The Cervical Anterior Longitudinal Ligament (ALL) Injuries: All You Need To Know – Centeno-Schultz Clinic

Cervical Anterior Longitudinal Ligament (ALL) Injuries – What to Know

Is chronic neck pain keeping you from enjoying daily life and activities? Neck feeling stiff, and hurting with computer work turning in the car, playing with your children? Have you been told your neck imaging is fine, you just have a whiplash injury and should be fine, but you know you are not? Sick of bouncing from doctor to doctor with no clear explanations to why you hurt and no options for relief? Told the pain is all in your head or to just take pain meds or suck it up? You may have an anterior longitudinal ligament injury.

After any trauma, it is possible the cervical ALL ligaments were injured causing some of your symptoms. Cervical anterior longitudinal ligament injuries are often missed in evaluating cervical pain and neck instability. Read here to learn the anatomy, mechanisms of injury, ways to diagnose ALL injury, treatment options and a novel treatment approach for repair.

Anatomy of the Anterior Longitudinal Ligament (ALL)

To understand the ALL it is important to review some basic spinal anatomy.  The Spine is composed of boney building blocks called vertebral bodies that stack upon another. In the Cervical Spine there are 7 vertebral bodies. Between these bones are spongy shock absorbers called the intervertebral discs. Behind the cervical bones and disks lies the cervical spinal cord. The spinal cord sends nerves out of the sides of the cervical spine through doors called neuroforamen. These nerves go to the shoulder and arms to control movement and record sensation.  Ligaments are like duct tape that connect bone to bone and prevent excess motion. The Anterior Longitudinal Ligament is a thick band that covers the bones and disks along the anterior (front) of the spine. It runs from the cervical spine (neck) down to the sacrum (tailbone). The ALL is the counterpart to the posterior longitudinal ligament (PLL) that runs down the posterior vertebral bodies. The ALL is much thicker and stronger than the PLL. This is because the ALL is the only front neck stabilizing ligament whereas in the back there are the ligamentum flavum, supraspinous and interspinous ligaments that help to stabilize. In this article we are focusing on the ALL in the cervical region.

Longus Colli muscle adjacent to ALL which lies in the middle of the neck bones.

What is the Function of the Anterior Longitudinal Ligament?

The function of the ALL is to resist excess spinal hyperextension. It helps to stabilize the front of the spine and confines and supports the intervertebral discs. Preventing hyperextension prevents excess stress on the posterior aspect of the disk and facet joints in the neck.

The ALL works in conjunction with a group of muscles call the longus colli in the front of the neck to maintain posture and prevent excess hyperextension. If the ALL is injured the longus coli muscle will have to work harder to maintain posture and support and become injured or unable to handle the extra load. If the Longus colli tendons are injured then that will lead to more stress on the ALL risking further injury.

How Can the Anterior Longitudinal Ligament Become injured?  

The most common cause of ALL ligament injuries is hyperextension injury and whiplash injuries.

Whiplash is a neck injury due to forceful, rapid back-and-forth whipping motion of the head and neck.  The back motion typically injures ALL, while the front motion can injure any of the many posterior (back) of the neck ligaments (1).  The C5-6 ALL band is the most susceptible to injury (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 with approximately 50% of Whiplash patients having reported chronic neck pain 15 years after the trauma (3).  ALL injuries usually occur concomitantly with other cervical injuries.  Facet joints, Discs, Muscles, Tendons and Nerves all can be injured during whiplash. Commonly the Longus coli muscles, directly adjacent to the ALL, are damaged and inactive in whiplash injury as well (4).

