Cervical spine ligamentum flavum gaps: MR characterisation and implications for interlaminar epidural injection therapy

Reg Anesth Pain Med. 2022 Aug;47(8):459-463. doi: 10.1136/rapm-2022-103552. Epub 2022 May 17.


Background: Cervical epidural steroid injections are commonly performed to manage pain from cervical spine disease. Cadaveric studies have demonstrated incomplete ligamentum flavum fusion in the central interlaminar region with resultant midline gaps. We performed an MR-based characterization of cervical ligamentum flavum midline gaps to improve understanding of their prevalence and guide interventionalists in procedural planning.

Methods: Fifty patients were retrospectively reviewed following institutional review board approval. Axial T2-weighted spinecho sequences were used to evaluate ligamentum flavum integrity at the interlaminar spaces of C5-C6, C6-C7 and C7-T1. Interlaminar spaces were further subdivided into superior, middle, and inferior portions, yielding 150 interlaminar regions characterized from C5 to T1. Subsequently, a novel categorization of gap morphology was performed, highlighting gap morphology (anterior, posterior, full, or no gap).

Results: Full gaps of the ligamentum flavum, with direct epidural space exposure, were observed with variable prevalence at all three levels evaluated. The highest incidence of full ligamentum flavum gaps were observed at C7-T1, occurring in 71.4% of patients at both its middle and inferior portions. The inferior aspect of C5-C6 demonstrated the lowest observed rates of full ligamentum flavum gap (2%).

Conclusions: Ligamentum flavum gaps occur in the lower cervical spine at high rates, with the highest prevalence of full thickness ligamentum flavum gaps at C7-T1. Interventionists must be aware of these important normal variants and evaluate preprocedural MRI to plan interventions.

Keywords: Back Pain; Injections, Spinal; Neck Pain; Nerve Block; Pain Management.

MeSH terms

  • Cervical Vertebrae / diagnostic imaging
  • Epidural Space / diagnostic imaging
  • Humans
  • Injections, Epidural
  • Ligamentum Flavum* / diagnostic imaging
  • Magnetic Resonance Imaging
  • Retrospective Studies