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Left lateral view of dissection of the 4th and 5th thoracic spinal nerves (5, 6) and intervertebral discs (d). The superior extraforaminal ligament attachments (ELAs) sometimes consist of two or three parts, passing the spinal nerves laterally. T 5,6 4th and 5th thoracic vertebra, c 5,6 5th and 6th costa, iim internal intercostals membrane
Source publication
An anatomical study of the extraforaminal attachments of the thoracic spinal nerves was performed using human spinal columns. The objectives of the study are to identify and describe the existence of ligamentous structures at each thoracic level that attach spinal nerves to structures at the extraforaminal region. During the last 120 years, several...
Context in source publication
Context 1
... the 2nd till the 9th thoracic spinal nerves, the superior ELAs show variations. These ligaments consist of one, two or three parts (Table 1). However, in one speci- men, the most ventral part of the superior ligament on the 6th, 7th and 8th level on the left side is not attached to the spinal nerve (Fig. 4). The 11th thoracic spinal nerve is caudally attached to the capsule of the costovertebral joint and the intervertebral foramen and dorsally to the iim (Fig. 3). These ligaments are attached to the nerve caudally and laterally along the entire width of the spinal nerve. Table 1 shows the variations in amount of ligaments on the thoracic level from the 2nd till the 11th thoracic level. Table 2 shows length and width of the ELAs and the angle between the extraforaminal ligament and the spinal nerve. In all specimens, from the 2nd till 9th thoracic level, the superior and inferior ligaments run from craniolateral to caudomedial forming a positive angle (Fig. ...
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Citations
... Pain associated with Kummell's disease is complex. However, the specific mechanisms responsible are unknown, and the following confounding factors might influence the choice of management: abnormal biomechanics and an excessive load on facet joints after fracture, irritation of nerve roots caused by the reduction in vertebral height, articular process, distortion and edema of foraminal ligaments, stimulation of the superior thalamus, and excitation of sympathetic pathways and adjacent short neural circuits as a result of the accumulation of mediators [12][13][14][15][16]. Data from real-world clinical practice have revealed that the manifestation of pain tends to be much more diverse. ...
Background:
Neuralgia is frequently noted in patients with Kummell's disease, and its mechanism is complex, rendering it challenging to treat. Percutaneous kyphoplasty (PKP) has been widely used to treat osteoporotic vertebral compression fractures with satisfactory outcomes. However, it is not optimal for managing severely collapsed vertebrae, as cement injection may not be feasible. This report describes the use of a selective nerve block for the treatment of neuralgia caused by severely collapsed vertebrae in a patient with Kummell's disease.
Case summary:
In our patient, three vertebrae were involved. The collapse of T11 was particularly severe. After managing T8 and T9 using PKP, these two segments were effectively strengthened; consequently, back pain was significantly relieved. However, the structure and strength of T11 could not be effectively restored using a minimally invasive surgical method because there was little room for cement injection. This caused obvious neuralgia according to the postoperative status of the PKP. Thus, we performed selective nerve blocks for the treatment of neuralgia, which resulted in satisfactory outcomes.
Conclusion:
Selective nerve block may be a possible therapeutic strategy for neuralgia due to severely collapsed vertebrae in Kummell's disease.
... Superior costotransverse ligaments are found just dorsal to the thoracic paravertebral space and connect the upper border of the neck of the rib of the inferior vertebra to the anterior and inferior aspect of the transverse process of the vertebra above [29]. Although they are composed of fibrous bands, recent literature suggests that they may be fenestrated thereby permitting (in theory) diffusion of LA molecules [30,31]. ...
Study objective
This narrative review discusses the anatomy, mechanism of action, techniques, pharmacology, indications, complications and substitutes for erector spinae plane (ESP) blocks.
