ZESPÓŁ WIĘZADŁA PODŁUŻNEGO PRZEDNIEGO – PROBLEM INTERDYSCYPLINARNY
1 Department of Physical Medicine, Institute of Physiotherapy, Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
Introduction: Approximately 1.5-2.5% of all patients treated due to discopathy have anterior longitudinal ligament lesions. An intervertebral disc moving under the anterior longitudinal ligament causes ligament displacement and irritation of the autonomic nervous system structures, resulting in a disturbed function of the organs controlled by this system.
Clinical image: Increased sympathetic system activity in the thoracic section may cause symptoms that mimic coronary heart disease while irritation of the autonomic structures in the lumbosacral section of the spine results in a clinical presentation similar to that of gastrointestinal or gynecological disorders. The clinical image of the most common disorders is presented. The diagnosis may be formulated with the use of magnetic resonance imaging. Treatment: pharmacotherapy is ineffective. Physiotherapy and rehabilitation constitute a method of choice in the treatment of this syndrome.
Wstęp: Chorzy z uszkodzeniem więzadła podłużnego przedniego stanowią 1,5 do 2,5% wszystkich chorych leczonych z powodu dolegliwości spowodowanych choroba krążka międzykręgowego. Przemieszczający się pod więzadło przednie krążek powoduje jego przesunięcie i podrażnienie struktur układu autonomicznego. Zaburzenia układu autonomicznego uwidaczniają się w formie upośledzenia funkcji kontrolowanych przez ten układ narządów. Zwiększona aktywność układu współczulnego w części piersiowej powoduje dolegliwości imitujące chorobę wieńcową. Podrażnienie struktur układu autonomicznego w części lędźwiowo-krzyżowej daje obraz kliniczny mogący odpowiadać schorzeniom przewodu pokarmowego / choroba wrzodowa/ lub kobiecym. Przedstawiono obraz kliniczny najczęściej obserwowanych zaburzeń.
Wnioski: Rezonans magnetyczny jest metodą, która umożliwia ustalenie rozpoznania. Leczenie farmakologiczne jest nieskuteczne. Postępowanie fizykalno- usprawniające jest metodą z wyboru w leczeniu schorzenia.
Wiad Lek 2017, 71, 6 cz. I, 1118-1121
Patients with anterior longitudinal ligament syndrome constitute 1,5−2,5% of all patients treated due to discopathy [1−6]. Two longitudinal ligaments, the anterior and posterior one, run along the vertebral bodies. The anterior longitudinal ligament is a strong wide band covering the anterior surface of the vertebrae. It runs from the base of the skull to the sacrum. It gradually becomes wider and thicker, limiting excessive spinal movements. The posterior longitudinal ligament is a considerably weaker, narrow band that runs on the posterior surface of the vertebral bodies facing the vertebral canal; it stretches during spinal flexion and limits excessive movements. A high load on the spine (both physiological and pathological) results in damage to the annulus fibrosus and displacement of the nucleus pulposus tissue. An intervertebral disc moving under the anterior longitudinal ligament causes ligament displacement and irritation of the autonomic nervous system structures, producing severe pain at the level of the protrusion. At the same time, the patient shows reflex responses of the autonomic system whose sympathetic part is located on the anterior surface of the spine. The autonomic system involves two neurons. The cell bodies of the first neurons are located within the central nervous system while their neurites end in a peripheral ganglion. Long neurons start at the ganglion and end in the tissue of the innervated organ. The preganglionic cell bodies of the sympathetic division lie within the eighth cervical segment, the entire thoracic section and the first three segments of the lumbar spinal cord. Their neural processes exit the spinal cord together with spinal nerves, then extend from the spinal nerves and create white rami communicantes that enter the sympathetic trunk. The thoracic portion of the sympathetic trunk includes 10−12 thoracic ganglia located on the lateral surfaces of the vertebrae and covered with pleura, giving off a number of rami communicantes to the autonomic ganglia located in the chest. Thoracic cardiac nerves branch off from the 2nd, 3rd, 4th and sometimes 5th thoracic ganglion, carrying heart rate increasing fibers to the cardiac plexus and pain fibers from the cardiac plexus. The greater and lesser splanchnic nerve arise from the thoracic part and run to the abdominal cavity and the celiac plexus, carrying fibers that cause vasoconstriction in the digestive tract (Fig. 1). The abdominal part of the sympathetic trunk consists of 3−5 lumbar ganglia. Apart from the rami communicantes, the ganglia of the abdominal sympathetic trunk give off lumbar splanchnic nerves. These are branches running to the renal, aortic, abdominal and the superior hypogastric