Anatomic Variations of Cervical and High Thoracic Ligamentum Flavum

( Sang Pil Yoon ),( Hyun Jung Kim ),( Yun Suk Cho ) 대한통증학회 2014 The Korean Journal of Pain Vol.27 No.4

Background:Epidural blocks are widely used for the management of acute and chronic pain. The technique of loss of resistance is frequently adopted to determine the epidural space. A discontinuity of the ligamentum flavum may increase the risk of failure to identify the epidural space. The purpose of this study was to investigate the anatomic variations of the cervical and high thoracic ligamentum flavum in embalmed cadavers.Methods:Vertebral column specimens of 15 human cadavers were obtained. After vertebral arches were detached from pedicles, the dural sac and epidural connective tissue were removed. The ligamentum flavum from C3 to T6 was directly examined anteriorly.Results:The incidence of midline gaps in the ligamentum flavum was 87%-100% between C3 and T2. The incidence decreased below this level and was the lowest at T4-T5 (8%). Among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Conclusions:The cervical and high thoracic ligamentum flavum frequently has midline intervals with various features, especially in the caudal portion of the intervertebral space. Therefore, the ligamentum flavum is not always reliable as a perceptible barrier to identify the epidural space at these vertebral levels. Additionally, it may be more useful to insert the needle into the cephalic portion of the intervertebral space than in the caudal portion. (Korean J Pain 2014; 27: 321-325)

Anatomic Variations of Cervical and High Thoracic Ligamentum Flavum

윤상필,김현정,최윤석 대한통증학회 2014 The Korean Journal of Pain Vol.27 No.4

Background: Epidural blocks are widely used for the management of acute and chronic pain. The technique of loss of resistance is frequently adopted to determine the epidural space. A discontinuity of the ligamentum flavum may increase the risk of failure to identify the epidural space. The purpose of this study was to investigate the anatomic variations of the cervical and high thoracic ligamentum flavum in embalmed cadavers. Methods: Vertebral column specimens of 15 human cadavers were obtained. After vertebral arches were detached from pedicles, the dural sac and epidural connective tissue were removed. The ligamentum flavum from C3 to T6 was directly examined anteriorly. Results: The incidence of midline gaps in the ligamentum flavum was 87%-100% between C3 and T2. The incidence decreased below this level and was the lowest at T4-T5 (8%). Among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Conclusions: The cervical and high thoracic ligamentum flavum frequently has midline intervals with various features, especially in the caudal portion of the intervertebral space. Therefore, the ligamentum flavum is not always reliable as a perceptible barrier to identify the epidural space at these vertebral levels. Additionally, it may be more useful to insert the needle into the cephalic portion of the intervertebral space than in the caudal portion.

Anatomic Variations of Cervical and High Thoracic Ligamentum Flavum

Yoon, Sang Pil,Kim, Hyun Jung,Choi, Yun Suk The Korean Pain Society 2014 The Korean Journal of Pain Vol.27 No.4

Background: Epidural blocks are widely used for the management of acute and chronic pain. The technique of loss of resistance is frequently adopted to determine the epidural space. A discontinuity of the ligamentum flavum may increase the risk of failure to identify the epidural space. The purpose of this study was to investigate the anatomic variations of the cervical and high thoracic ligamentum flavum in embalmed cadavers. Methods: Vertebral column specimens of 15 human cadavers were obtained. After vertebral arches were detached from pedicles, the dural sac and epidural connective tissue were removed. The ligamentum flavum from C3 to T6 was directly examined anteriorly. Results: The incidence of midline gaps in the ligamentum flavum was 87%-100% between C3 and T2. The incidence decreased below this level and was the lowest at T4-T5 (8%). Among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Conclusions: The cervical and high thoracic ligamentum flavum frequently has midline intervals with various features, especially in the caudal portion of the intervertebral space. Therefore, the ligamentum flavum is not always reliable as a perceptible barrier to identify the epidural space at these vertebral levels. Additionally, it may be more useful to insert the needle into the cephalic portion of the intervertebral space than in the caudal portion.

Ligamentum Flavum Cyst of Lumbar Spine: A Case Report and Literature Review

서동호,박혜란,오재상,도재원 대한척추신경외과학회 2014 Neurospine Vol.11 No.1

Ligamentum flavum cysts have rarely been reported and known to be the uncommon cause of spinal compression and radiculopathy. A 63-year-old man presented right sciatica lasting for 1 month. Lumbar computerized tomography and magnetic resonance imaging demonstrated an extradural cystic mass adjacent to the L5-S1 facet joints. Partial hemilaminectomy and flavectomy at the L5-S1 space were performed, and then the cystic mass was excised. Histopathology confirmed a connective tissue cyst, which is consistent with the ligamentum flavum. Microscopic examination of the cyst wall revealed that it is closely packed collagen fibril. The symptom of patient was improved after surgery. Because of rarity of ligamentum flavum cysts and nonspecific clinical and radiologic findings, the preoperative diagnosis is not easy. The histologic featuresof ligamentum flavum cysts are distinct from other cystic lesion of lumbar spine. This study presents a case and literature review of ligamentum flavum cyst. We summarize the pathophysiology, occurrence, differential diagnosis of rare ligamentum flavum cyst, especially on lumbar spine.

