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Anterior Longitudinal Ligament: The Cause of Your Neck Pain

The neck pain is unrelenting, and all started after being rear ended at a stoplight. Spine X-rays demonstrated some abnormal movement of the Spinal bones.  Both conservative care and medications have failed.  Your doctor thinks you have injured a Spinal ligament.  What is the Anterior Longitudinal Ligament?  What is the role of the Anterior Longitudinal Ligament?  What ligaments are injured in a Whiplash type accident?   Are there different types of ligament injuries? What happens if the Anterior Longitudinal Ligament is injured? Does MRI show ligament injuries?  Can Spinal ligaments heal and what are the limitations?  What are the treatment options for injuries to the Anterior Longitudinal Ligament?  Let’s dig in. 

What Is the Anterior Longitudinal Ligament (ALL)?

A ligament is a thick piece of connective tissue that connects bone to bone. Think of it as duct tape that holds bones together.  The Anterior Longitudinal Ligament (ALL) is an important ligament located in the front of the neck.  It starts at the base of the skull and extends down across the Cervical, Thoracic and Lumbar Spine ending at the Sacrum.  It is approximately one inch is width and has three layers:  superficial, intermediate and deep.  

What Is the Role of the Anterior Longitudinal Ligament? 

To understand the role of the role of the ALL it is important to review some spinal anatomy.  The Spine is composed of boney building blocks that stack on upon another. In the Cervical Spine there are 7 boney building blocks.  Sandwiched between each of the building blocks is a sponey shock absorber called a Disc.  At each level of the Spine, Nerves exit through a boney doorway called the Neuroforamen.  The Anterior Longitudinal Ligament covers the front portion of the Spine.  It covers both the boney building block and the Disc.

The Anterior Longitudinal Ligament has 3 important roles:

  • Stabilizes the Spine
  • Limits motion
  • Confines, supports, and reinforces the anterior wall of the Disc 

Which Ligaments Are Injured in Whiplash Type Accident?

Whiplash is a neck injury due to forceful, rapid back-and-forth whipping motion of the head and neck.  Whiplash can also be described as “an acceleration-deceleration mechanism of energy to the neck” (1). The incidence of Whiplash injuries varies greatly between different parts of the world.  For example, in Quebec Canada incidence is as high as 70 per 100,000 (2).  It is estimated that there are 1,000,000 cases of Whiplash per year in the United States. Injuries can be significant and long lasting. Approximately 50% of Whiplash patients  have reported chronic neck pain 15 years after the trauma (3).

Whiplash trauma can cause injury to multiple Spinal structures and ligaments, Facet joints, Discs, Muscles, Tendons and Nerves. The Anterior Longitudinal Ligament is particularly susceptible to injury due to the rapid back and forth whipping motion of the neck (4). 

Are there Different Types of Anterior Longitudinal Ligament Tears? 

Absolutely!  Various types of trauma including motor vehicle accidents that can cause injury to the Anterior Longitudinal Ligament.  Ligament injuries are classified into three grades.

Grade 1 sprain:  Mild and includes slight stretching of the fibers and partial tear of the ligament..

Grad 2 sprain: More severe and involves a full thickness partial tear but the ligament is still intact.

Grade 3 sprain: Most severe and involves the entire ligament.  The two edges of the ligament are pulled apart.  This is otherwise known as a rupture. 

What Happens if the Anterior Longitudinal Ligament is Injured?

The Anterior Longitudinal Ligament provides critical support to the Spine and Discs.  Injury to the ALL can cause the following:

Spinal instability:  Movement of one or more of the Vertebral Bodies (boney building blocks).  This is referred to as Listhesis. 

Loss of support and reinforcement of the Disc making the Disc vulnerable to injury including Disc Protrusion and Herniation.

Disc Injury:  Movement of the Vertebral bodies creates a shearing force on the Disc creating irritation and injury

Nerve Injury: Movement of one or more Vertebral Bodies can also irritate exiting nerve roots causing radiating extremity pain.

Spinal Stenosis: Movement of one or more Vertebral Bodies can narrow the Spinal Canal

Injury to the ALL can cause irritation or injury to the Nerves within the Longitudinal Ligament resulting in pain and restriction in range of motion.

ALL Injury can also lead to bone formation within the ligament causing pain and dysfunction.

Does an MRI Show Ligament Injury?

Yes!  MRI is an effective radiographic study to evaluate injuries to the Cervical ligaments which include the Anterior Longitudinal Ligament (5).   Common findings include blood or swelling adjacent the ligament tear.  In addition, there may be movement of the boney building blocks in the Spine such that one or more move backwards in relationship to the others.  This is called Retrolisthesis. 