plexus. The pelvic sympathetic trunk includes 4−5 sacral ganglia. The autonomic nervous system regulates internal organ function and the body’s internal environment and takes part in every internal bodily function. Autonomic system disorders are manifested by impairment of organ functions controlled by this system. Neurogenic dysfunctions are often difficult to distinguish from organic ones. The disorders are very varied and there are still no sufficiently reliable methods of autonomic nervous system assessment [7−10]. Irritation of the sympathetic system by a displaced anterior longitudinal ligament causes increased heartbeat and vasoconstriction. Within the abdominal cavity, stimulation of these fibers relaxes stomach and intestinal walls, decreases peristalsis, increases sphincter tone, inhibits the secretion of digestive juices and causes vasoconstriction. Postganglionic fibers originating from the ganglia of the lumbar sympathetic trunk reach the pelvic organs and lower limbs. Irritation of the sympathetic nervous system at this level of the spine by a displaced anterior longitudinal ligament inhibits peristalsis in the sigmoid colon, contracts the uterine muscles, the internal anal sphincter, prostatic smooth muscles, the seminal vesicles and vasa deferentia, and causes vasoconstriction in the pelvis and lower limbs [11−14].
Patients with anterior longitudinal ligament syndrome mainly complain of uncharacteristic pain of various location, associated with increased activity of the sympathetic system [15, 6]. The autonomic nervous system plays a role in the etiopathogenesis of internal organ diseases, such as coronary heart disease, hypertensive disease, peptic ulcer, asthma and many other disorders [4, 5, 8−14]. Patients with anterior longitudinal ligament syndrome at the thoracic level of the spine usually experience uncharacteristic pain of various location. Diagnostic imaging reveals damage within the anterior longitudinal ligament (Fig. 2A−B). Other disorders associated with increased sympathetic activity need to be ruled out. Increased sympathetic system activity results in vasoconstriction and local ischaemia while abnormal tissue metabolism causes pain.
Irritation of the sympathetic system in the thoracic section causes crushing burning pain in the region of the heart that radiates to the left shoulder and scapula and is accompanied by the feeling of distention in the chest. These complaints are often misinterpreted and prompt doctors to refer their patients for coronary arteriography. Thorough history-taking reveals that the pain does not follow physical exercise, and the concomitant signs help direct the diagnosis.
The patients may complain of epigastric pain radiating to the left, but the pain does not increase after meals and a physical examination does not show local pain on palpation.
Protrusions of the nucleus pulposus under the anterior longitudinal ligament in the abdominal part of the spine result in dull burning pain of various intensity in the middle abdomen. The symptoms are often triggered by a change in position of the body or by spinal rotation. The pain is not accompanied by nausea and a physical examination does not show pain on palpation and abdominal guarding.
Women often experience stabbing pain in the lesser pelvis accompanied by dull diffuse pain in the sacral area that radiates to the urinary bladder, combined with a hypersensitive bladder without association with the menstrual cycle, and hypogastric pain that is difficult to localize and radiates to the sacrum. Sometimes the symptoms reported by the patients are so worrying that an exploratory laparotomy is conducted.
A thorough physical examination and history-taking allow for appropriately targeted diagnostic work-up and treatment. Routine x-rays do not show lesions in the longitudinal ligament, but CT or MRI scans reveal damage within the anterior longitudinal ligament. It is necessary to rule out other disorders associated with increased sympathetic system activity during the diagnostic work-up.
Management of a patient with symptoms of anterior longitudinal ligament syndrome is difficult. The treatment should be aimed first of all at managing pain. Pharmacotherapy is ineffective. The lack of treatment efficacy often results in the pain becoming chronic, which causes deep anxiety and depression [14, 15].
Nonsteroidal anti-inflammatory drugs do not bring relief and sedatives allow for only a slight improvement. Appropriately targeted physical therapy and rehabilitation are a method of choice in the treatment of this syndrome [16−18].
A sympathetic trunk blockade is performed with the use of ultrasound at a dose of 0.6 W/cm2 on the sympathetic trunk ganglia (procedure duration: 6−8 minutes).
Interference current therapy is applied to the lumbosacral spine (frequency: 90−100 Hz, procedure duration: 20 minutes).
