Radiographic analysis of the correlation between ossification of the nuchal ligament and sagittal alignment and segmental stability of the cervical spine in patients with cervical spondylotic myelopathy

Abstract

Background

Ossification of the nuchal ligament (ONL) caused by chronic injury to the nuchal ligament (NL) is very common in instability-related cervical disorders.

Purpose

To determine possible correlations between ONL, sagittal alignment, and segmental stability of the cervical spine.

Material and Methods

Seventy-three patients with cervical spondylotic myelopathy (CSM) and ONL (ONL group) and 118 patients with CSM only (control group) were recruited. Radiographic data included the characteristics of ONL, sagittal alignment and segmental stability, and ossification of the posterior longitudinal ligament (OPLL). We performed comparisons in terms of radiographic parameters between the ONL and control groups. The correlations between ONL size, cervical sagittal alignment, and segmental stability were analyzed. Multivariate logistic regression was used to identify the independent risk factors of the development of ONL.

Results

C2–C7 sagittal vertical axis (SVA), T1 slope (T1S), T1S minus cervical lordosis (T1S-CL) on the lateral plain, angular displacement (AD), and horizontal displacement (HD) on the dynamic radiograph increased significantly in the ONL group compared with the control group. The size of ONL significantly correlated with C2–C7 SVA, T1S, AD, and HD. The incidence of ONL was higher in patients with OPLL and segmental instability. Cervical instability, sagittal malalignment, and OPLL were independent predictors of the development of ONL through multivariate analysis.

Conclusion

Patients with ONL are more likely to have abnormal sagittal alignment and instability of the cervical spine. Thus, increased awareness and appreciation of this often-overlooked radiographic finding is warranted during diagnosis and treatment of instability-related cervical pathologies and injuries.

Keywords

Ossification of nuchal ligament cervical instability cervical sagittal alignment sagittal vertical axis T1 slope cervical spondylotic myelopathy

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References

Johnson

Zhang

Jones

. The fine connective tissue architecture of the human ligamentum nuchae. Spine 2000; 25: 5–9.

Mercer

Nikolai

. Clinical anatomy of ligamentum nuchae. Clin Anat 2003; 16: 484–493.

Mitchell

Humphreys

O'Sullivan

. Attachments of the ligamentum nuchae to cervical posterior spinal dura and the lateral part of the occipital bone. J Manipulative Physiol Ther 1998; 21: 305–319.

Kadri

Al-Mefty

. Anatomy of the nuchal ligament and its surgical applications. Neurosurgery 2007; 61: 301–304.

Sasai

Saito

Akagi

, et al. Cervical curvature after laminoplasty for spondylotic myelopathy–involvement of yellow ligament, semispinalis cervicis muscle, and nuchal ligament. J Spinal Disord 2000; 13: 26–30.

Shingyouchi

Nagahama

Niida

. Ligamentous ossification of the cervical spine in the late middle-aged Japanese men. Its relation to body mass index and glucose metabolism. Spine 1996; 21: 2474–2478.

Tsai

Weng

Chen

, et al. Correlation between the ossification of nuchal ligament and clinical cervical disorders. Kaohsiung J Med Sci 2012; 28: 538–544.

Luo

Wei

. Clinical significance of nuchal ligament calcification and the discussion on biomechanics. Zhongguo Gu Shang 2010; 23: 305–307.

Chazal

Tanguy

Bourges

, et al. Biomechanical properties of spinal ligaments and a histological study of the supraspinal ligament in traction. J Biomech 1985; 18: 167–176.

10.

Takeshita

Peterson

Bylski-Austrow

, et al. The nuchal ligament restrains cervical spine flexion. Spine 2004; 29: 388–393.

11.

Ferguson

Caplan

. Cervical spondylitic myelopathy. Neurol Clin 1985; 3: 373–382.

12.

Wang

Shi

, et al. Cervical intervertebral disc degeneration induced by unbalanced dynamic and static forces: A novel in vivo rat model. Spine 2006; 31: 1532–1538.

13.

Scapinelli

. Sesamoid bones in the ligamentum nuchae of man. J Anat 1963; 97: 417–422.

14.

Scapinelli

. Localized ossifications in the supraspinous and interspinous ligaments of adult man. Rays 1988; 13: 29–33.

15.

Scheer

Tang

Smith

, et al. Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine 2013; 19: 141–159.

16.

Jun

Kim

Ahn

, et al. T1 slope and degenerative cervical spondylolisthesis. Spine 2015; 40: 220–226.

17.

Tang

Scheer

Smith

, et al. The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 2012; 71: 669.

18.

Ames

Blondel

Scheer

, et al. Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine 2013; 38: 149–160.

19.

Knott

Mardjetko

Techy

. The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. Spine J 2010; 10: 994–998.

20.

Harrison

Cailliet

, et al. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine 2000; 25: 2072–2078.

21.

Shi

Jia

, et al. Clinical characteristic and radiology measurement on degenerative lower cervical instability. Chinese Journal of Spine and Spinal Cord 1998; 8: 255–257.

22.

Wang

Zou

Jiang

, et al. Analysis of radiography findings of ossification of nuchal ligament of cervical spine in patients with cervical spondylosis. Spine 2014; 39: E7–11.

23.

Martins

Nastri

. Interpreting reproducibility results for ultrasound measurements. Ultrasound Obstet Gynecol 2014; 43: 479–480.

24.

Ohtsuka

Terayama

Yanagihara

, et al. A radiological population study on the ossification of the posterior longitudinal ligament in the spine. Foresight 1987; 106: 89–93.

25.

Fujimori

, et al. Ossification of the posterior longitudinal ligament of the cervical spine in 3161 patients: a CT-based study. Spine 2015; 40: E394–403.

26.

Lee

Son

Seo

, et al. Factors determining cervical spine sagittal balance in asymptomatic adults: correlation with spinopelvic balance and thoracic inletalignment. Spine J 2015; 15: 705–712.

27.

Hyun

Kim

Jahng

, et al. Clinical impact of T1 slope minus cervical lordosis after multilevel posterior cervical fusion surgery: a minimum 2-year follow up data. Spine 2017; 42: 1859–1864.

28.

Hyun

Kim

Jahng

, et al. Relationship between T1 slope and cervical alignment following multi-level posterior cervical fusion surgery: Impact of T1 slope minus cervical lordosis. Spine 2016; 41: E396–402.

29.

Smith

Lafage

Ryan

, et al. Association of myelopathy scores with cervical sagittal balance and normalized spinal cord volume: analysis of 56 preoperative cases from the AOSpine North America Myelopathy study. Spine 2013; 38: 161–170.

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