Can Spinal Ligaments Heal?

 Ligament healing is an extensive 3 phase process that takes months.  If a given ligament is allowed sufficient time to heal and is supported during the healing phase many Grade 1 injuries can heal.  The problem with Spinal ligament injuries is twofold: 

Patients rarely allow sufficient time to heal which requires significant activity modification for months.  

External bracing is not a practical option.  Unlike a knee or ligament injury where a knee or ankle brace can be applied, external Spinal braces are rarely used and poorly tolerated by most patients.  

Treatment Options for Anterior Longitudinal Ligament Injuries

At the Centeno-Schultz Clinic treatment of Spinal ligaments is a central portion of our philosophy and treatment protocol.  We view the Spine as a collection of many parts working in a synchronized fashion. This approach is known as the Functional Spinal Unit (FSU) and is radically different from the approach used in most pain clinic which focus on one or more “Pain Generators”. To learn more about this approach please click here

Anterior Longitudinal Ligament injuries have been successfully treated using precise ultrasound and x-ray guided injections.  Blind injections, those without guidance are below the standard of care and put the patient at risk for Nerve, Disc and blood vessel injury.

Dr. John PItts was instrumental in developing this injection technique.  An intimate working knowledge of the Spinal anatomy along with years of x-ray and ultrasound guided injections allowed for him to develop and refine this injection.  We have all mastered this injection.  It is a complex, highly skilled injection that you family doctor or orthopedic surgeon cannot perform.  Below is x-ray image of my recent Anterior Longitudinal Ligament injection.  

Healing of ligaments following PRP or Bone Marrow Concentrate injections which contain stem cells take time.  There are three distinct phases: inflammatory, proliferative and tissue remodeling.  To learn more about ligament healing click on video below.

In Summary

  • The Anterior Longitudinal Ligament is a small ligament in the front of your neck.  It starts at the base of the Skull and extends into the Sacrum.
  • The Anterior Longitudinal Ligament has three important roles:  stabilization, limits movement and supports the front wall of the discs. 
  • Whiplash type traumas can cause injury to multiple structures in the spine including the Anterior Longitudinal Ligament.
  • Ligament injuries are graded based on the severity of the injury:  Grade 1, Grade 2 and Grade 3.
  • Injury of the Anterior Longitudinal Ligament can result in Spinal Instability, Spinal Stenosis and injury to the Discs, Nerves and Facet joints. 
  • MRI is an effective radiographic imaging technique to identify ligamental injury.
  • Most Grade 1 and some Grade 2 injuries can heal on their own if allowed to.  Unfortunately, effective bracing of the spine of prolonged periods is rarely tolerated.
  • At the Centeno-Schultz Clinic we have pioneered a procedure where the Anterior Longitudinal Ligament injures can be treated with precisely guided injections of PRP or Bone Marrow Concentrate. 

If you or a loved one has sustained trauma to the spine and has not responded to conservative therapy please schedule a telemedicine consultation. Ligament injuries are quite common and often times missed leading to Spinal Instability, and injury to the Discs, Facets and Nerves.  Stop the suffering and learn from a board certified, fellowship trained physician what your Regenerative treatment options are today.

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2.Rosenfeld M, Seferiadis A, Gunnarsson R. Active involvement and intervention in patients exposed to whiplash trauma in automobile crashes reduces costs: a randomized, controlled clinical trial and health economic evaluation. Spine (Phila Pa 1976). 2006 Jul 15;31(16):1799-804. doi: 10.1097/01.brs.0000225975.12978.6c. Erratum in: Spine (Phila Pa 1976). 2012 Nov 15;37(24):E1537- 40. PMID: 16845354.

3.Squires B, Gargan MF, Bannister GC. Soft-tissue injuries of the cervical spine. 15-year follow-up. J Bone Joint Surg Br. 1996 Nov;78(6):955-7. doi: 10.1302/0301-620x78b6.1267. PMID: 8951014.

4.Stemper BD, Yoganandan N, Pintar FA, Rao RD. Anterior longitudinal ligament injuries in whiplash may lead to cervical instability. Med Eng Phys. 2006 Jul;28(6):515-24. doi: 10.1016/j.medengphy.2005.09.011. Epub 2005 Nov 10. PMID: 16289824.

5.Katzberg RW, Benedetti PF, Drake CM, Ivanovic M, Levine RA, Beatty CS, Nemzek WR, McFall RA, Ontell FK, Bishop DM, Poirier VC, Chong BW. Acute cervical spine injuries: prospective MR imaging assessment at a level 1 trauma center. Radiology. 1999 Oct;213(1):203-12. doi: 10.1148/radiology.213.1.r99oc40203. PMID: 10540663.