Patients with hypogastric pain receive Terapuls treatment (t =60 ms, f =400 Hz, P =500 W – position 2, procedure duration: 20−25 minutes).
Kinesiotherapy is conducted in order to improve the statics of the spine.
1. Anterior longitudinal ligament syndrome is a difficult diagnostic and therapeutic problem.
2. Knowledge of the clinical image of this syndrome will facilitate the work of internal medicine specialists, family physicians, neurologists and other doctors.
3. Physical therapy and rehabilitation are a method of choice in the treatment of this syndrome.
1. Coakley FV, Vive J, Finlay DB, Shannon RS. Childhood ossification of the anterior longitudinal ligament of the cervical spine. Clin Radiol. 1995;50:115-116.
2. Duggal N, Mendiondo I, Pares HR et al. Anterior lumbar interbody fusion for treatment of failed back surgery syndrome: an outcome analysis. Neurosurgery. 2004;54:643-644.
3. Chacko AG, Daniel RT. Multilevel cervical oblique corpectomy in the treatment of ossified posterior longitudinal ligament in the presence of ossified anterior longitudinal ligament. Spine. 2007;32:575-580.
4. Lee SE, Jahng TA, Kim HJ. Correlation between cervical lordosis and adjacent segment pathology after anterior cervical spinal surgery. Eur Spine J. 2015;24:2899-2909.
5. Murayama K, Inoue S, Tachibana T, et al. Ossified posterior longitudinal ligament with massive ossification of the anterior longitudinal ligament causing dysphagia in a diffuse idiopathic skeletal hyperostosis patient. Medicine. 2015;94:1290-1295.
6. Sugimura Y, Miyakoshi N, Kasukawa Y et al. Histological evaluation of symptomatic ossification of the anterior longitudinal ligament treated with etidronate disodium: a case report. J Med Case Rep. 2016;10:320-325.
7. Kim JN, Kwon ST, Ryu KN. Invagination of intra-abdominal structures in the lumbar intervertebral disc space. Skeletal Radiol. 2016;45:1593-1601.
8. Yoshii T, Sakai K, Hirai T et al. Anterior decompression with fusion versus posterior decompression with fusion for massive cervical ossification of the posterior longitudinal ligament with a >50% canal occupying ratio: a multicenter retrospective study. Spine J. 2016;16:1351-1357.
9. Marchi L, Pimenta L, Oliveira L et al. Distance between great vessels and the lumbar spine: MRI study for anterior longitudinal ligament release through a lateral approach. J Neurol Surg A Cent Eur Neurosurg. 2017;78:144-153.
10. Haładyna W, Marciniszyn E, Kuliński W. [Discopathies – a current diagnostic and therapeutic problem]. Acta Balneol. 2011;53:33-137.
11. Taniguchi T, Maejima H, Watarai A et al. A case of psoriasis with diffuse idiopathic skeletal hyperostosis involved with ossifications of posterior and anterior longitudinal ligament. Rheumatol Int. 2012;32:1343-1345.
12. Engstrom J, Martin JB. Disorders of the autonomic nervous system. In: Fauci AS, Braunwald E, Isselbacher KJ et al., eds. Harrison’s Principles of Internal Medicine. New York, Toronto: McGraw-Hill; 1998:2372.
13. Malik M, ed. Clinical guide to cardiac autonomic tests. Dordrecht, London: Kluwer Acad. Publ.; 1998.
14. Schwartzman R, Heckmann K, Maier H. New treatment for reflex sympathetic dystrophy. New Engl J Med. 2000;343:654-659.
15. Prusinski A, Rozentryt P. [Autonomic nervous system disorders]. In: Kozubski W, Liberski PP, eds. [Nervous system disorders]. Warsaw: PZWL; 2004.
16. Kulinski W, Haładyna W, Wilk A. [Assessment of physical therapy in patients with multilevel cervical discopathy after surgical treatment with interbody implants]. Fizjoter Pol. 2010;10:149-155.
17. Kuliński W. [Physiotherapy in spinal pain syndrome – selected aspects]. Kwart Ortop. 2009;3:258-267.
18. Kulinski W. [Physiotherapy]. In: Kwolek A, ed. [Medical rehabilitation]. Wrocław: Elsevier Urban & Partner; 2012:351411.
Address for correspondence:
Division of Physical Medicine, Jan Kochanowski University, Kielce
Fig. 1. Sympathetic division in the thoracic section.
Fig. 2A-B. Examples of damage to the anterior longitudinal ligament.