p38 Mitogen-Activated Protein Kinase Is Involved in Interleukin-6 Secretion from Human Ligamentum Flavum–Derived Cells Stimulated by Tumor Necrosis Factor-α

Yagi Kiyoshi,Goto Yuta,Kato Kenji,Suzuki Nobuyuki,Kondo Akira,Waseda Yuya,Mizutani Jun,Kawaguchi Yohei,Joyo Yuji,Waguri-Nagaya Yuko,Murakami Hideki 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.6

Study Design Human ligamentum flavum–derived cells (HFCs) were obtained from surgical samples for a basic experimental study. Purpose We sought to evaluate the inflammatory response of human ligamentum flavum cells to investigate hypertrophic changes occurring in the ligamentum flavum. Overview of Literature Lumbar spinal stenosis (LSS) is a disease commonly observed in the elderly. The number of patients with LSS has increased over time, yet the pathomechanisms of LSS still have not been fully elucidated. One of the clinical features of LSS is hypertrophy of the ligamentum flavum, which results in narrowing of the lumbar spinal canal. Some reports have suggested that ligamentum flavum hypertrophy is associated with inflammation and fibrosis; meanwhile, the p38 mitogen-activated protein (MAP) kinase is involved in the hypertrophy of human ligamentum flavum cells. Methods HFCs were obtained from patients with LSS who underwent surgery. HFCs were stimulated by tumor necrosis factor-α (TNF-α) and a p38 MAP kinase inhibitor, SB203580. Phosphorylation of the p38 MAP kinase was analyzed by western blotting. The concentration of interleukin-6 (IL-6) in the conditioned medium was measured by enzyme-linked immunoassay and IL-6 messenger RNA expression levels were determined by real-time polymerase chain reaction. Results TNF-α induced the phosphorylation of p38 MAP kinase in a time-dependent manner, which was suppressed by the p38 MAP kinase inhibitor, SB203580. TNF-α also stimulated IL-6 release in both a time- and dose-dependent manner. On its own, SB203580 did not stimulate IL-6 secretion from HFCs; however, it dramatically suppressed the degree of IL-6 release stimulated by TNF-α from HFCs. Conclusions This is the first report suggesting that TNF-α stimulates the gene expression and protein secretion of IL-6 via p38 MAP kinase in HFCs. A noted association between tissue hypertrophy and inflammation suggests that the p38 MAP kinase inflammatory pathway may be a therapeutic molecular target for LSS.

다발성 황색인대 골화에 의한 척수병증 1례

강동수,오석전,정환영,김남규,김광명,이승로 대한신경외과학회 1991 Journal of Korean neurosurgical society Vol.20 No.7

The authors report on case of myelopathy due to multiple ossification of ligamentum flavum at the level of thoracic spine. The prominant symptoms were numbness of both leg & foot, gait disturbance, spatic motor weakness. Motor power was mild decreased. Metrizamide myelography, CTMM, MRI showed prominant ossified ligamentum flavum at T₄T_(5) T_(7) T_(8) T_(10), which compressed arachnoid space & spinal cord, most prominant at the level of T_(8). Total laminectomy was made from the level of T₄to that of T_(10) by two staged operation. There was marked compression of the dural sac by the ossified ligamentum flavum. Removal of the lesion produced satisfactory decompression. In post-operative state, pre-operative symptom was improved, but there was still impairment of position and touch sense below T_(10) at Right side. Left side was normalized. Microscopic examination of nodule revealed ossification of ligamentum flavum.

Transforming Growth Factor-β Induces Interleukin-6 Secretion from Human Ligamentum Flavum–Derived Cells through Partial Activation of p38 and p44/42 Mitogen-Activated Protein Kinases

Goto Yuta,Kato Kenji,Yagi Kiyoshi,Kawaguchi Yohei,Yonezu Hiroki,Koshimae Tomoko,Waguri-Nagaya Yuko,Murakami Hideki,Suzuki Nobuyuki 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.6