Interventions
The Medline, Embase and Google Scholar databases (inception-last week of April 2020) were searched. For indications and alternative blocks, a systematic analysis of the available evidence was carried out. In order to highlight the best evidence available, only randomized trials with prospective registration, blinded assessment and sample size justification were retained for analysis.
Main results
The collective body of anatomical studies suggests that ESP block may work through a combination of different mechanisms (e.g., local anesthetic spread to the thoracic paravertebral space, epidural space, and dorsal ramus). Compared to control, the available evidence suggests that ESP block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal surgical interventions. Erector spinae plane blocks and thoracic paravertebral blocks seem to provide comparable benefits for thoracoscopic and breast cancer surgery when performed with a similar number of injections. Currently, ESP blocks should be favored over intercostal blocks since, at best, the latter provide similar analgesia to ESP blocks despite requiring multiple-level injections.
Conclusions
In recent years, ESP blocks have become the topic of considerable clinical interest. Future trials are required to investigate their optimal technique, dose of local anesthetic and perineural adjuvants. Moreover, additional investigation should compare ESP blocks with robust multimodal analgesic regimens as well as truncal blocks such as thoracic epidural block, midpoint transverse process to pleura block, PECS block, quadratus lumborum block, and transversus abdominis plane block.
... Superior costotransverse ligaments are found just dorsal to the thoracic paravertebral space and connect the upper border of the neck of the rib of the inferior vertebra to the anterior and inferior aspect of the transverse process of the vertebra above [29]. Although they are composed of fibrous bands, recent literature suggests that they may be fenestrated thereby permitting (in theory) diffusion of LA molecules [30,31]. ...
... 7 8 The costovertebral ligaments are innervated by the lateral branch of the thoracic dorsal rami of C8 and Th1-Th11, and some studies suggest that these ligaments add a protective mechanism against traction and compression of the nerves by maintaining proper positioning of the nerves in the intervertebral foramen. 9 Since the ligaments often get injured during the dislocation of the costovertebral joints, it is not surprising that neurological damage would occur in a patient with a costovertebral dislocation. There are multiple causes for scapular winging, including iatrogenic, idiopathic and traumatic injuries. ...
Rib fractures due to blunt trauma are a common chest injury seen at the emergency department; however, injuries to the costovertebral joints are very rare. We present a case of a 24-year-old man who was admitted after a high-speed car collision and was assessed in a level 1 trauma centre in Amsterdam. He had multiple injuries, including dislocation of the costovertebral joint of ribs 7–10. After performing a literature search we concluded that patients with traumatic costovertebral joint dislocations have a high incidence of vertebral fractures, neurological deficits and additional fractures. We believe that isolated dislocation of one or multiple costovertebral joint(s) can safely be treated conservatively. Close monitoring of the patients is advisable as these injuries are caused by high impact and are associated with other injuries.
... Together, these FLs center the nerve root in the foramen, reducing friction, and improving blood flow and electrophysiological transmission. [15][16][17][18][19][20][21][35][36][37][38][39] The role of these cervical FLs in holding and maintaining the central position of the nerve roots in their respective foramen and the result of this tethering is highlighted by physiological studies showing a 70% decrease in action potential amplitude with only 6% nerve root strain and complete conduction block at 12% strain. 40 Moreover, blood flow is decreased at 8% strain and intraneural circulation ceases completely at 15%. ...
Background Nerve root tethering upon dorsal spinal cord (SC) migration has been proposed as a potential mechanism for postoperative C5 palsy (C5P). To our knowledge, this is the first study to investigate this relationship by anatomically comparing C5–C6 nerve root translation before and after root untethering by cutting the cervical foraminal ligaments (FL).
Objective The aim of this study is to determine if C5 root untethering through FL cutting results in increased root translation.
