Cervical Ligament Research Articles

Upper Cervical Ligamentous Disruption in a Patient With Persistent Whiplash Associated Disorders

The patient was a 51-year-old female with persistent pain resulting from 2 rear-end vector motor vehicle accidents 7 years ago (head turned at impact during the second motor vehicle accident). She self-referred to our physical therapy practice with symptoms that included constant neck pain, dizziness/unsteadiness, fatigue, and self-reported anxiety. Active cervical range of movement was also notably reduced and reproduced “clunking” in the upper cervical region. Based on the patient's history and examination findings, the physical therapist was concerned about the possibility of upper cervical ligament damage. It was suggested to her physician that proton-density weighted magnetic resonance imaging be performed. The radiologist's findings led to the commencement of physical therapy aimed at addressing range-of-motion deficits, pain, and motor control of the cervical region. After 4 months, the patient reported feeling less anxious and more stable, with less mechanical clunking, and is now able to engage i...

Fatores de risco não habituais para metástase linfonodal no câncer do colo do útero

To investigate the variables associated with pelvic lymph node metastasis in patients with carcinoma of the uterine cervix at stages IB and IIA.The study was carried out with 289 patients with invasive carcinoma of the uterine cervix (IB and IIA) who underwent radical surgery, admitted to the Gynecology Department of the Treatment and Research Center of the Hospital do Câncer A. C. Camargo, between 1980 and 1999. Data were collected from patient's records and from review of the histological sections from the uterine cervices and the lymph nodes, including sociodemographic data (age at diagnosis, skin color), clinical data (disease stage, preoperative hemoglobin level, body mass index) and histopathological data (histological type, histological grade, blood and/or lymphatic capillary embolization, perineural invasion, depth of tumor invasion into cervical stroma, intensity of inflammatory reaction in the uterine cervix, tumor necrosis, tumor size, invasion of the lateral cervical ligaments and uterine body, and lymph node status). Associations between lymph node metastasis and the different variables were evaluated by means of the chi-square test, Fisher's exact test and multiple logistic regression.Pelvic lymph node metastasis was found in 65 patients (22.5%). The following risk factors for lymph node metastasis were identified by multivariate analysis: hemoglobin level <10.0 g% (OR = 3.6; 95% CI: 1.210.7), tumor invasion of the middle third (OR = 3.3; 95% CI: 1.110.7) and deep third of the uterine cervix (OR = 5.4; 95% CI: 1.717.3), absent or slight inflammatory reaction in the uterine cervix (OR = 2.4; 95% CI: 1.15.2) and keratinizing squamous cell carcinoma (OR = 3.3; 95% CI: 1.47.6).This study identified four risk factors for pelvic lymph node metastasis in patients with carcinoma of the uterine cervix at stages IB and IIA. Of these, three are not usually described in literature as predictive variables for lymph node metastasis (preoperative anemia, absent or slight inflammatory reaction and keratinizing of squamous cell carcinoma).

Proximity of the Lateral Talar Process to the Lateral Stabilizing Ligaments of the Ankle and Subtalar Joint

Fractures of the lateral process of the talus have become more frequent as the sport of snowboarding has gained popularity. The anatomy of the ligamentous attachments to the process has been described, but ligament proximity to the lateral talar process has never been specified. The objective of this cadaver study was to measure the proximity of the lateral talar process to the various lateral stabilizing ligaments of the ankle and subtalar joint: the anterior talofibular ligament, lateral talocalcaneal ligament, posterior talofibular ligament, interosseous ligament, cervical ligament, and lateral root of the extensor retinaculum. After thawing, all musculotendinous structures from 10 fresh-frozen cadaver lower limbs were carefully removed and the distal fibula was reflected to enable adequate exposure of the lateral talar process and ligamentous attachments. The apex of the lateral process was defined. Subsequently, the distance from the apex to the nearest edge and center of these surrounding ligaments was independently measured by two examiners. The average apex-edge distances were 9.3 mm (posterior talofibular); 8.7 mm (anterior talofibular), 3.4 mm (lateral talocalcaneal), 13.9 mm (interosseous), 19.1 mm (cervical), and 13.0 mm (lateral root of extensor retinaculum). The average apex-center distances for those ligaments found to actually insert on the lateral talar process were 18.0 mm (posterior talofibular), 15.7 mm (anterior talofibular), and 6.2 mm (lateral talocalcaneal). Contrary to previous reports, our cadaver dissections identified that only three ligaments attach to the lateral process of the talus: lateral talocalcaneal, anterior talofibular, and posterior talofibular. Familiarity with these anatomic relationships may help guide the clinical treatment of lateral talar process fractures.