Study Design: This experimental study was performed using human ligamentum flavum–derived cells (HFCs).Purpose: To investigate the intracellular signaling mechanism of interleukin-6 (IL-6) secretion in transforming growth factor-β (TGF- β)-stimulated HFCs.Overview of Literature: Lumbar spinal stenosis (LSS) is a prevalent disease among the elderly, characterized by debilitating pain in the lower extremities. Although the number of patients with LSS has increased in recent years, the underlying pathomechanism remains unclear. Clinical examinations typically rely on magnetic resonance imaging to diagnose patients, revealing ligamentum flavum hypertrophy. Some studies have suggested an association between ligamentum flavum hypertrophy and inflammation/fibrosis, and expression of TGF-β and IL-6 has been observed in surgically obtained ligamentum flavum samples. However, direct evidence linking TGF-β and IL-6 expression in HFCs is lacking.Methods: HFCs were obtained from patients with LSS who had undergone decompression surgery. The cells were stimulated with TGF-β and pretreated with either the p38 mitogen-activated protein (MAP) kinase inhibitor SB203580 or the p44/42 MAP kinase inhibitor FR180204. IL-6 secretion in the cell culture medium and IL-6 messenger RNA (mRNA) expression levels were analyzed using an enzyme-linked immunoassay and real-time polymerase chain reaction, respectively.Results: TGF-β administration resulted in a dose- and time-dependent stimulation of IL-6 release. Treatment with SB203580 and FR180204 markedly suppressed TGF-β–induced IL-6 secretion from HFCs. Moreover, these inhibitors suppressed IL-6 mRNA expression in response to TGF-β stimulation.Conclusions: Our findings indicate that TGF-β induces IL-6 protein secretion and gene expression in HFCs through the activation of p38 or p44/42 MAP kinases. These results suggest a potential association between IL-6–mediated inflammatory response and tissue hypertrophy in LSS, and we provide insights into molecular targets for therapeutic interventions targeting LSS-related inflammation through our analysis of the MAP kinase pathway using HFCs.

흉추부 황색인대 골화증 : 환자 16예의 임상적 분석 A Clinical Analysis of 16 Cases

현명훈,김남규,백광흠,신형식,김재민,고용,오성훈,오석전,김광명 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.8

The authors are reporting 16 cases of ossification of the thoracic ligamentum flavum. Thoracic ossified ligamentum flavum cause myelopathy as a result of pressure on the spinal cord and nerve roots The prominent sysmptoms were numbness of the foot or leg motor weakness sphincter disturbance and exaggerated tendon reflexes The male to female ratio was 13:8 and the 5th decade was the most prevalent age group. The predominant regions involved were T9-T10 and T10-T11 Total laminectomy was performed in all patients and the prognosis was good in most cases. The thoracic ossified ligamentum flavum and neurologic disorders due to compression of the thoracic vertebrae by other diseases do not show much of a difference in terms of symptoms In the past due to the lack of knowledge of this disease treatment was performed inapproapriately However at the present with the improvement of CT and MRI and the increased recognition of this disease we believe that good prognosis can be made if appropriate treatment is delivered at the time of diagnosis

CPPD 결정침착 질환에 의한 경부 측수증(cervical myelopathy) 1예

김재일,석현정,정선미,이은영,이창근,유빈,문희범 대한내과학회 2004 대한내과학회지 Vol.66 No.2

저자들은 우측 상지와 하지의 근력약화와 강직성 보행장애가 있어 내원한 57세 여자 환자에서 CPPD 결정침착질환에 의한 황색인대의 칼슘침착과 그에 수반된 경부측수증 1예를 경험하였기에 보고하는 바이다. Calcium pyrophosphate dihydrate (CPPD) deposition disease is an inflammatory arthropathy that is defined by the deposition of CPPD crystals in articular and periarticular structure. Spinal involvement in CPPD deposition disease is rare. We reported a rare case of CPPD deposition disease that caused compressive cervical myelopathy. A 57-year-old woman was admitted to the hospital with 1 week history of progressive paresis of the right upper and lower extremities. Computed tomography showed the round and nodular calcified ligamentum flavum. Magnetic resonance imaging showed a low intensity epidural mass pressing and distorting the cervical cord at C-4 and 5 levels on both T1 and T2- weighted images. Radiographic findings were consistent with calcification of the ligamentum flavum in the C-4 and 5 levels causing cord compression. The lesion was eventually removed by hemilaminectomy. The mass was composed of a very hard crystal like calcified deposition in the ligamentum flavum. The histopathological evaluation of the exicised ligamentum flavum revealed the characteristic crystals of CPPD.

초음파 중재 하 황색인대 침도시술 방법에 대한 프로토콜

Kang Kyungho,Oh Kichang,Kim Jaehyo,Chu Hongmin 대한침도의학회 2023 대한침도의학회지 Vol.7 No.1

Background: The aim of this article is to propose the safe and effective protocol for ultrasound-guided acupotomy procedure at ligamentum flavum. Deep needling at the ligament flavum can cause side effects such as leakage of cerebrospinal fluid or hematoma, or exacerbation of the patient’s symptoms, which are difficult to respond to in primary medical institutions. In this regard, the need to present a safer and more accurate method of needling at ligamentum flavum is enhanced. Methods: While treating 12 patients aged 60-80 years, the method of needling the shortest length with identifing the tip of acupuncture on the image was studied. An ultrasound machine was used with GE LOGIQ P9 XDclear and C1-6D Single Crystal Convex Probe. The initial study used a SMC 0.40×60 mm needle. After the operation became proficient with the needle, MAANSHAN BOND MEDICAL INSTRUMENTS CO. LTD. GB 60×60 acupotomy was used. Results: A safe procedure method and a manual for education methods were proposed. Conclusion: Because of the long axis entry, the procedure can be performed without missing the full length and tip of the acupuncture on image. It can be performed with small invasion compared to previous in-plane studies performed by laying down the angle.