Methods Six cadaveric dissections were performed. Nerve roots were exposed via C4–C6 corpectomies and supraclavicular brachial plexus exposure. Pins were inserted into the C5–C6 roots and adjacent foraminal tubercle. Translation was measured as the distance between pins after the SC was dorsally displaced 5 mm before and after FL cutting. Clinical feasibility of FL release was examined by comparing root translation between standard and extended (complete foraminal decompression) foraminotomies. Translation of root levels before and after FL cutting was compared by two-way repeated measures analysis of variance. Statistical significance was set at 0.05.
Results Significantly more nerve root translation was observed if the FL was cut versus not-cut, p = 0.001; no difference was seen between levels, p = 0.33. Performing an extended cervical foraminotomy was technically feasible allowing complete FL release and root untethering, whereas a standard foraminotomy did not.
Conclusion FL tether upper cervical nerve roots in their foramina; cutting these ligaments untethers the root and increases translation suggesting they could be harmful in the context of C5P. Further investigation is required examining the value of root untethering in the context of C5P.
... Among the non-midline back pain, the ribs were the most common site, most of which are considered to be the result of stimulation of the intercostal nerve at the affected vertebral segment [19]. The speci c mechanism underlying the pain is not clear at present, and the possible reasons may be stimulation of the displaced fracture block, decreased vertebral height, and local in ammatory stimulation [19,20]. Such patients after PKP or PVP achieve more rapid relief, but intercostal nerve pain of some patients still exist to different degrees and the residual time also varies. ...
Background: A small but significant proportion of patients experienced residual back pain after PVP or PKP treatment. The aim of the present study was to explore risk factors that may affect residual back pain after PKP or PVP. This study identified the risk factors of residual back pain after PKP or PVP, allowing proper intervention and improved clinical outcome.
Methods: From January 2010 to January 2017, a total of 853 patients were treated by PVP or PKP at The First Affiliated Hospital of Xi’an Jiaotong University. We recorded the Visual Analog Scale (VAS) scores. Patients with a VAS score > 3 post-operatively and at the 1 month follow-up evaluation were grouped into the “residual back pain” group. The others were grouped into the control group. The following possible risk factors were collected: age; gender; weight; bone mineral density (BMD); surgical approach; surgical type; cement distribution; anesthesia; hypertension; diabetes; smoking; alcohol consumption; vertebral fracture type, and vertebral fracture location. Risk factors associated with residual back pain were evaluated using logistic regression analysis.
Results: The incidence of residual back pain after PVP/PKP is 9.61%. Results showed that cement distribution, smoking, vertebral fracture type and vertebral fracture location were independently associated with residual back pain after PVP or PKP in the early post-operative stage.
Conclusion: Unsatisfactory cement distribution, smoking history, osteogenic vertebral tumors, osteolytic vertebral tumors, and thoracic fractures were independently associated with residual back pain after PVP or PKP at the early post-operative stage.
... Among the non-midline back pain, the ribs were the most common site, most of which are considered to be the result of stimulation of the intercostal nerve at the affected vertebral segment [19]. The speci c mechanism underlying the pain is not clear at present, the possible reasons may be the stimulation of the displaced fracture block, decreased vertebral height, and local in ammatory stimulation [19,20]. Such patients after PKP or PVP achieve more rapid relief, but intercostal nerve pain of some patients still exist to different degrees and the residual time also varies. ...
Background: A small but significant proportion of patients experienced residual back pain after PVP or PKP treatment. The aim of the present study was to explore risk factors that may affect residual back pain after PKP or PVP. This study identified the risk factors of residual back pain after PKP or PVP, allowing proper intervention and improved clinical outcome.
Methods: From January 2010 to January 2017, a total of 853 patients were treated by PVP or PKP at The First Affiliated Hospital of Xi’an Jiaotong University. We recorded the Visual Analog Scale (VAS) scores. Patients with a VAS score > 3 post-operatively and at the 1 month follow-up evaluation were grouped into the “residual back pain” group. The others were grouped into the control group. The following possible risk factors were collected: age; gender; weight; bone mineral density (BMD); surgical approach; surgical type; cement distribution; anesthesia; hypertension; diabetes; smoking; alcohol consumption; vertebral fracture type, and vertebral fracture location. Risk factors associated with residual back pain were evaluated using logistic regression analysis.
