Ligamentum Flavum Hematoma granulomatous change of the ligamentum flavum. examined 24 individuals using MRI before and after an external axial load. Many studies suggest that the ligamentum flavum is a key factor in the pathogenesis of lumbar spinal stenosis [1–6]. Error bars span one standard deviation. Lateral ligamentum flavum thickness was significantly greater in low back pain subjects compared to asymptomatic subjects. It is worth noting that between both thickness measurements, a moderate correlation coefficient was obtained (r = 0.418. p < 0.01). Given that the parent study for this research was not designed to obtain normative data, our results might be limited due to relatively small subject population. The Journal of Orthopaedic Research, a publication of the Orthopaedic Research Society (ORS), is the forum for the rapid publication of high quality reports of new information on the full spectrum of orthopaedic research, including life sciences, engineering, translational, and clinical studies. Nevertheless, there have been few reports describing the natural history of the LF. Thickness differences between low back pain and asymptomatic subjects were then examined by level. Statistical significance was set at the level of p < 0.05. Analyzed the data: AAEO NI RT. Hypertrophy of the ligamentum flavum (LF) has also been considered as a major cause of LCSS (7). https://doi.org/10.1371/journal.pone.0128321.g002. Alejandro A. Espinoza Orías, Analysis of variance and t-tests were carried out to evaluate the relationship between ligamentum flavum thickness and patient variables. All patients underwent MR imaging and computed tomography (CT) of the lumbar spine. Howard S. An, Similar results were obtained when comparing lateral thickness in males versus females (3.06 ± 0.66 mm versus 2.93 ± 0.64 mm, respectively, p = 0.078). In a nutshell, this is what spinal ligaments called ligamentum flavum do. In contrast, the present study found a low, positive but significant correlation between ligamentum flavum thickness and disc grade (using the Pfirrmann classification system). Ligamentum flavum thickness was compared between right and left sides, and the data was pooled to form average thickness values. The scout view helped in choosing this image to account for orientation and location. Ligamentum flavum images were captured and enlarged 800% using a bilinear interpolation size conversion algorithm that allowed for enhanced image quality and provided a basis for more accurate measurement [17]. More importantly, few studies exist that examine the possible correlation between ligamentum flavum thickness and other factors such as disc height and grade of disc degeneration. Direct relationships between increasing age, ligamentum flavum thickness and have been insinuated by others working in the field of spine biomechanics. Ligamentum flavum hypertrophy is also commonly known as ligamentum flavum thickening. Partial spinal stenosis is rarely anything of consequence and is actually a completely normal part of aging for the cervical and lumbar spinal regions. Study Design. R01-AT006692-01A1. Lumbar spinal canal stenosis is 1 of the most common spinal disorders in elderly patients. The center slice (at mid-disc level) was selected for subsequent analysis from the axial images at each lumbar level from L1/2 to L5/S1. Everyone accepts the role of ligamentum flavum hypertrophy in the development of symptomatic disease. We believe the medial and lateral measurements provide a better understanding of how ligamentum flavum thickness varies and may affect symptomatology. Competing interests: The authors have declared that no competing interests exist. Ligamentum flavum hypertrophy refers to abnormal thickening of the ligamentum flavum.If severe, it can be associated with central canal stenosis.. Large uniform dorsal disc bulge at L4/5 which coupled with facet joint and ligamentum flavum hypertrophy results in a mild degree of focal canal stenosis here. This is supported by MRI evidence of facet joint degeneration and ligamentum flavum hypertrophy at the L3/4 level, as well as degenerative intervertebral discs at L4/5 and L5/S1 (figure 1). Materials and Methods Sixty-three individuals were part of this IRB-approved study: twenty-seven with chronic low back pain, and thirty-six as asymptomatic. Wrote the paper: AAEO JJM JYBL HSA. Learning points . Tissue inhibitors of matrix metallo-proteinase (TIMPs) are proteinase inhibitors that suppress extracellular matrix degradation. Canal narrowing, in part, results from hypertrophy of the ligamentum flavum. Arrows indicate lateral thickness (LAT) and medial (MED) thickness. The thickness at the L5/S1 level varied by method but was comparatively thicker using the lateral measurement. Ligamentum flavum hypertrophy, also known as ligamentum flavum thickening, is a health condition related to the spine and lower back. Ligamentum flavum thickness of more than 4 mm measured on computed tomography (CT) and magnetic resonance imaging is considered hypertrophy, but causes of hypertrophy and distribution characteristics remain poorly understood. Funding: This work was supported by two National Institutes of Health grants: National Institute for Arthritis and Musculoskeletal and Skin Diseases (www.niams.nih.gov) Grant No. Slipped Disc Statistical significance was achieved at fewer levels than with the medial ligamentum flavum measure, with L1 thickness being significantly less than L3, L4, and L5; and L2 significantly less than L4. I had surgery on my lower back 1 year ago, my MRI Report is saying AT L2-3, there is redemonstration of mild ligamentum flavum hypertrophy and facet arthropathy. Justin J. Munns, A 1.5-T