• The Korean Journal of Pain
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• v.27 no.4
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• pp.321-325
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• 2014

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.

• Journal of Korean Neurosurgical Society
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• v.39 no.1
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• pp.75-77
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• 2006

The authors experience a rare case of the cervical radiculomyelopathy due to calcification of ligamentum flavum at the level of C4-6 and report it with review of the literature. A 60-year-old woman was admitted, complaining progressive quariparesis, gait disturbance and neck pain. She had been treated with diabetes mellitus and hypertension for several years. On radiologic study, calcification of ligamentum flavum[CLF] at the C4-6 level was demonstrated on cervical spine CT and MR scan. Decompressive laminectomy of the C 4-6 and removal of CLF were performed. During operation, thecal sac was severely compressed by hypertrophic ligamentum flavum and there were tight adhesion between calcified ligamentum flavum and dura. After the operation, her motor function and neck pain improved and she could walk with an assistant.

• Journal of Korean Neurosurgical Society
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• v.44 no.1
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• pp.47-51
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• 2008

Ligamentum flavum hematoma is a rare condition. Twenty cases including present case have been reported in English-language literature. Among them, only one case reported in pure thoracic spine. A 72-year-old man presented with thoracic myelopathy without precedent cause. Magnetic resonance images revealed a posterior semicircular mass which was located in T7 and T8 level compressing the spinal cord dorsally. T7-8 total laminectomy and extirpation of the mass was performed. One month later following surgery, the patient fully recovered to normal state. Pathologic result was confirmed as ligamentum flavum hematoma. Ligamentum flavum hematoma of rigid thoracic spine is a very rare disease entity. Most reported cases were confined to mobile cervical and lumbar spine. Surgeons should be aware that there seems to be another different pathogenesis other than previously reported cases of mobile cervical and lumbar spine.

• Annals of Clinical Neurophysiology
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• v.10 no.2
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• pp.109-111
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• 2008

Ossification of the ligamentum flavum (OLF) usually occurs in the lower thoracic spine, and is rare in the cervical region. We report the case of a 67-year-old woman who presented a seven month's history of progressive weakness and paresthesia in her right upper extremity. MRI and CT scans of the spine revealed the presence of ossified ligamentum flavum from C3-C4. A cervical laminectomy resulted in a good post-operative improvement of muscle strength.

• Journal of Korean Neurosurgical Society
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• v.49 no.1
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• pp.58-60
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• 2011

Ligamentum flavum hematoma (LFH) is a very rare condition of dural compression; most are observed in the mobile cervical and lumbar spine regions. A 67-year-old man who had a long level interbody fusion at L3-S1 four years ago presented with symptoms suggestive of dural compression. Magnetic resonance imaging showed a posterior semicircular mass located at the adjacent L2-L3 level. After decompression of the spinal canal and removal of the mass lesion, pathological examination of the surgical specimen revealed a hematoma within the ligamentum. The patient fully recovered to normal status after surgery. Here, we report our experience with a LFH in the adjacent segment after a long level fusion procedure and discuss the possible associated mechanisms.

• Annals of Clinical Neurophysiology
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• v.4 no.1
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• pp.67-69
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• 2002

Ossification of the ligamentum flavum(OLF) is not infrequent in the cervical and lumbar regions but is very rare in the thoracic spine. We reported a 62-year-old women with left thoracic intercostal neuralgia due to an OLF. Physical and neurological examination were normal. MRI showed an OLF with compression of the thecal sac in the posterolateral aspect of the T9-T10 level. Laminectomy and removal of the ligament resulted in marked clinical improvement. OLF is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare.

• The Korean Journal of Pain
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• v.25 no.2
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• pp.99-104
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• 2012

Background: Previous studies have shown that if performed without radiographic guidance, the loss of resistance (LOR) technique can result in inaccurate needle placement in up to 30% of lumbar epidural blocks. To date, no study has shown the efficacy of measuring the depth of the posterior complex (ligamentum flavum, epidural space, and posterior dura) ultrasonographically to distinguish true and false LOR. Methods: 40 cervical epidural blocks were performed using the LOR technique and confirmed by epidurograms. Transverse ultrasound images of the C6/7 area were taken before each cervical epidural block, and the distances from the skin to the posterior complex, transverse process, and supraspinous ligament were measured on each ultrasound view. The number of LOR attempts was counted, and the depth of each LOR was measured with a standard ruler. Correlation of false and true positive LOR depth with ultrasonographically measured depth was also statistically analyzed. Results: 76.5% of all cases (26 out of 34) showed false positive LOR. Concordance correlation coefficients between the measured distances on ultrasound (skin to ligamentum flavum) and actual needle depth were 0.8285 on true LOR. Depth of the true positive LOR correlated with height and weight, with a mean of $5.64{\pm}1.06cm$, while the mean depth of the false positive LOR was $4.08{\pm}1.00cm$. Conclusions: Ultrasonographic measurement of the ligamentum flavum depth (or posterior complex) preceding cervical epidural block is beneficial in excluding false LOR and increasing success rates of cervical epidural blocks.