Isolated Ligamentous Cervical Spinal Injury in the Polytrauma Patient with a Head Injury

The evaluation of the cervical spine in the unconscious trauma patient is a difficult and controversial topic in trauma management. Conventional cervical clearance protocols consisting of plain radiology and computed tomography may not adequately detect unstable cervical ligament and disc injuries, even though a high-risk mechanism of injury has occurred. We present two cases where cervical clearance protocols, utilising plain X-rays and multi-slice computed tomography, failed to identify significant ligamentous spinal injuries. A delay in diagnosis or a missed spinal injury can lead to delays in treatment, thereby increasing the risk of neurological deterioration with the potential devastating sequela of quadriplegia. Therefore, in the unconscious trauma patient who, by definition, has sustained a high-risk mechanism injury, we routinely recommend the use of magnetic resonance imaging in addition to plain X-rays and computed tomography, to evaluate further discoligamentous status.

The opisthotonic posture of vertebrate skeletons: postmortem contraction or death throes?

An extreme, dorsally hyperextended posture of the spine (opisthotonus), characterized by the skull and neck recurved over the back, and with strong extension of the tail, is observed in many well-preserved, articulated amniote skeletons (birds and other dinosaurs, pterosaurs, and at least placental mammals). Postmortem water transport may explain some cases of spinal curvature in fossil tetrapods, but we show how these can be distinguished from causes of the opisthotonic posture, which is a biotic syndrome. Traditional biotic explanations nearly all involve postmortem causes, and have included rigor mortis, desiccation, and contraction of tendons and ligaments. However, examination of the process of rigor mortis and experimental observations of drying and salinity in carcasses of extant animals show that these explanations of the “dead bird” (opisthotonic) posture account for few or no cases. Differential contraction of cervical ligaments after death also does not produce the opisthotonic posture. It is not postmortem contraction but perimortem muscle spasms resulting from various afflictions of the central nervous system that cause these extreme postures. That is, the opisthotonic posture is the result of “death throes,” not postmortem processes, and individuals so afflicted assumed the posture before death, not afterward. The clinical literature has long recognized that such afflicted individuals perish from asphyxiation, lack of nourishment or essential nutrients, environmental toxins, or viral infections, among other causes. Accepting the actual causes of the opisthotonic posture as perimortem and not postmortem provides insights into the causes of death of fossilized specimens, and also revises interpretations of paleoenvironmental conditions of many fossil deposits. The opisthotonic posture tells us more about the circumstances surrounding death than about what happened after death. Finally, the opisthotonic posture appears to have a phylogenetic signal: it is so far reported entirely in ornithodiran archosaurs (dinosaurs and pterosaurs) and in crown-group placentals, though the distribution in mammals may expand with further study. It seems important that the opisthotonic posture has been observed extensively only in clades of animals that are known or thought to have high basal metabolic rates: hypoxia and related diseases would be most likely to affect animals with high oxygen use rates.

