One of the more critical ligaments in your spine is generally unknown for most patients. That’s despite being responsible for causing lots of back pain and general havoc. That structure is called the ligamentum flavum. Let’s dig in.
Ligaments and the Spine
If we had to hold a competition between different spinal structures like discs, vertebra (spinal bones), nerves, muscles, facet joints, and ligaments—you could make a credible argument that the ligaments are some of the most important structures. However, when’s the last time you read an MRI report that even commented on the status of the ligaments? You see lots of things talked about in those reports like disc bulges, facet joints, nerves, etc…. Ligaments just usually don’t make the list. Why?
The Ligamentum Flavum
In medicine, like law, we physicians love to use Latin. Why? It makes sure we can use big words that patients won’t understand. Such is the case with the term, “ligamentum flavum”. That bit of ancient Greek and Roman Latin means “yellow ligament”. Now we could just say yellow ligament and that would be easier, but then you would know what we’re talking about!
This ligament is in fact yellow and lives in the very back of the spinal canal. Before we get into what it does, you may want to watch the video above if you haven’t done that yet. For example, it’s important to know that the spinal canal is where the spinal cord and spinal nerves live and is created by the holes in the vertebrae that stack one on the other.
Central Canal Stenosis
In medicine, the word stenosis means less room in a canal where something traverses. That could be an artery or a vein or in the spine, the term usually refers to the spinal or foraminal canals. Here we’re discussing the main spinal canal that goes up and down through the vertebrae, also called the “central canal”.
In central canal stenosis, this area gets too small. We’ll discuss this area in terms of the low back today, as it’s often easier to see the structures in that area. In this case, there are a number of structures that can impinge on this canal and make it smaller.
As you can see, the disc bulging from the front or the facet joints from the backside (also called facet hypertrophy) can make the spinal canal stenotic (smaller). In the same way, the ligamentum flavum from the backside can get bigger and cause the canal to be smaller as well.
Ligamentum Flavum Hypertrophy
All ligaments or tendons that get overworked and can’t completely heal themselves get bigger, which in medicine we call hypertrophy. That happens because a dense ligament is young and strong, but when your body can no longer completely heal the ligament, it keeps throwing new weaker tissue at the area. On the one hand, weaker tissue reduces the likelihood that the ligament will ultimately fail and tear, but on the other, that ligament now takes up much more space.
The ligamentum flavum also hypertrophies, usually because of degenerative instability. That means it gets beat up by the extra movement between the vertebra caused by loose ligaments and disc collapse. Now ordinarily that wouldn’t be a problem but remember this ligament lives in the spinal canal and the spinal nerves run through that canal. Hence a smaller canal means that these nerves get crunched.
Patients with central canal stenosis due to an enlarged ligamentum flavum love low back flexion. In fact, there’s something called a “shopping cart sign” where they can walk through a grocery store without pain or leg symptoms if they lean forward a bit on a shopping cart.
How Do You Fix This?
The traditional way that central canal stenosis has been handled has been surgical. Basically, a big back surgery (wide laminectomy/discectomy) to open up the canal by taking out the disc bulge, removing the inside of the facet bones and lamina (back of the spinal canal), and then cutting out the ligamentum flavum. While this generally works to allow more room for the spinal nerves and reduce symptoms, removing all of that stuff often leads to more instability. That can then lead to the disc bulging again and the facets getting more arthritis and the cycle repeats. Because of that problem, surgeons these days often add fusion, which is where the spine is bolted together. However, that can then lead to the adjacent segments above and below getting too much wear and tear and breaking down (called adjacent segment disease).
Can This Problem Be Helped Without Surgery?
I will describe the interventional OrthoBiologics procedure we use to help central canal stenosis and degenerative disc disease. In addition to injecting your platelet-based products into the ligaments, around nerves (epidural), into arthritic facets, and into atrophied muscles, we can also directly inject the ligamentum flavum. Why? The goal is to get it smaller and denser by promoting repair within the ligament. We don’t need a huge amount of room, just a few millimeters less buckling when the person stands, and that can make a huge difference in standing and walking tolerance.
The upshot? Now you know about the yellow ligament that lives in the back of the spinal canal that can cause so much misery for so many people. Our first goal should always be to keep the ligaments and all of your other critical parts and pieces and thus avoid surgery. We can usually do that with our platelet based DDD procedure!
MILD procedure
A minimally invasive lumbar decompression procedure is an innovative approach for effectively treating Ligamentum Flavum-related issues in the lower back. This advanced surgical technique aims to alleviate pressure on the spinal nerves by gently removing excess ligamentum flavum tissue. Unlike traditional open surgeries, this method involves smaller incisions, reduced scarring, and quicker recovery times, making it a preferred choice for many patients seeking relief from back pain and discomfort associated with ligamentum flavum problems.
Conclusion
In conclusion, the ligamentum flavum, or the yellow ligament, is a crucial but often overlooked component of the spine. It plays a significant role in conditions like central canal stenosis, which can cause severe back pain and nerve-related symptoms. While surgery has traditionally been the go-to solution, alternative approaches like interventional OrthoBiologics offer hope for patients without the need for extensive surgery.
FAQs
1. What is the function of the ligamentum flavum?
The ligamentum flavum, or yellow ligament, helps facilitate motion between the vertebrae and keeps them aligned, particularly allowing for bending forward or flexion.
2. What is central canal stenosis?
Central canal stenosis refers to the narrowing of the spinal canal, which can lead to impingement on the spinal nerves and cause various symptoms, including back pain and numbness.
3. How does ligamentum flavum hypertrophy occur?
Ligamentum flavum hypertrophy happens when the ligament undergoes structural changes due to overuse and degenerative instability, leading to it getting larger and potentially causing spinal canal compression.
4. Can central canal stenosis be treated without surgery?
Yes, alternative treatments like interventional OrthoBiologics can help reduce the symptoms of central canal stenosis by promoting repair within the ligamentum flavum, thus avoiding extensive surgery.
5. What is the primary goal in addressing spine-related issues?
The primary goal in managing spine-related problems should be to preserve the integrity of critical spinal structures, including ligaments, and explore non-surgical options before considering surgical interventions.
