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Cervical spine ligamentum flavum gaps: MR characterisation and implications for interlaminar epidural injection therapy
  1. Jatin Joshi1,
  2. Michelle Roytman2,
  3. Rohit Aiyer3,
  4. Elizabeth Mauer4 and
  5. J. Levi Chazen5
  1. 1Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
  2. 2Department of Radiology, Weill Cornell Medicine, New York, New York, USA
  3. 3Richmond Interventional Pain Management, Staten Island, New York, USA
  4. 4Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA
  5. 5Department of Radiology, Hospital for Special Surgery, New York, New York, USA
  1. Correspondence to Dr Jatin Joshi, Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA; jhj9003{at}


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.

  • Injections, Spinal
  • Neck Pain
  • Pain Management
  • Nerve Block
  • Back Pain

Data availability statement

Data are available on reasonable request.

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Data availability statement

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  • Contributors JJ, JLC devised the project, the main conceptual ideas and conducted the MR analysis. EM performed the statistical analysis of the project. JJ, JLC, RA and MR contributed in table, figure and manuscript preparation. JJ and JLC act as guarantors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.