with a nonelastic structure. 3. 1– 3 The most common location is the lower thoracic spine, and, because symptoms progressively worsen with time, early diagnosis and surgical treatment of this disease are more critical than for spinal stenosis caused by other diseases. 3, 31,32 Ossification of the ligamentum flavum is very rare among black patients, with only a few reports in the literature. Being that this structure basically forms the rear border of the central spinal canal, thickening of the ligament will decrease the available space within the rear of the canal. Lee, page 29 With the newly increased space available for the spinal cord, the spinal cord can float away from the vertebral body. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. URL: https://www.sciencedirect.com/science/article/pii/B9780323079549000141, URL: https://www.sciencedirect.com/science/article/pii/B9780323079549000050, URL: https://www.sciencedirect.com/science/article/pii/B9780443101786500037, URL: https://www.sciencedirect.com/science/article/pii/B9780323045834000023, URL: https://www.sciencedirect.com/science/article/pii/B9780323077477000150, URL: https://www.sciencedirect.com/science/article/pii/B9781416068396101625, URL: https://www.sciencedirect.com/science/article/pii/B978143770373310048X, URL: https://www.sciencedirect.com/science/article/pii/B9781437703733100508, URL: https://www.sciencedirect.com/science/article/pii/B9780123742483000331, URL: https://www.sciencedirect.com/science/article/pii/B9780323400664000114, Microscopic Anatomy of the Zygapophysial Joints, Intervertebral Discs, and Other Major Tissues of the Back, Clinical Anatomy of the Spine, Spinal Cord, and Ans (Third Edition), is softer and more extensible than the outer layer, and is made up of elastic fibers, similar to the, Giles & Taylor, 1987; Yamashita et al., 1996, The muscular, ligamentous, and neural structure of the lumbosacrum and its relationship to low back pain, Movement, Stability & Lumbopelvic Pain (Second Edition), .) Once in the operating room, it is essential to identify the correct disc for resection. The ligamentum flavum (flava – plural) is one of the many spinal structures often implicated in contributing to back pain and neck pain conditions via the formation of central spinal stenosis. They indicated, however, that patients with OPLL that affects multiple levels and those with concurrent OLF may not do as well in long-term follow-up. For thoracic stenosis due to OPLL, multiple treatment options have been described, including laminectomy, laminoplasty, resection of the PLL, anterior decompression and fusion via thoracotomy, and posterior decompression and fusion.21,22 Anterior decompression with fusion has been supported by a recent long-term study.23Fujimura et al reviewed the data of 33 patients followed for more than 5 years after anterior decompression and fusion was performed for myelopathy in the thoracic spine due to ossification of the PLL. Medical definition of ligamentum flavum: any of a series of ligaments of yellow elastic tissue connecting the laminae of adjacent vertebrae from the axis to the sacrum. It also slows the last few degrees of spinal flexion. An anterior cervical discectomy (ACD) without fusion is rarely performed today, and is almost never performed for multilevel disease. The location of the compressive pathology in cervical stenosis is important, as it dictates the operative approach. This spinal ligament is prone to calcification, Many patients with thoracic disc herniations are asymptomatic. Spinal ligaments, such as the ligamentum flavum (LF), are prone to degeneration and iatrogenic injury that can lead to back pain and nerve dysfunction. The capsular ligaments are attached immediately peripheral to the lateral margins of the articular facets joining adjacent articular processes. A ligament made of collagen would just as well resist flexion but would not shorten without buckling. Generally, open posterior decompression, with or without fusion, is selected to treat OLF. Learn faster with spaced repetition. First off, the main purpose of the ligamentum flava is to link the vertebrae (the little rings on the spine) together in order to ensure flexibility and momentum. Histological examination of the ligamentum flavum revealed a consolidated hematoma with granulomatous change.A review of the English literature revealed 29 cases of hematoma in the lumbar ligamentum flavum. It's stretched in flexion, it`s fibers resist separation of spinous processes during forward flexion, during hyperflexion interspinous ligament and supraspinous ligament are the first to fail. Histological examination of the ligamentum flavum revealed a consolidated hematoma with granulomatous change.A review of the English literature revealed 29 cases of hematoma in the lumbar ligamentum flavum. We performed minimally invasive posterior decompression using a microendoscope and investigated the … Introduction. (See Figure 2-12.) Surgery consisted of decompressive laminectomy with removal of the ossified ligamentum flavum. The proponents of laminoplasty suggest that this procedure may produce less instability than other modes of decompression.19 Prognosis after surgery depends on the extent of compression and neurological deficit. By continuing you agree to the use of cookies. Synovial extensions, or cysts, protrude out of the Z joint and along the attachment sites of the ligamentum flavum to the adjacent superior and inferior articular processes. Thoracic ossification of the ligamentum flavum (OLF), which is the primary cause of thoracic spinal canal stenosis and myelopathy in our previous retrospective review, 1 is reported almost exclusively in East Asian countries 2 such as China, 3 Japan, 4 and Korea. The data The synovial joint recesses and the development of synovial joint cysts are discussed in further