{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T07:53:34Z","timestamp":1781164414970,"version":"3.54.1"},"reference-count":17,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Reg Anesth Pain Med"],"accepted":{"date-parts":[[2022,5,1]]},"published-print":{"date-parts":[[2022,8]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Cervical epidural steroid injections are commonly performed to manage pain from cervical spine disease. Cadaveric studies have demonstrated incomplete ligamentum flavum fusion in the central interlaminar region with resultant midline gaps. We performed an MR-based characterization of cervical ligamentum flavum midline gaps to improve understanding of their prevalence and guide interventionalists in procedural planning.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Fifty patients were retrospectively reviewed following institutional review board approval. Axial T2-weighted spinecho sequences were used to evaluate ligamentum flavum integrity at the interlaminar spaces of C5\u2013C6, C6\u2013C7 and C7\u2013T1. Interlaminar spaces were further subdivided into superior, middle, and inferior portions, yielding 150 interlaminar regions characterized from C5 to T1. Subsequently, a novel categorization of gap morphology was performed, highlighting gap morphology (anterior, posterior, full, or no gap).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Full gaps of the ligamentum flavum, with direct epidural space exposure, were observed with variable prevalence at all three levels evaluated. The highest incidence of full ligamentum flavum gaps were observed at C7\u2013T1, occurring in 71.4% of patients at both its middle and inferior portions. The inferior aspect of C5\u2013C6 demonstrated the lowest observed rates of full ligamentum flavum gap (2%).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Ligamentum flavum gaps occur in the lower cervical spine at high rates, with the highest prevalence of full thickness ligamentum flavum gaps at C7\u2013T1. Interventionists must be aware of these important normal variants and evaluate preprocedural MRI to plan interventions.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/rapm-2022-103552","type":"journal-article","created":{"date-parts":[[2022,5,23]],"date-time":"2022-05-23T13:41:56Z","timestamp":1653313316000},"page":"459-463","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":11,"title":["Cervical spine ligamentum flavum gaps: MR characterisation and implications for interlaminar epidural injection therapy"],"prefix":"10.1136","volume":"47","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3344-7848","authenticated-orcid":false,"given":"Jatin","family":"Joshi","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle","family":"Roytman","sequence":"additional","affiliation":[{"name":"Department of Radiology, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5066-4014","authenticated-orcid":false,"given":"Rohit","family":"Aiyer","sequence":"additional","affiliation":[{"name":"Richmond Interventional Pain Management, Staten Island, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Mauer","sequence":"additional","affiliation":[{"name":"Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J Levi","family":"Chazen","sequence":"additional","affiliation":[{"name":"Department of Radiology, Hospital for Special Surgery, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2022,5,17]]},"reference":[{"key":"2025101109212965000_47.8.459.1","first-page":"7","article-title":"Clinical implications of epidural fat in the spinal canal. A scanning electron microscopic study","volume":"60","author":"Reina","year":"2009","journal-title":"Acta Anaesthesiol Belg"},{"key":"2025101109212965000_47.8.459.2","unstructured":"Bogduk N . Clinical anatomy of the lumbar spine and sacrum. 4th ed. Edinburgh, Scotland: Elsevier, 2005."},{"key":"2025101109212965000_47.8.459.3","doi-asserted-by":"crossref","unstructured":"Mathis JM , Golovac S . Image-Guided spine interventions. 14. 2nd ed. New York, NY: Springer, 2010.","DOI":"10.1007\/978-1-4419-0352-5"},{"key":"2025101109212965000_47.8.459.4","doi-asserted-by":"crossref","first-page":"259","DOI":"10.36076\/ppj.2015\/18\/259","article-title":"Do the gaps in the ligamentum flavum in the cervical spine translate into dural punctures? an analysis of 4,396 fluoroscopic interlaminar epidural injections","volume":"18","author":"Manchikanti","year":"2015","journal-title":"Pain Physician"},{"key":"2025101109212965000_47.8.459.5","doi-asserted-by":"crossref","DOI":"10.4103\/sni.sni_85_18","article-title":"Major risks and complications of cervical epidural steroid injections: an updated review","volume":"9","author":"Epstein","year":"2018","journal-title":"Surg Neurol Int"},{"key":"2025101109212965000_47.8.459.6","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000000614"},{"key":"2025101109212965000_47.8.459.7","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0b013e31820fc7f2"},{"key":"2025101109212965000_47.8.459.8","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1148\/rg.2017160043","article-title":"Fluoroscopically guided epidural injections of the cervical and lumbar spine","volume":"37","author":"Shim","year":"2017","journal-title":"Radiographics"},{"key":"2025101109212965000_47.8.459.9","unstructured":"Manchikanti L , Falco FJE . Safeguards to prevent neurologic complications after epidural steroid injections: analysis of evidence and lack of applicability of controversial policies."},{"key":"2025101109212965000_47.8.459.10","unstructured":"R Core Team . R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2020. https:\/\/www.R-project.org\/"},{"key":"2025101109212965000_47.8.459.11","doi-asserted-by":"publisher","DOI":"10.1097\/00000542-200312000-00023"},{"key":"2025101109212965000_47.8.459.12","doi-asserted-by":"crossref","first-page":"321","DOI":"10.3344\/kjp.2014.27.4.321","article-title":"Anatomic variations of cervical and high thoracic ligamentum flavum","volume":"27","author":"Yoon","year":"2014","journal-title":"Korean J Pain"},{"key":"2025101109212965000_47.8.459.13","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1136\/rapm-00115550-199621050-00001","article-title":"Epidural anatomy examined by cryomicrotome section. 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