Discrepancies between classic anatomy and modern gynecologic surgery on pelvic connective tissue structure: Harmonization of those concepts by collaborative cadaver dissection

The purpose of this study was to solve a disagreement regarding the anatomy of the pelvic connective tissue in 19th and 20th century, and to establish new surgical anatomy. The study involved the dissection 26 female cadavers. The ligamentous structure of the pelvis was examined by developing the paravesical and pararectal spaces, using our standard procedure of radical hysterectomy. The lateral ligamentous structure of the pelvis was a plate complex, which consisted of the vesicohypogastric fascia, the transverse cervical ligament, and lateral ligament of the rectum. The 3-dimensional relationship of this complex and the pelvic organs was sagittaly perpendicular. The pelvic connective tissue was classified into 2 systems, musculofascial and mesentery-like structures. The authors examined the discrepancies in 19th century anatomy for the pelvic connective tissue that is widely accepted in today's medical field, therewith proposing a new surgical anatomy for this structure.

Cervical Spine Considerations When Anesthetizing Patients with Down Syndrome

It is characterized by mental retardation, as well as craniofacial, upper airway, cardiovascular, and gastrointestinal anomalies. One manifestation of DS relevant to anesthesiologists is upper cervical spine instability produced by ligamentous laxity, skeletal anomalies, or both. This instability can result in neurologic impairment, including quadriplegia. However, there are no evidencebased practical guidelines to aid anesthesiologists in caring for these patients. The risk of spinal cord injury during anesthesia is unknown, as are the preoperative factors that might aid in accurately defining the risk in specific patients. Review of Normal Upper Cervical Spine Anatomy The structures relevant to this discussion include the base of the skull, the atlas (C1), and the axis (C2). The articulations between these structures are complex but are designed to facilitate maximal movement without compressing the spinal cord. The motions are flexion extension and rotation; little lateral bending occurs in this area.

Cervical Spine Ligament Injury during Simulated Frontal Impact

The supraspinous and interspinous ligaments, ligamentum flavum, and capsular and posterior longitudinal ligament strains were monitored during simulated frontal impact of whole cervical spine specimens with muscle force replication and compared with corresponding physiologic strain limits. To quantify the strains in the cervical spine ligaments during simulated frontal impact and investigate injury mechanisms. Clinical and biomechanical studies have documented injuries to cervical spine ligaments during frontal impact. There are no biomechanical studies investigating subfailure injury mechanisms to these ligaments during simulated frontal impacts of increasing severity. The whole cervical spine with muscle force replication model and a bench-top sled were used to simulate frontal impacts at 4, 6, 8, and 10 g horizontal accelerations of the T1 vertebra. The peak ligament strains during frontal impacts were compared with physiologic strain limits determined during intact flexibility testing. Significant increases (P < 0.05) in the supraspinous and interspinous ligaments and the ligamentum flavum strains beyond physiologic limits were observed throughout the cervical spine, with the highest strains occurring at C3-C4. Significant increases were observed in the capsular ligament strains only during the 10 g impact, whereas the posterior longitudinal ligament strains did not exceed physiologic limits. The supraspinous and interspinous ligaments and the ligamentum flavum may be at risk for injury due to excessive strains during frontal impacts.

Traumatic brain injury in children – clinical implications

Traumatic brain injury (TBI) is the leading cause of death in childhood; however only very few studies focusing on the specific pathophysiology and treatment have been published to date. Head trauma is more likely in young children than in adults given the same deceleration of the body due to their large and heavy heads and weak cervical ligaments and muscles. Resulting brain injury is more severe due to their thin, pliable skulls and the yet unfused sutures. Accordingly, children below the age of 4 years have lower chances of a full recovery after severe TBI, although in general, neurologic recovery after severe brain injury in children is better than in adults. The time course of brain injury can be divided into two steps: primary and secondary injury. Primary brain injury exclusively results from the initial impact. In contrast, adverse physiologic conditions during recovery after head trauma may account for additional brain damage, which is then referred to as secondary brain injury. As primary brain injury can only be influenced by preventive measures, all therapeutic efforts during the post-injury period focus on the reduction of secondary injury to the traumatized brain. Several mechanisms have been identified to be involved in the development of post-traumatic secondary brain injury, which render the rationale for the key treatment strategies. Three evidence based measures are of critical importance to prevent or minimize secondary brain injury: (1) avoid hypoxemia, (2) avoid post-traumatic arterial hypotension, and (3) refer the traumatized child to an experienced trauma team at a center that provides the availability of special equipment, e.g. for surgical procedures and airway management, for this age group. For several other therapeutical means, e.g. hypothermia or specific surgical interventions, clinical evidence to date is insufficient to allow recommendation as rescue treatment for children at risk of severe neurological sequelae following TBI. This review discusses the clinical implication of pathophysiologic mechanisms of TBI in the developing brain according to the recent literature and current guidelines. It follows the clinical approach to a head injured child, that can be divided into three phases, i.e. initial assessment and stabilization, followed by first tier, and if necessary second tier therapeutic interventions to assure adequate oxygenation and perfusion of the brain.