MR (GE Excite 2, GE Healthcare, Milwaukee, WI) unit was used to obtain 3.0 mm-thick axial proton-density images using standard clinical protocol in which the slice orientation is parallel to the endplates at each disc level. Ligamentum flavum hypertrophy is a condition in which the ligamentum flava grows wider and larger and expands toward the central spinal canal.It’s also known as ligamentum flavum thickening. A total of 63 volunteers were enrolled in this study (Rush University Medical Center IRB Approval No. Abnormalities of the disk usually do not cause symptoms of central stenosis in a normal-sized canal. No, Is the Subject Area "Age groups" applicable to this article? Alternative Medicine, Herniated Disc Depression Using the lateral measurement, the order of ligamentum flavum thickness from least to greatest was L1, L2, L5, L3, and L4. At L3-4, there is mild facet arthropathy, the canal and neuroforamina are patent. Ligamentum flavum hypertrophy is a condition in which the ligamentum flavum (LF) thickens due to stresses placed on the spine. Sairyo et al. Yes This patient guide examines the role played by ligamentous inflammation in the posterior spinal canal and its relationship to intervertebral herniation. Yes Summary of Background Data. However, it is still possible that this report may be underpowered to reveal differences that truly exist. The IRB-approved consent documents were signed both by the principal investigator and the subject and a copy was provided to the subjects. This yellow ligament attaches to the inside of the vertebrae, rearward of the central spinal canal. Our objective was compariso n of histological properties of ligamentum flavum in Lumbar spinal ca nal stenosis patients with and without diabetes mellitus. The significance level was α = 0.05. (B) Bilinear interpolation result showing an 800% enlarged image. When examined by lumbar level, the overall trend was an increase in ligamentum flavum thickness by level caudally from L1/2 (labeled L1) to L4/5 (labeled L4). It is also, difficult to standardize and adjacent slices might not be consistent in terms of displaying the appropriate views, especially in the posterior processes. These differences were not significant at L1 and L2 (p = 0.08 and p = 0.06, respectively), however only L3 reached significance at p = 0.04 (Fig 2A). Odd ratio and 95% confidence interval were calculated. This is extremely rare, but is possible and is often not correctly diagnosed until an operation is performed. This paper is to describe percutaneous endoscopy in the treatment of lumbar spinal stenosis secondary to ligamentum flavum hypertrophy targeted and to investigate the efficacy and safety of percutaneous endoscopy in the treatment of this kind of lumbar spinal stenosis in elderly patients. As a control group, 20 ligaments of 10 human corpses were processed in the same way. Hypertrophy of ligamentum flavum (LF) contributes to lumbar spinal stenosis (LSS) and is caused mainly by fibrosis. In (A) the symptomatic medial thickness tended to be larger than in the normal (L1: p = 0.0839, and L2: p = 0.0652, respectively). Previous studies measuring ligamentum flavum thickness have differed in their method of measurement, using either computed tomography (CT) or magnetic resonance (MR) imaging [2, 5, 13–16]. Yes The current study elegantly shows the role of segmental motion, mechanical stress, and angiogenesis in hypertrophy of the ligamentum flavum. PLoS ONE 10(5): At L4-5, there is disc desiccation. Statistical significance varied by measurement method. Yes Here are the symptoms and causes of ligamentum flavum hypertrophy … Medial thickness in grade 3 tended to be larger than that in grade 1 (p = 0.0601). Reasons for exclusion in the low back pain group were prior surgery for back pain, age over 60 years, claustrophobia or other contraindication to MR and CT imaging, severe osteoporosis, severe disc collapse at multiple levels, severe spinal stenosis, destructive process involving the spine, litigation or compensation proceedings, extreme obesity, congenital spine defect, or previous spinal injury. P01-AR48152-10; National Center for Complementary and Alternative Medicine (nccam.nih.gov) Grant No. https://doi.org/10.1371/journal.pone.0128321.g003. The finding that an increase in lateral ligamentum flavum thickness was more significant than medial ligamentum flavum thickness is also notable. Thoracic Discs Yes The MR images at the mid-disc level were captured and enlarged 800% using a bilinear interpolation size conversion algorithm that allowed for enhanced image quality. Previous studies have not agreed upon a uniform method of measuring ligamentum flavum thickness. It … A post hoc analysis was completed to reveal a power of (1-ß) = 0.87. It was found that low back pain subjects had slightly thicker medial ligamentum flavum in the upper lumbar all levels, except at L4 and L5 where thickness was almost equal and no significant differences were found (p = 0.74 and p = 0.32, respectively). Performed the experiments: RT JJM JYBL AAEO. After selection, the MR images were analyzed by custom software written in Visual C++ (Microsoft Foundation Class). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This condition is usually found in patients suffering from a herniated disc, prolapsed disc, extruded disc (or slipped disc) or protruded disc. These differences reached statistical significance (p = 0.0018 and p < 0.0031, respectively, Fig 2B). The authors found the ligamentum flavum to be the primary cause of canal encroachment, with bulging of the ligament leading to 50 to 85% of the reduction in canal area [22]. Citation: Munns JJ, Lee JYB, Espinoza Orías AA, Takatori R, Andersson GBJ, An HS, et al. Purpose To examine ligamentum flavum thickness using magnetic resonance (MR) images to evaluate its association with low back pain symptoms, age, gender, lumbar level, and disc characteristics. Yes Herniated Disc  > Herniated Disc Diagnosis > Ligamentum Flavum Hypertrophy, What is a Herniated Disc? 00042801; study no. Overall, greater medial thickness was found in symptomatic subjects (3.41 ± 0.82 mm) than in asymptomatic subjects (3.16 ± 0.85 mm; p = 0.0098). Even though many studies have shown the significance of ligamentum flavum hypertrophy in patients with spinal stenosis or at the advanced stage of spondylosis, few studies have systematically examined ligamentum flavum thickness and its relation to age and lumbar level at early stages of the degenerative cascade [1, 5, 13–16]. I have seen a few cases in which the ligamentum flavum has become so inflamed or lax that it has actually captured and compressed a nerve root. Lohr M, Hampl JA, Lee JY, Ernestus RI, Deckert M, Stenzel W (2011) Hypertrophy of the lumbar ligamentum flavum is associated with inflammation-related TGF-beta expression. Ligamentum flavum hypertrophy is also known as ligamentum flavum thickening. here. Patient has some other reason for central canal stenosis, such as a significant abnormal spinal curvature or spondylolisthesis condition. The fact that moderate correlation coefficients were obtained between thickness measurements and disc height also shows that loss of disc height might be one of the contributing factors to instability associated with disc degeneration [18, 19] and stenosis. While traditionally the focus of discussion has been on the bulging of the disc leading to compression of the cauda equina, there is growing evidence that identifies ligamentum flavum buckling and hypertrophy as the key pathologic feature of spinal stenosis. Measurement lines were perpendicular to ligamentum flavum length (Fig 1). With redundancy or hypertrophy the ligament is larger and can cause compression on the nerves of … The calcification, the elastic/collagenous fibre ratio as well as the configuration of the fibres were evaluated with an image analyzing computer. Lateral recess stenosis, which is a frequent finding in older patients with lumbar radiculopathy, may have an earlier basis with lateral thickening of the ligamentum flavum and low back pain. Lumbar Discs It can take years before repetitive tr… flavum, along with hypertrophy of the ligamentum flavum, are associated with lumbar spinal stenosis. Primary and secondary efficacy outcome measures achieved statistical superiority in the MILD group compared to the control group. These findings of our study, together with the current literature, support the idea that early changes in the ligamentum flavum may play a key role in chronic low back pain symptoms. This is reasonable, given the close proximity of the lateral measurement to the facet joint, where motion and instability are most appreciable. s? One of the imaging modalities included in the study was MRI to evaluate the quality of the subjects’ intervertebral discs. Although this serves to increase the specificity of our findings, the sensitivity of the study may have been compromised. In our series of 63 subjects, we found ligamentum flavum thickness differs between symptomatic and asymptomatic subjects and increases with higher disc degeneration grade, older age and lower lumbar level. Joe Y. Thickness measurements are associated with disc degeneration grade as shown in Fig 3. Patient has a congenitally narrowed central canal and moderate to advanced spinal degeneration in addition to ligament hypertrophy. Additionally, both measurements were moderately correlated, which was an expected result. Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, United States of America, Current address: Private Practice, Orange, California, United States of America. Yes Die Ligamenta flava sind jeweils zwischen den Wirbelbögen ausgespannt und wurden deshalb früher auch als Ligamenta interarcualia bezeichnet. Intractable Herniated Disc Pain Such stenosis results from ligamentum flavum hypertrophy, inferior articulating process (IAP), facet hypertrophy of the cephalad vertebra, vertebral body osteophytosis, vertebral body compression fractures and herniated nucleus pulposus (HNP). This important observation may lead to more refined and durable … Know the facts about the condition before seeking any drastic treatment option to minimize your chances of falling victim to failed spinal surgery syndrome, since invasive procedures are the usual therapy protocol. Data Availability: The data file is available at public repository Figshare.com. Nozomu Inoue, Current address: Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus, Ohio, United States of America, Affiliation Herniated Disc FAQ Lateral thickness in symptomatic patients (3.14 ± 0.57 mm) was also shown to be significantly greater than that in asymptomatic subjects (2.91 ± 0.70 mm), with p = 0.0019. https://doi.org/10.1371/journal.pone.0128321.t003. It is a degenerative disease which involves the compression of nerves. Lumbar spinal stenosis represents a significant cause of pain and disability in the aging population. Why We do Flexion Exercises For Lumbar canal Stenosis, Facet Joint arthropathy and Ligamentum flavum hypertrophy. Hansson et al. Each subject was screened by the authors for pre-existing lumbar spine pathology and pain episodes in order to classify each subject as asymptomatic or symptomatic. The patient's hypertension and/or unrecognised minor trauma may also have contributed to the pathogenesis of his haematoma. 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