detail with the lumbar region, where they have been studied the most extensively (see Chapter 7). The elastic quality of the ligamentum flavum helps preserves your spinal curves during movement and assists the trunk in straightening up after youve bent forward. Significant complications have been reported with posterior laminectomy alone,29 including cord contusion and lack of improvement of symptoms. Inoue H, Seichi A, Kimura A, Endo T, Hoshino Y. Eur Spine J, 22 Suppl 3:S416-20, 06 Oct 2012 Hypertrophy or ossification of the ligamentum flavum was not recognized in the sections. Although each ligament is considered to be distinct, a ligamentum flavum frequently blends with the ligamentum flavum of the opposite side (Panjabi et al., 1991b) and also blends with the interspinous ligament. Under such circumstances, it usually increases in thickness and may calcify or become infiltrated with fat (Ho et al., 1988). It consists of an outer layer of white and shining dense fibroelastic connective tissue with bundles of collagen fibers coursing parallel with one another. A ligamentum and epidural fat-sparing approach, performed by creating a flap of the ligamentum as described previously, decreases postoperative epidural broses and can improve results.8,34 However, this can make it more difficult to get a good view of the nerve root. The elastic property of these ligaments assists in the restoration of the vertebral column to the neutral position following flexion. Animal study suggests stress on back causes hypertrophy of ligamentum flavum. It acts as a passive stabilizing tissue, restoring the spine to a neutral posture following flexion and extension [3]. A Woodson dissector can be used to carefully free any adherent portions of dura. The flavum is noted to retain its elastic content with age and to demonstrate shortening and thickening as a result of its elasticity when its insertion is incised. Surgical decompression is often required when stenosis results in myelopathy or debilitating radiculopathy. It is an extremely elastic ligament, which connects the spinal bones through its two laminae, articular joints (facets and pedicles) attachment points on each side of the spine, from C2-S1. The ligamenta flava (singular, ligamentum flavum, Latin for yellow ligament) are a series of ligaments that connect the ventral parts of the laminae of adjacent vertebrae.Each ligamentum flavum connects two adjacent vertrebrae, beginning with the junction of the axis and third cervical vertebra, continuing down to the junction of the fifth lumbar vertebra and the sacrum. The posterior elements are then “booked” open, utilizing the scored side as a hinge, and held open with suture, structural grafts/spacers, or plate and screws. 1.4). However, they have a poor blood supply, which slows the healing of these structures once they are damaged (Giles, 1992b). The ligamentum flavum between C1 and C2 is usually thin and membranous and is pierced by the C2 spinal nerve. 1 doctor agrees. Both patients regained normal motor function after removal of the pathologically infolded ligamentum. Posterior instrumentation and fusion is usually warranted when performing three or more cervical corpectomies or when doing four or more cervical discectomies. Ossification of the ligamentum flavum (OLF) of the spine is characterized by ectopic bone formation in the OLF and is highly prevalent in the population of East Asia.1, 2 The ossified ligaments form osteophytes that gradually increase in size, which, in turn, causes compression of the spinal cord and may lead to severe neurological symptoms. Repair and regeneration strategies for these tissues are lacking, perhaps due to limited understanding of spinal ligament formation, the elaboration of its elastic fibers, maturation and homeostasis. This replacement with collagen causes the ligamentum flavum to thicken (up to 10 times its normal width in some instances), which in turn can cause stenosis of the vertebral canal. Ligamentum Flavum. The average CSA of the ligamentum flavum at L4-5 (30 mm2) (fusion level) was significantly less than that at L1-2 to L3-4 or L5-S1. The articular capsule of a typical Z joint covers the joint’s posterolateral surface. Therefore this ligament actually may do work; that is, it may aid in extension of the spine. Thickening of the ligamentum flavum was measured on the axial T1-weighted image that was perpendicular to the axis of the spinal canal and parallel to the laminae, where the ligamentum flavum was seen along its entire length. Sagittal CT reconstructions or MR images are essential to determine the appropriate level, and plain radiography or fluoroscopy in the operating room is standard practice for localization. Repair and regeneration strategies for these tissues are lacking, perhaps due to limited understanding of spinal ligament formation, the elaboration of its elastic fibers, maturation and homeostasis. It may be beneficial to resect a significant amount of vertebral body in cases of multilevel disc disease, or when the disc is in the lower thoracic spine, which may render the spine unstable and require secondary fusion. In the cervical region they are only slightly developed as part of the ligamentum nuchae.6 The interspinous ligaments add stability to the spine by checking excessive flexion.6 Along with the supraspinous ligament the interspinous ligaments are typically the first structures to rupture in extreme flexion.7, The intertransverse ligaments connect the ipsilateral transverse processes of adjacent vertebrae. Hypertrophy of Ligamentum Flavum is a common finding in patients with a herniated disc, protruded disc, prolapsed disc or extruded Disc (Slipped Disc or Slip Disc).Injury, poor posture and longstanding spine conditions are the leading cause of Hypertrophy of Ligamentum Flavum. The ligamenta flava increase in length