Results: The incidence of residual back pain after PVP/PKP is 9.61%. Results showed that cement distribution, smoking, vertebral fracture type and vertebral fracture location were independently associated with residual back pain after PVP or PKP in the early post-operative stage.
Conclusion: Unsatisfactory cement distribution, smoking history, osteogenic vertebral tumors, osteolytic vertebral tumors, and thoracic fractures were independently associated with residual back pain after PVP or PKP at the early post-operative stage.
... There have been many researches about the EFL in the lumbar region [2,3,15,18,20,21,23,32]. Recently, some studies about the EFL in the cervical [4,17,19,28] or thoracic [13,16] regions have been conducted. Kraan et al. [15][16][17] investigated the EFLs in the cervical, thoracic, and lumbar segment levels and described the lengths, widths, and angles for all ligaments were similar 1 3 each other. ...
... Recently, some studies about the EFL in the cervical [4,17,19,28] or thoracic [13,16] regions have been conducted. Kraan et al. [15][16][17] investigated the EFLs in the cervical, thoracic, and lumbar segment levels and described the lengths, widths, and angles for all ligaments were similar 1 3 each other. In addition, Kraan et al. [17] focused on the biomechanical functions of the EFL and discussed the EFL in the three segment levels had the similar role to serve as the optimal positioning element of the nerves. ...
... In the thoracic region, the morphology of the superior costotransverse ligament (SCL) has been reported [6,8,10,11,13,16,24]. In general, the SCL is attached to the cranial transverse process and the caudal rib [13] and it is divided into the anterior part of the SCL (ASCL) and the posterior part of the SCL by the posterior ramus of the spinal nerve. ...
PurposeThe current study was conducted to clarify the morphology of the extraforaminal ligament (EFL) at the cervicothoracic junction and to compare the attachment of the EFL and the positional relation between the EFL and the spinal nerves, additionally to clarify the details within the connecting bundles at the cervicothoracic junction. Materials and methodsThe EFLs from the 4th cervical to the 4th thoracic vertebrae were dissected in 56 sides of 28 Japanese cadavers (11 males, 17 females). The range of age was 62.0–99.0 years. In addition, connecting bundles were analyzed by histological examination. ResultsVentral to the spinal nerve, the capsulotransverse ligament (CTL), transforaminal ligament (TFL) and the ligament between the 7th cervical vertebra and the 1st rib were attached to the transverse process and rib. The EFL ventral to the 1st thoracic nerve was not observed in all sides. Dorsal to the spinal nerve, the anterior part of the superior costotransverse ligament (ASCL) and the ligament homologous to the ASCL were attached to the transverse process and rib. The superior radiating ligament (SRL) and the ligament homologous to the SRL were identified. The connecting bundles identified between the 7th cervical and the 1st thoracic nerve were histologically confirmed to consist of nerves and vessels. Conclusions
The EFLs at the cervicothoracic junction were found to be homologous. The connecting bundles were observed between the 7th cervical and the 1st thoracic nerve. Interestingly, the 1st thoracic level alone might be a unique level at the cervicothoracic junction.
... There are very dense attachments named extraforaminal ligaments between the nerve root and transverse process to protect the nerve root from stretching [1-11, 14-21, 24]. It can be presumed that these structures serve a protective function by distributing stresses on the neural structures during movement of the spine and extremities [8,9,[14][15][16][17][18][19][20]24]. However, the authors hypothesize that these ligaments may play a potential role in the entrapment of the nerve root as well as protective functions and have been suggested as a possible source of neuralgia [22,23,26]. ...
