What is Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening & How is it Treated?

What is Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening?

Ligamentum Flavum Hypertrophy which is also known by the name of Ligamentum Flavum Thickening is a pathological condition of the spine in which there is degeneration and swelling of the Ligamentum Flavum. This condition is quite common for people who have chronic back pain.

In some cases, Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening may also result in spinal stenosis which may contribute further to the pain that an individual suffers due to Ligamentum Flavum Hypertrophy.

Anatomically speaking, the ligamentum flavum is form by thick layer of fibrous tissue which holds the vertebrae together. The ligament flavum is a longitudinal strip of tough fibrous tissue that is spread from neck to sacrum. The ligament flavum lies posterior (behind) spinal cord in spinal canal and attached to lamina bone of vertebral column. The section of Ligamentum Flavum that’s hypertrophied or enlarged protrudes into spinal canal and lies against the spinal cord. Such condition is also known as spinal stenosis.

This may not be a problem for healthy individual with wide spinal canal but it tends to be a problem in individuals who already are dealing with congenital spinal stenosis, fracture of vertebra or spinal stenosis cause by disc bulge or thinning of disc.

There is no clear cut reason as to why the thickening occurs but usually it is seen in individual who have abnormality in the vertebral column that has cause spinal cord injury. The degenerative disease of vertebral column like osteoarthritis causes in few cases hypertrophy of Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening.

What is Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening?

What Causes Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening?

As stated above, there is no clear cause for Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening. Studies have suggested that this condition is normally seen in elderly people who have abnormalities of vertebral column and disc.1Traumatic backinjury following motor vehicle or motor bike injury may cause traumatic hypertrophy of ligamentum flavum.

Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening can also be caused due to normal wear and tear of the spinal cord with age. Animal study suggests stress on back causes hypertrophy of ligamentum flavum.2Such stress may cause hypertrophy of ligamentum flavum in manual worker. The severe symptoms like back pain, tingling, numbness and muscle weakness are observed in patient suffering with abnormal spina column disease like scoliosis.3There are many cases where there is no cause for Ligamentum Flavum Hypertrophy identified and such cases are stated as idiopathic Ligamentum Flavum Hypertrophy.

What are the Symptoms of Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening?

Individuals suffering with Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening and not spinal stenosis may complain of occasional back pain cause by muscle fatigue or spasm. But pain become severe and may be associated with tingling, numbness and muscle weakness when ligamentum flavum hypertrophy causes spinal stenosis or narrowing of spinal canal. This is because the thickening or hypertrophy may cause the already existing spinal condition to get worsened. The symptoms experienced in such cases are usually felt below the affected level of the thickening or hypertrophy. The symptom like pain, tinging, numbness and weakness in muscles are caused because of irritation or pinch of spinal cord and spinal nerve. Spinal cord is either irritated or pinch within spinal canal. Similarly, spinal nerve is pinched in spinal foramina when ligamentum flavum thickens on side and encroaches into spinal foramina on lateral side.

If the individual suffering with asymptomatic spinal stenosis because of enlarged ligamentum flavum also has a herniated disc or has severe degenerative arthritis then the spinal foramina get further smaller and narrower. Such conditions further increases pressure over spinal cord and spinal nerve that aggravates the symptoms of pain and nerve lesion. Such cases may need emergency surgery to prevent permanent nerve damage resulting in permanent numbness and weakness in tissue as well as muscle that is supplied by the injured spinal nerve.

Normal aging causes degeneration of the disc that causes narrowing of spinal foramina, hypertrophy of ligamentum flavum and osteoporosis that may result in fracture of body of vertebra. Such condition associated with ligamentum flavum hypertrophy may cause an injury to the spinal cord and further cause pain and difficulty with movements. Normally individuals who are above age 50 are most predisposed to getting Ligamentum Flavum Hypertrophy.

How is Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening Diagnosed?

The best way to diagnose Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening is by doing an MRI scan of the spine, which will reveal clear thickening of the ligamentum flavum on the images. In some cases, Ligamentum Flavum Hypertrophy is identified when the MRI is being done for other spinal issues like ruling in or out a disc herniation or disc bulge.

How is Ligamentum Flavum Hypertrophy or Ligamentum Flavum Thickening Treated?

The treatment plan depends on severity of pain and presence of associated complains like tingling, numbness and weakness in muscles.

Conservative treatment- Mild to moderate pain is treated with conservative treatment. Conservative treatment does not help if pain is associated with symptoms like tingling, numbness and muscle weakness.

Heat therapy- Mild to moderate pain is treated with heal therapy and stretching of back. Heat treatment is applied over most painful area of back. Heat treatment involves placing of warm wet towel or hot water in rubber bac over the most painful area. During physical therapy infra-red light is used for heat therapy.

Cold therapy-Cold therapy involves application of ice in plastic or rubber bag over most painful area of back.

Stretching and Yoga therapy- The stretching or yoga of back often reduces pain by removing the pressure over the spinal cord. Stretching or yoga therapy is often combined with heat or cold treatment.

Massage therapy– Massage therapy is advised only if pain cause by ligamentum hypertrophy is associated with muscle spasm.