from C2-3 to C7-T1. In general, anteriorlyoriented lesions require a direct ventral approach such as a transthoracic, thoracoscopic, or posterolateral (e.g., costotransversectomy, extracavitary) technique for safe resection that avoids cord manipulation, with bony reconstruction as necessary. The lumbar ligamentum flavum does not consist of two layers, but is confluent instead with the interspinous ligament that attaches to the zygapophyseal joints. Pulmonary function tests should be performed on patients with questionable pulmonary reserve if thoracotomy is considered. The elastic fibers within the ligamentum flavum prevent it from buckling into the intervertebral foramen (IVF) and vertebral canal, thus sparing the contents of these regions. A second component can be related to an age-related loss of elastic fibers and elasticity of the ligamentum flavum, contributing to their progressive loss of tension in the elderly (Nachemson & Evans 1968, Ramsey 1966). The supraspinous ligament helps maintain the upright position of the head. Depending on the location and nature of the disc herniation, anterior, thoracoscopic, lateral, or posterior approaches may be used, the details of which are largely beyond the scope of this chapter. Both patients had neurological deficits preoperatively and regained normal function postoperatively. Modification of activities, physical therapy, and the careful use of nonsteroidal antiinflammatory drugs are the mainstays of conservative care. To convey this anatomy better, we suggest describing the lumbar ligamentum flavum as a structure that consists of interlaminar and interspinous parts. They connect adjacent spinous processes, and their attachments extend from the root to the apex of each process, meeting the supraspinous ligament at the back and the ligamenta flava in front. Hypertrophy of the ligamentum flavum was diagnosed when the thickness exceeded 4 mm. The elastin prevents buckling of the ligament into the spinal canal during extension, which would cause canal compression. Ossification of the ligamentum flavum is reported to occur most often in the thoracic and thoracolumbar regions of the spine, where it may compress either the posterior aspect of the spinal cord or the exiting nerve roots (Hasue et al., 1983) (see Chapter 6). 1. A detailed description of the fiber direction of the outer part of the lumbar Z joint capsules and the clinical significance of the fiber direction in the lumbar capsule is given in Chapter 7. At rest (in a neutral position), the ligaments have a pretension, ideally keeping the ligaments from buckling (Nachemson & Evans 1968). Discal calcifications, which are more common in the thoracic spine,28 are associated with a greater degree of dural adhesion or associated dural calcification. Gregory D. Cramer, in Clinical Anatomy of the Spine, Spinal Cord, and Ans (Third Edition), 2014. This yellow ligament is the strongest. Ligamentum Flavum connects the vertebrae by firmly attaching to the front of each spinal segment (vertebrae). If the compressive pathology is secondary to redundant ligamentum flavum, hypertrophied facet joints, or other posterior pathology, then a posterior approach allows the surgeon to directly decompress the offending agent. Venous plexus bleeding deep to the ligamentum can be controlled with bipolar electrocautery, thrombin-soaked Gelfoam, and pledget packing. Where their posterior margins meet, they are partially united, with intervals for veins connecting internal to posterior external vertebral venous plexuses.6 These fibroelastic structures permit separation of the lamina in flexion and at the same time brake the movement so that its limit is not reached abruptly.6. When symptoms do exist, unlike patients with OPLL and OLF, conservative treatment and time can be sufficient to treat the majority of herniations. There was no significant antecedent injury in either case. As stated previously, medially and anteriorly the joint capsule is formed by a lateral continuation of the ligamentum flavum. The multifidus lumborum muscle attaches to the articular capsule, which lies just medial to the primary attachment of this muscle to the mamillary process. The phrase ligamentum flavum means \"yellow ligament\". 32 years experience Internal Medicine. The articular capsules are thinner superiorly and inferiorly, where they form capsular recesses that cover fat-filled synovial pads. The buckling further results in narrowing of these regions, which can compromise the neural elements running within them (e.g., spinal cord, cauda equina [lumbar region], or exiting nerve roots). To prepare for the passage of the sublaminar wire, the ligamentum flavum on the underlying surfaces of the posterior arches of C1 and C2 is elevated off the superior and inferior surfaces of the lamina using a microcurette. This elastic ligament forms a significant portion of the roof of the spinal canal. These events favor the deposition of calcium (Kashiwagi 1993), thus nearly all flaval ligaments in a sampling of patients with lumbar spinal stenosis had histological signs of ossification (Schrader et al 1999). Die Ligamenta flava findet man vom Axis bis zum ersten Segment des Os sacrum.Ihre Gewebedicke nimmt dabei von zervikal nach lumbal zu.. The conclusion of this study was the recommendation that a facetectomy should involve less than 50% of the facet joint in the absence of fusion, in order to avoid spinal instability.5 Postlaminectomy kyphosis after posterior cervical decompression alone is common when there is evidence of hypermobility on preoperative flexion-extension radiographs. The posterior and lateral aspect of each lumbar inferior articular process (IAP) has a “lip” that projects further posteriorly than the medial aspect of the IAP, which is more anteriorly located. 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