Probabilistic design analysis of the influence of material property on the human cervical spine.

Studies reported previously in the literature have described the importance of material variation on the cervical responses and have examined some effects by varying the material properties, but there is no systematic approach using statistical methods to understand the influence of material variation on a cervical spine model under a full range of loading conditions, especially under compression and anterior and posterior shear. A probabilistic design system based on Monte Carlo simulation methods using Latin hypercube sampling techniques is used to analyze the material sensitivity of a C4-C6 cervical spine model involving 13 uncertain input parameters on the biomechanical responses and disc annulus stresses under compression, anterior shear, posterior shear, flexion, extension, lateral bending, and axial rotation. The loading types and range of values were as follows: compression, 0-1 mm; anterior shear, 0-2 mm; posterior shear, 0-3.5 mm; flexion, extension, lateral bending, and axial rotation. 0-1.8 Nm with 73.6-N preload. For each case, the load-deflection and key stress values at various spinal components were captured after each load step. The model was also validated under the same conditions. The minimum and maximum predicted responses were within the range of the experimental data. Ignoring compression loading, the combined effects on the biomechanical responses of the cervical ligaments under the remaining loads are enormous. Their total impacts are almost equal to or slightly less than the influence of disc annulus. Results show that the fiber mechanical properties did not have a significant effect on the compressive stiffness. This study reveals important features that help us identify the critical input parameters and enable us to reduce the development time of a patient-specific biomechanical model.

Development of a finite element model of the upper cervical spine and a parameter study of ligament characteristics.

Numeric techniques were used to study the upper cervical spine. To develop and validate an anatomic detailed finite element model of the ligamentous upper cervical spine and to analyze the effect of material properties of the ligaments on spinal kinematics. Cervical spinal injuries may be prevented with an increased knowledge of spinal behavior and injury mechanisms. The finite element method is tempting to use because stresses and strains in the different tissues can be studied during the course of loading. The authors know of no published results so far of validated finite element models that implement the complex geometry of the upper cervical spine. The finite element model was developed with anatomic detail from computed tomographic images of the occiput to the C3. The ligaments were modeled with nonlinear spring elements. The model was validated for axial rotation, flexion, extension, lateral bending, and tension for 1.5 Nm, 10 Nm, and 1500 N. A material property sensitivity study was conducted for the ligaments. The model correlated with experimental data for all load cases. Moments of 1.5 Nm produced joint rotations of 3 degrees to 23 degrees depending on loading direction. The parameter study confirmed that the mechanical properties of the upper cervical ligaments play an important role in spinal kinematics. The capsular ligaments had the largest impact on spinal kinematics (40% change). The anatomic detailed finite element model of the upper cervical spine realistically simulates the complex kinematics of the craniocervical region. An injury that changes the material characteristics of any spinal ligament will influence the structural behavior of the upper cervical spine.

Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial

Background Cervical lordosis has been shown to be an important outcome of care; however, few conservative methods of rehabilitating sagittal cervical alignment have been reported. Objective To study whether a seated, retracted, extended, and compressed position would cause tension in the anterior cervical ligament, anterior disk, and muscle structures, and thereby restore cervical lordosis or increase the curvature in patients with loss of the cervical lordosis. Study design Nonrandomized, prospective, clinical control trial. Methods Thirty preselected patients, after diagnostic screening for tolerance to cervical extension with compression, were treated for the first 3 weeks of care using cervical manipulation and a new type of cervical extension-compression traction (vertical weight applied to the subject’s forehead in the sitting position with a transverse load at the area of kyphosis). Pretreatment and posttreatment Visual Analogue Scale (VAS) pain ratings were compared along with pretreatment and posttreatment lateral cervical radiographs analyzed with the posterior tangent method for changes in alignment. Results are compared to a control group of 33 subjects receiving no treatment and matched for age, sex, weight, height, and pain. Results Control subjects reported no change in VAS pain ratings and had no statistical significant change in segmental or global cervical alignment on comparative lateral cervical radiographs (difference in all angle mean values < 1.3°) repeated an average of 8.5 months later. For the traction group, VAS ratings were 4.1 pretreatment and 1.1 posttreatment. On comparative lateral cervical radiographs repeated after an average of 38 visits over 14.6 weeks, 10 angles and 2 distances showed statistically significant improvements, including anterior head weight bearing (mean improvement of 11 mm), Cobb angle at C2-C7 (mean improvement of −13.6°), and the angle of intersection of the posterior tangents at C2-C7 (mean improvement of 17.9°). Twenty-one (70%) of the treatment group subjects were followed for an additional 14 months; improvements in cervical lordosis and anterior weight bearing were maintained. Conclusions Chiropractic biophysics (CBP) technique’s extension-compression 2-way cervical traction combined with spinal manipulation decreased chronic neck pain intensity and improved cervical lordosis in 38 visits over 14.6 weeks, as indicated by increases in segmental and global cervical alignment. Anterior head weight-bearing was reduced by 11 mm; Cobb angles averaged an increase of 13° to 14°; and the angle of intersection of posterior tangents on C2 and C7 averaged 17.9° of improvement.

Catastrophic injuries in wrestlers.

There is a paucity of comprehensive information on catastrophic wrestling injuries. Our objective was to develop a profile of catastrophic injuries in wrestling and a list of relevant risk factors. Retrospective review. We retrospectively reviewed 35 incidents that were reported to the National Center for Catastrophic Sports Injury Research over an 18-year period from 1981 until 1999. Except in the case of one male college athlete, all injuries occurred in male high school wrestlers. There were 2.11 direct catastrophic injuries per year or 1 per 100000 participants. The majority of injuries occurred in match competitions (80%), with a trend toward more injuries in the low- and middle-weight classes. The position most frequently associated with injury was the defensive position during the takedown maneuver (74%), followed by the down position (23%), and the lying position (3%). Catastrophic injuries included 27 cervical fractures or major cervical ligament injuries, 4 spinal cord contusions with transient quadriparesis, 3 severe head injuries, and an acutely herniated lumbar disc. The injuries resulted in quadriplegia in 11, residual neurologic deficits in 6, paraplegia in 1, and death in 1 head-injured athlete. Although catastrophic injuries in wrestling are rare, they do occur. Referees can help prevent such injuries by strictly enforcing penalties for slams and by gaining more awareness of dangerous holds. Coaches may also prevent serious injuries by emphasizing proper wrestling techniques.

Assessment of a synthetic anterior cervical ligament in a spinal fusion model in sheep