• Investigative Magnetic Resonance Imaging
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• v.22 no.1
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• pp.18-25
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• 2018

Purpose: To investigate the various imaging factors associated with aggravation of lumbar disc herniation (LDH) and develop a scoring system for prediction of LDH aggravation. Materials and Methods: From 2015 to 2017, we retrospectively reviewed the magnetic resonance imaging (MRI) findings of 60 patients (30 patients with aggravated LDH and 30 patients without any altered LDH). Imaging factors for MRI evaluation included the level of LDH, disc degeneration, back muscle atrophy, facet joint degeneration, ligamentum flavum thickness and interspinous ligament degeneration. Flexion-extension difference was measured with simple radiography. The scoring system was analyzed using receiver operating characteristic (ROC) analysis. Results: The aggravated group manifested a higher grade of disc degeneration, back muscle atrophy and facet degeneration than the control group. The ligamentum flavum thickness in the aggravated group was thicker than in the group with unaltered LDH. The summation score was defined as the sum of the grade of disc degeneration, back muscle atrophy and facet joint degeneration. The area under the ROC curve showing the threshold value of the summation score for prediction of aggravation of LDH was 0.832 and the threshold value corresponded to 6.5. Conclusion: Disc degeneration, facet degeneration, back muscle atrophy and ligamentum flavum thickness are important factors in predicting aggravation of LDH and may facilitate the determination of treatment strategy in patients with LDH. The summation score is available as supplemental data.

• Journal of Korean Neurosurgical Society
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• v.29 no.10
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• pp.1377-1382
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• 2000

Ossification of ligamentum flavum(OLF) is a type of ectopic bone formation developed within the spinal ligament. Thoracic myelopathy is common symptom of OLF but radiculopathy is uncommon. We present 3 operated cases of OLF. Two showed myelopathy and one radiculomyelopathy. Main symptoms were motor weakness, sensory disturbance, incoordination of both legs, and back pain. One patient complained of left girdle pain in T4 dermatome. Deep tendon reflex(DTR) was increased in all cases. The diagnosis was made from myelogram, CT and MRI. Sufficient posterior decompressive laminectomy and medial facetectomy were performed. Postoperative diagnosis was comfirmed by histopathological examination. One patient could return to work 3 months after operation and two patients showed satisfactory improvement 2-3 months after operation. Early diagnosis and appropriate surgical treatment were prerequisite of good outcome.

• The Korean Journal of Pain
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• v.22 no.2
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• pp.158-162
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• 2009

Background: The loss of resistance (LOR) method is most commonly used to identify the epidural space. This method is thought to rely on the penetration of the ligamentum flavum. Unfortunately the exact morphology of the ligamentum flavum is variable at different vertebral levels. Especially, it has been pointed out that the lower cervical ligamentum flavum may be discontinuous in the midline in up to 50% of patients. Thus, the LOR method may be inaccurate to confirm the cervical epidural space. The aim of this study is to determine which method is the safest and most exact for confirming the cervical epidural space. Methods: 100 adult, chronic renal failure patients who were undergoing an arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. During the cervical epidural puncture, we identified the cervical epidural space by subjectively feeling the resistance with using a finger just through the ligamentum flavum, and we also used the drip infusion method, the loss of resistance method using air, and the hanging drop method. By using 5 grades, we classified the extent of whether or not the techniques were effective. Results: Using the drip infusion method, we identify the epidural space in all the patients as ＋/＋＋ grade. The catheter insertion method was also successful in identifying those epidural spaces over a ${\pm}$ grade. The pseudo LOR was over ${\pm}$ grade in 47 patients. Conclusions: The combined LOR/hanging drop with drip infusion method is useful for confirming the cervical epidural space.