Acupuncture– Acupuncture is yet another alternative treatment for treating Ligamentum Flavum Hypertrophy where the acupuncturist utilizes needles as a means of stimulating certain areas under the skin. There has been some efficacy seen with this form of treatment for Ligamentum Flavum Hypertrophy.

Chiropractic therapy- The chiropractic therapy involves manipulation of back and repositioning of ligaments. Chiropractic manipulation of back may stabilize the spine column and also strengthen the paravertebral muscles. Chiropractic therapy is useful inpatient suffering mild to moderate hypertrophy of ligamentum flavum. People with

Medications-

NSAIDS-Non-steroidal anti-inflammatory drugs are used for mild to moderate pain that may have cause by nerve inflammation. Spinal stenosis caused by ligamentum flavum hypertrophy often causes inflammation of sensory and motor nerve fibers because of irritation or pinch. Such inflammation causes nerve swelling and pain. The NSAIDs treatment helps to reduced nerve swelling and pain. The NSAIDS frequently used are Motrin, Naproxen and Celebrex. Published research data suggests NSAIDs is helpful to relive symptoms in patient suffering spinal stenosis cause by ligamentum flavum hypertrophy.4

Muscle relaxants- Ligamentum hypertrophy causes irritation of motor fibers of spinal nerve that results in muscle spasm. Muscle spasm is treated with muscle relaxants. Most common muscle relaxants used are Flexeril, Soma and Relaxants.

Opioids-Opioids are used for severe pain that is not responding to conservative treatment, NSAIDs and physical therapy. Long term opioid therapy causes dependence and addiction. Opioids are prescribed for severe pain only and medications discontinued after surgery or when pain intensity become tolerable. Opioids prescribed are Vicodin, Lortab, Oxycodone and Morphine.

Physical therapy-

Physical therapy often does not help if pain is severe. Mild to moderate pain is treated with physical therapy and NSAIDs.

Cortisone Injection- Patient suffering with pain, tingling, numbness and weakness in muscles supplied by the nerve that is pinched most often need surgical treatment to prevent permanent nerve damage. In such cases cortisone injection is recommended to diagnosed the nerve that is pinched and also to relieve the symptoms until surgery is schedule. Cortisone injection helps to decrease the nerve swelling and edema of nerve that decreases the symptoms like pain, tingling, numbness and weakness in muscles.

Surgery- Surgery is recommended when all above treatment fails to relieve the symptoms.

Endoscopic surgery- The surgical procedures done for treating Ligamentum Flavum Hypertrophy are usually minimally invasive procedures which require a very small incision through which instruments are inserted along with a camera and the abnormality is treated. Surgery involves removal lamina and part of ligamentum flavum that is compressing the spinal nerve or spinal cord.

Laminectomy- Minor spinal stenosis caused by hypertrophy of ligamentum flavum is treated by single or multiple level partial or complete laminectomy. Partial or complete removal of lamina creates larger space for spinal cord and spinal nerve. The ligamentum flavum bulges outside once lamina is removed that relieves the pressure inside spina canal and helps to take the pressure off the spinal cord and spinal nerve.

Spinal fusion surgery- Severe spinal stenosis causes by large ligamentum flavum hypertrophy is treated with spinal fusion surgery. Spinal fusion surgery involves removal single or multiple level lamina and then adjacent vertebra are fused with metal plate and screw.5Spinal fusion surgery is advised when symptoms like pain, tingling, numbness and weakness of muscles does not respond to all alternative treatment.

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References

  1. Prevalence and Distribution of Incidental Thoracic Disc Herniation, and Thoracic Hypertrophied Ligamentum Flavum in Patients with Back or Leg Pain: A Magnetic Resonance Imaging-Based Cross-Sectional Study.

    Han S1, Jang IT2., World Neurosurg. 2018 Dec;120:e517-e524.

  2. Mechanical stress induces elastic fibre disruption and cartilage matrix increase in ligamentum flavum.

    Hayashi K1, Suzuki A2, Abdullah Ahmadi S1, Terai H1, Yamada K1, Hoshino M1, Toyoda H1, Takahashi S1, Tamai K1, Ohyama S1, Javid A1, Suhrab Rahmani M1, Hasib MM1, Nakamura H1., Sci Rep. 2017 Oct 12;7(1):13092.

  3. Lumbar scoliosis associated with spinal stenosis in idiopathic and degenerative cases.

    Le Huec JC1, Cogniet A2, Mazas S2, Faundez A3., Eur J Orthop Surg Traumatol. 2016 Oct;26(7):705-12.

  4. Clinical outcome of lumbar spinal stenosis based on new classification according to hypertrophied ligamentum flavum.

    Sakai Y1, Ito S2, Hida T3, Ito K3, Harada A2, Watanabe K4., J Orthop Sci. 2017 Jan;22(1):27-33.

  5. Fusion Surgery for Lumbar Spinal Stenosis.

    Peul WC, Moojen WA., N Engl J Med. 2016 Aug 11;375(6):601. doi: 10.1056/NEJMc1606502.

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