Background context: The anterior cervical ligament is routinely excised during cervical interbody fusion. Loss of this ligament may predispose to instability at the fusion site. Anterior plating restores stability but leads to a risk of stress shielding. An alternative approach would be to use a less rigid fixation system that would provide anterior support while allowing micromotion that could enhance bone healing within the fusion site.Purpose: To determine whether augmentation of an interbody fusion with a synthetic ligament enhances fusion.Study design: Prospective randomized study in a large animal model of cervical fusion.Outcome measures: The primary outcome was evidence of interbody fusion, as determined by radiography, computed tomography (CT), histology and biomechanical testing.Methods: Twelve skeletally mature sheep underwent single level (C2–3) anterior discectomy and interbody fusion using fresh frozen allograft. In six animals, the fusion was augmented with a braided polyethylene device rigidly fixed to C2 and C3 with screws. Sheep were euthanized 12 weeks postoperatively. Specimens were radiographed and then examined by CT. Six fusion sites (three control, three augmented) were used for nondestructive biomechanical testing to assess the stability of the fusion site. The remaining specimens were processed for undecalcified histology.Results: As determined by radiography, the augmented group had 83% solid union as compared with 67% in the control group (p<.05). There was no difference regarding bone graft dislodgment between the two groups. The extension stiffness of the augmented group was significantly higher (p<.05) than that of controls, but there was no significant difference between the two groups in flexion stiffness. There was no significant difference in bone formation in the two groups as determined by CT and histology, although there was a trend for increased endochondral ossification in the augmented repairs. There was no evidence of significant adverse tissue reactions to the ligament.Conclusions: Use of a synthetic ligament was associated with a moderate increase in fusion rate and a statistically significant increase in fusion site stiffness in extension. The use of an augmentation device, such as this synthetic ligament, may be beneficial in cervical fusion, especially when multilevel surgery is being contemplated.

Elongation behavior of calcaneofibular and cervical ligaments in a closed kinetic chain: pathomechanics of lateral hindfoot instability.

Numerous reconstructive procedures are performed to correct both ankle and subtalar instability after trauma although the precise pathology which results in this chronic instability and pain is not yet known. This study examined the role of the calcaneofibular (CLFL) and cervical ligaments (CRVL) during physiologic loading and demonstrated the effect of CLFL deficiency on the CRVL. Talar and subtalar tilt as well as inversion range of motion before and after CLFL sectioning were studied. Eleven osteoligamentous fresh frozen cadaver legs were used in which each foot was taken through six positions: neutral, 35 degrees plantarflexion, dorsiflexion, inversion, plantarflexion-inversion, and dorsiflexion-inversion. The CLFL and CRVL stretched the greatest in dorsiflexion-inversion. The most interesting finding was that the CRVL was elongated relative to neutral in all other test positions of the foot. However, the CLFL was shortened relative to neutral in plantarflexion and plantarflexion-inversion. In the CLFL deficient state, CRVL ratios demonstrated significant increases in length of the CRVL. Talar tilt increased on average more than 9 degrees with CLFL deficiency (p < 0.008) while subtalar tilt did not change significantly. The maximum tibiocalcaneal angle, recorded for dorsiflexion-inversion, increased more than 5 degrees after sectioning the CLFL (p < 0.05).

Tarsal sinus: arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome.

To evaluate the tarsal sinus by using different imaging techniques and specialized planes. Magnetic resonance (MR) imaging of the tarsal sinus was performed in 10 cadavers. Conventional arthrography of the anterior and posterior subtalar joints was then performed. Tarsal sinus ligaments were evaluated further on initial and reconstructed MR arthrograms along and perpendicular to their axes. Pathologic correlation was performed in five specimens suspected of having tarsal sinus lesions on the basis of initial imaging findings. In 37 patients with a clinical diagnosis of sinus tarsi syndrome, MR images of the ankle were obtained before and after intravenous gadolinium-based contrast material administration and were reviewed to verify the integrity of the tarsal sinus ligaments. Two complete and three partial cervical ligament (CL) tears and one complete interosseous talocalcaneal ligament (ITCL) tear were diagnosed with MR imaging. Only one complete and one partial CL tear were seen after evaluation of both initial and reconstructed MR arthrograms and confirmed with pathologic correlation. In 18 patients, the diagnosis was confirmed at MR imaging, which depicted ITCL and CL tears in 11 patients, isolated CL tears in three patients, ganglia in three patients, and pigmented villonodular synovitis in one patient. Cadaveric study results indicate that initial and reconstructed MR arthrograms along and perpendicular to the ligament axes are potentially useful for further evaluation of individual tarsal sinus structures.

