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. It has also been suggested that the shortening and lengthening of the ligamenta flava with spinal motion results in small, frequent, repetitive movements that assist in the nutrition of the posterior joint cartilage, the nucleus pulposus, and the cartilage plates of the disc, a function that would be expected to be absent or impaired by joint fixation. Raynor et al reported a cadaveric study comparing the potential degrees of instability on biomechanical testing of intact specimens, and following 50% facetectomy, and 70% facetectomy. Compared to other ligaments, the LF is an unusually elastic ligament due to its high proportion of elastic fibers. In normal anatomy the pressure gradient between the CSF and the epidural space would be noticed quickly as one passes through the epidural space into the spinal fluid. Under such circumstances, it usually increases in thickness and may calcify or become infiltrated with fat (Ho et al., 1988). Therefore this ligament actually may do work; that is, it may aid in extension of the spine. FH Willard, in Movement, Stability & Lumbopelvic Pain (Second Edition), 2007. 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. Both the relatively avascular nature of the thoracic spinal cord and adhesion of dural sac to the PLL are thought to contribute to these complications. The natural history of cervical myelopathy is that of a stepwise progression of symptoms alternating with periods of nonprogressive neurological symptoms. The ligamentum flavum, located between individual laminae, represents a medialward continuation of the articular capsule of the facet joint (Fig. The ligamentum flavum is a connective tissue which links the individual vertebrae together. Anterior cervical discectomy and fusion (ACDF) has been described with good results without the use of instrumentation. 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. 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. 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 articular capsule of a typical Z joint covers the joint’s posterolateral surface. Depending on the extent of compression, laminoplasty, partial or total laminectomy, circumferential decompression, and decompression with fusion have been proposed. The ligamentum flavum also runs in front of the facet joint capsules. This treatment plan only works in cases in which a neutral or lordotic curve of the cervical spine is maintained. In adults, the ligamentum arteriosum has no useful function. The multifidus is one of the muscles running along the spine. The lamina is the bony portion of vertebrae that form the back wall of the spinal canal. Posteriorly the capsule is much thinner and loosely attached. Operative indications include symptoms that are recalcitrant to nonoperative treatment as well as development of myelopathy. 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. There … In the neck region the ligaments are thin, but broad and long; they are thicker in the thoracic region, and thickest in the lumbar region. The elastic property of these ligaments assists in the restoration of the vertebral column to the neutral position following flexion. 2. However, when conditions are perfectly met, ligamentum flavum thickening can create symptomatic and possibly extreme stenosis symptoms in some patients. This difference reduces, but does not eliminate, the need for epidural test dosing, and contrast imaging. 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). Surgical treatment is recommended for patients with myelopathy. Ligamentum flavum Function. We see the continuous nature of the thoracolumbar fascia-supraspinous ligament-ligamentum flavum connection. 1 doctor agrees. 1. Modification of activities, physical therapy, and the careful use of nonsteroidal antiinflammatory drugs are the mainstays of conservative care. The decompression involves removal of more than 50% of the facet joint. Learn more. The epidural space is entered when the needle passes through the ligamentum flavum into the desired location. This tissue is similar to the type of connective tissue that comprises the other spinal ligaments, except theres a degree of elasticity to it. A posterior-only approach is only indicated if neutral or lordotic alignment of the cervical spine is maintained. The ligamenta flava (singular, ligamentum flavum) are paired ligaments (left and right) that run between the laminae of adjacent vertebrae (see Fig. Orthopedics | Lumbar Ligamentum Flavum Hematoma Treated With Endoscopy --> Abstract Hematoma of the ligamentum flavum is a rare cause of neural … The articular capsules are thinner superiorly and inferiorly, where they form capsular recesses that cover fat-filled synovial pads. The change of pressure can also be detected by the hanging drop technique in which the sudden change in pressure leads to a sudden retraction of the drop which is allowed to hang at the surface of the needle hub. With the newly increased space available for the spinal cord, the spinal cord can float away from the vertebral body. The interspinous ligaments are thin and almost membranous. For multiple-level posterior cervical spinal cord compression, laminoplasty is another option. This anatomical term is usually found on spinal MRI reports, particularly those detailing a … The Ligamentum Flavum forms a cover over the dura mater: a layer of tissue that protects the spinal cord. Background and Objectives: Ossification of the ligamentum flavum (OLF) is a relatively common cause of thoracic myelopathy. The ligamentum flavum, or the yellow ligament, is a thick, segmental ligament that runs between the lamina of adjacent vertebrae (Fig. However, the lateral fibers of this ligament course anterior to the Z joint, attach to its margins, and form its anterior capsule. The less-experienced surgeon may perform partial removal of these tissues. Finally, failure of the elastic properties of this ligament has also been related to the development of adolescent idiopathic scoliosis (Hadley-Miller et al 1994). 