... The anatomical configuration of these ligaments suggests that they have a mechanical role in spinal nerve protection due to traction. Kraan et al. [14][15][16][17] and Shi et al. [24] reported that extraforaminal ligaments play an important role in the prevention of damage of the spinal nerve. Grimes et al. [12] and De Peretti et al. [6] described the anatomical relationships and biomechanical properties of the extraforaminal ligaments. ...
Purpose:
The purpose of this study was to elucidate the anatomy and clinical importance of extraforaminal ligaments in the cervical region.
Methods:
This study was performed on eight embalmed cadavers. The existence and types of extraforaminal ligaments were identified. The morphology, quantity, origin, insertion, and orientation of the extraforaminal ligaments in the cervical region were observed.
Results:
Extraforaminal ligaments could be divided into two types: transforaminal ligaments and radiating ligaments. It was observed that during their course, transforaminal ligaments cross the intervertebral foramen ventrally. They usually originate from the anteroinferior margin of the anterior tubercle of the cranial transverse process and insert into the superior margin of the anterior tubercle of the caudal transverse process. The dorsal aspect of the transforaminal ligaments adhere loosely to the spinal nerve sheath. The length, width and thickness of these ligaments increased from the cranial to the caudal direction. A single intervertebral foramen contained at least one transforaminal ligament. A total of 98 ligaments in 96 intervertebral foramina were found. The spinal nerves were extraforaminally attached to neighboring anterior and posterior tubercle of the cervical transverse process by the radiating ligaments. The radiating ligaments consisted of the ventral superior, ventral, ventral inferior, dorsal superior and dorsal inferior radiating ligaments. Radiating ligaments originated from the adjacent transverse processes and inserted into the nerve root sheath. The spinal nerve was held like the hub of a wheel by a series of radiating ligaments. The dorsal ligaments were the thickest. From C2-3 to C6-7 at the cervical spine, radiating ligaments were observed. They developed particularly at the level of the C5-C6 intervertebral foramen.
Conclusions:
This anatomic study may provide a better understanding of the relationship of the extraforaminal ligaments to the cervical nerve root.
... Transforaminal ligaments (TFLs) in the lumbar vertebral region have been described in detail [1][2][3][4][5][6]. Some researchers have reported that TFLs, similar to those in the lumbar vertebral region, also exist in intervertebral foramina (IVFs) in the thoracic vertebral region [3,7]. Very few studies have been conducted on TFLs in cervical IVFs. ...
Purpose:
To evaluate the utility of magnetic resonance three-dimensional fast-imaging employing a steady-state acquisition (MR 3D-FIESTA) sequence to study cervical EFLs using the anatomical results of cadavers as the gold standard.
Methods:
Part I: The cervical regions of five embalmed adult cadavers were scanned using the MR 3D-FIESTA sequence. Ligamentous structures in the intervertebral foramina (IVFs) between C4 and T1 in the MRI scans were identified by a radiologist. Part II: After the specimens were scanned, gross and microscopic anatomical studies were conducted on the IVFs between C4 and T1 in the specimens by an anatomist. Part III: Using the anatomical results of the cadavers as the gold standard, the utility of the MR 3D-FIESTA sequence for imaging cervical EFLs was evaluated. Specificity, sensitivity, positive and negative predictive values (PPV and NPV, respectively) and accuracy were calculated.
Results:
The occurrence rate of transforaminal ligaments (TFLs) in the IVFs between C4 and T1 was 42.5%. The results obtained by the radiologist using the MR 3D-FIESTA sequence to identify TFLs are as follows: specificity 96.2%, sensitivity 76.5%, PPV 92.9%, NPV 86.2%, and accuracy 88.4%.
Conclusion:
MR 3D-FIESTA sequences clearly showed cervical EFLs. In the 3D-FIESTA sequence scans that the radiologist believed to indicate the presence of a cervical TFL, the probability that the TFL existed was approximately 93%. When the radiologist believed that no TFL was present in the 3D-FIESTA sequence scan, the probability that a TFL existed was 14%.