Asymmetry of Cervical Joints and Ligaments Perfectly Normal

Asymmetry of Cervical Joints and Ligaments Perfectly Normal

An anatomical investigation of the human cervical facet capsule, quantifying muscle insertion area.

Facet capsule injury has been hypothesised as a mechanism for neck pain. While qualitative studies have demonstrated the proximity of neck muscles to the cervical facet capsule, the magnitude of their forces remains unknown owing to a lack of quantitative muscle geometry. In this study, histological techniques were employed to quantify muscle insertions on the human cervical facet capsule. Computerised image analysis of slides stained with Masson's trichrome was performed to characterise the geometry of the cervical facet capsule and determine the total insertion area of muscle fibres into the facet capsule for the C4-C5 and C5-C6 joints. Muscle insertions were found to cover 22.4+/-9.6% of the capsule area for these cervical levels, corresponding to a mean muscle insertion area of 47.6+/-21.8 mm2. The magnitude of loading to the cervical facet capsule due to eccentric muscle contraction is estimated to be as high as 51 N. When taken in conjunction with the forces acting on the capsular ligament due to vertebral motions, these forces can be as high as 66 N. In that regard, these anatomical data provide quantitative evidence of substantial muscle insertions into the cervical facet capsular ligament and provide a possible mechanism for injury to this ligament and the facet joint as a whole.

Computer-assisted assessment of lateral column movement following plantar fascial release: A cadaveric study

In patients who fail conservative treatment, releasing the plantar fascia relieves heel pain but destabilizes the lateral column of the foot. After surgery, pain can present in the area of the sinus tarsi, extensor digitorum brevis muscle, between the fourth and fifth metatarsals, and at the calcaneocuboid joint. The precise mechanism and involved structures for this painful compensation remains unclear. The authors hypothesized that the lateral plantar fascial band, bifurcate and cervical ligaments, lateral talocalcaneal ligament, and interosseous talocalcaneal ligament become excessively strained after this surgery. Using eight cadaver lower extremity limbs amputated 7 cm above the ankle joint, structural changes in the foot in response to staged release of the plantar fascia were measured. All ligament, tendon, and osseous structures were exposed along the plantar, medial, and lateral aspects of the foot and ankle. Using a servohydraulic system, compressive loads in increasing increments (50 lbs) were applied along the tibial axis. Tissue and bony structure displacement in the foot was measured using images electronically captured from two fixed cameras and a digital camera following each load change. All measurements were made in pixels and converted to millimeters in a spreadsheet program. Except for plantar fascial measurements, data were expressed as percentage of initial baseline. As expected, increasing compressive loads changed all measurements [repeated measures ANOVA, p<.04]. When releasing the plantar fascia, the inferior sinus tarsi space widened (intact, 85.4+/-10.8%; 1/4 release, 87.7+/-13.0; 1/2 release, 88.3+/-9.2; 3/4 release, 91.2+/-8.8; p<.04). Lateral length increased and medial height decreased, while medial length and lateral height were unchanged as the fascia was sequentially released. Significant movement of the inferior sinus tarsi strained the bifurcate and cervical ligaments, the lateral talocalcaneal ligament, and interosseous talocaneal ligament, which may account for pain following surgery. The initial 1/4 cut of the plantar fascia exerted the greatest mechanical alteration of the foot, suggesting that a partial release may relieve heel pain while optimizing the patient's chances of maintaining structural integrity with 75% of the plantar fascia intact.

The nomenclature and sectional imaging anatomy III: capsular membranes and minor spinal ligaments.

This paper is the third in a series of three that organizes the complex anatomy of the cervical, thoracic, and lumbar spinal ligaments. It describes and color-codes the anatomy and nomenclature of the capsular membranes and minor spinal ligaments. The first two articles describe the dorsal and ventral ligaments, respectively.