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 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 intersegmental ligaments that connect adjacent vertebrae include the ligamenta flava, the interspinous, intertransverse, and capsular ligaments. Ligamentum Flavum Hypertrophy Details. The capsules are longer and looser in the cervical region than in the lumbar and thoracic regions. They are largely replaced by intertransverse muscles in the cervical region and consist of a few scattered fibers in this area. This distensible ligament is composed of elastic fibers (80%) and collagenous fibers (20%), the elastic fibers imparting the ligament its yellow color and flexible nature (Bogduk & Twomey 1991). It connects inside the vertebral structure, posterior to the central canal. It is composed of 80% elastic fiber and 20% colla-gen fiber3). Ossification of the ligamentum flavum (OLF) is a phenomenon where there is a formation of ossific-calcific components in the ligamentum flavum.It is recognized causes of myelopathy (especially in the thoracic and to a lesser degree the cervical region). 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. 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 ligament made of collagen would just as well resist flexion but would not shorten without buckling. 0. 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. A kyphotic deformity in the cervical spine often mandates an anterior approach to restore the normal cervical sagittal alignment. It acts as a passive stabilizing tissue, restoring the spine to a neutral posture following flexion and extension . 5, 6 In addition, hypertrophy of the ligamentum flavum (LF) was discussed to play an important role for development of LSS. Studies of the form and function of the ligamentum flavum have been made directly, by investigating the structure and indirectly, by appraising properties of analogous elastic tissue structures. Ligamentum flavum hypertrophy, also known as ligamentum flavum thickening, is a health condition related to the spine and lower back. 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. Recurrent stenosis has been documented, making routine follow-up necessary.20. Despite the elasticity of the ligamentum flavum, it is known to be a significant source of root compression in the lumbar region (Okuda et al 2005). The phrase ligamentum flavum means \"yellow ligament\". Specifically, there is a decrease in elastic fibers and a concomitant increase in the density of collagen fibers, along with a shift to high-molecular-weight proteoglycans (Kashiwagi 1993, Okada et al 1993). Surgical decompression is often required when stenosis results in myelopathy or debilitating radiculopathy. 162-7). Both patients regained normal motor function after removal of the pathologically infolded ligamentum. Limits flexion along with other ligaments of vetebral column. ligamentum flavum pronunciation. Degenerative change of the ligamentum flavum can result in elastic fibers being replaced with collagen. Ligamentum flavum are long ligamentous structures in humans that are extended from the second cervical up to the lumbosacral vertebra. Once in the operating room, it is essential to identify the correct disc for resection. The most important anatomic landmarks for epidural anesthesia are the spinal column and adjoining connective tissue, especially the spinal ligaments (ligamentum flavum and interspinous and supraspinous ligaments). A female asked: what does bilateral ligamentum flavum infolding mean? 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. The ligamentum flavum is a connective tissue which links the individual vertebrae together.  They are best seen from the interior of the vertebral canal; when looked at from the outer surface they appear short, being overlapped by the lamina of the vertebral arch. In fact, Panjabi and colleagues (1991b) were unable to find ligamenta flava between C1 and C2 in their study of six cervical spines. The ligamentum flavum locates within the spinal canal posterolaterally connecting two adjacent laminae and is di-vided into two portions: capsular portion and interlaminar portion2). 1– 5). Because these ligaments lie in the posterior part of the vertebral canal, their hypertrophy can cause spinal stenosis, particularly in patients with diffuse idiopathic skeletal hyperostosis. Both had large flaps of ligamentum flavum arising from the caudal lamina which infolded upon reduction and became trapped between the spinal cord and cephalad lamina. The ligamentum flavum is unique in that it contains yellow elastin, which causes it to constrict naturally. They connect adjacent vertebrae from the sacrum to the axis bridging the posterior elements of the spinal canal.6 Their attachments extend from zygapophyseal capsules to where the laminae fuse to form spines. The intertransverse ligaments become taut in contralateral lateral flexion.21. It may also protect the discs from injury.6 The ligamenta flava form the medial and anterior aspects of the capsular ligaments. 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. Discectomy without fusion has been reported in a prospective, randomized trial to be equivalent to ACDF for the treatment of cervical radiculopathy.1 For the treatment of myelopathy, ACD without fusion has been reported to result in good relief of neck and arm pain as well as a 76% rate of return to work.2 However, ACD without fusion has been shown in other case series to be associated with worsening of preexisting cervical myelopathy in 3.3% of cases.3 Worsening of symptoms after ACD without fusion was also reported by Nandoe Tewarie et al in a retrospective review of 102 patients evaluated up to 18 years after surgery.4 While ACD alone has been shown to be successful in the treatment of cervical myeloradiculopathy, the possibility of worsening of symptoms, combined with the difficulty of revision of anterior cervical surgery, makes this a possible yet unattractive surgical option. 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