How to Diagnose Anterior Longitudinal Ligament Injuries

First your doctor should take a detailed medical history, ask about your symptoms, and do a comprehensive physical examination. On examination you may have tenderness in the front of the neck or pain over the longus colli and there can be pain in the neck with extension. Imaging can provide more objective evidence of ALL injury, but your doctor has to actively look for it as it is not something commonly discussed in an imaging report.  The ALL is a ligament so it helps to provide dynamic stability. Thus to assess for instability or damage to a ligament you need movement based imaging. The best way to diagnose ALL injuries is with a digital motion Xray (Videofluoroscopy). A DMX takes X Ray pictures of a patient moving in different planes and takes measurements of how the bones move in relation to each other. If that movement is excess, they suggest ligament injury. See figure below for sample images and reports.  The next best test would be flexion extension X-rays or a flexion extension MRI. On a Xray, the physician can see widening of the spaces in the front between neck bones with the patient in neck extension compared to neutral which suggests ALL injury. Also, if a bone is siding backwards on the bone below it with extension, this is called retrolisthesis and suggests ALL injury. On an MRI, sometimes it is difficult to visualize the ALL directly, but sometimes you can see swelling in or around the ligament suggestive of injury. Also, anterior disk bulging seen on MRI suggests ALL injury.

In the extension view, we see the C3 bone moving backwards on the C4 bone (Yellow arrow). The red lines show excess movement at C3 and C4. 

This would be a common report from the DMX. 

Extension translation of the bones is abnormal if more than 2mm. So the DMX can show instability where just visually looking at the image you may miss it.

Types of Anterior Longitudinal Ligament injuries

There are 3 classifications of ligament injuries:

Grade 1: Mild stretching or small partial tear of the ligament less than 50% of the width. 

Grade 2: Moderate ligament injury with tearing of greater than 50% of the ligament fibers. 

Grade 3: Complete tear of the ligament. Complete tears can be non retracted meaning the fibers of the ligament are still approximated with each other. Complete retracted tears refer to ligament fibers that are completely torn apart and typically require surgery to repair. 

Symptoms of Anterior Longitudinal Ligament Injury

ALL injury causes spinal instability. This instability can lead to disc injury, nerve irritation, spinal stenosis (less space around the nerves), and facet joint arthritis. These injuries can cause several different symptoms pending of which structures are injured, at what levels, and how severe. Typical symptoms of ALL injury are: 

•   Pain in the neck or upper back 
•   Stiffness and spasm in the neck and upper shoulder muscles.
•   Pain that radiates down the shoulders, arms, fingers and throughout the body.
•   Numbness and tingling in the arms and fingers.
•   Soreness in the neck or upper shoulder area.
•   Stiffness or difficulties with neck movement.
•   Pain that gets worse in extension
•   Shoulder pain.
•   Pain solely in the arm, forearm, hand and fingers.
•   Electrical shooting sensations from the neck down through the shoulders and towards the fingers.
•   Weakness in one or both of arms, hands or fingers.
•   Headache.
•   Nausea, dizziness, imbalance.
•   In severe cases, severe neurologic symptoms, dysautonomia, etc.
•   In severe cases with spinal cord injury: loss of bowel or bladder control or leg weakness (this would be signs of a surgical emergency)

All of these symptoms can cause a significant loss of normal function, inability to participate in enjoyable activities, limit the ability to perform everyday tasks, and can really affect your mood and health.

Common Treatments for Anterior Longitudinal Ligament Injury

Initial treatment of ALL injuries is similar to other conditions causing neck pain. Conservative measures are used as the first line of treatment when appropriate and can progress to more invasive treatments as necessary. Rarely, sometimes surgery is the only option. 

Conservative Measures:

•   Rest, heat, ice, anti-inflammatory supplements such as turmeric and fish oil
•   Stretching
•   Physical therapy
•   Chiropractic care
•   Massage
•   Medications such as Tylenol or nonsteroidal anti-inflammatory medications.
•   Working on good posture and neutral spine alignment, appropriate ergonomics at workstation
•   Yoga poses or other modalities that focus on alignment such as Tai Chi, etc.
•   Dry needling or trigger point injections

Pain Injections:

If conservative measures fail, then many patients may be offered a steroid injection with local anesthetic. That  may help diagnose if the pain may be coming from a particular facet joint or nerve and can provide some temporary pain relief. Unfortunately, these steroids have toxicity to cartilage and other orthopedic tissues including bones and have to be used with caution. These typically only provide short-term pain relief. The injections do not directly address ALL ligament injury at all however. 

Another injection-based option is a nerve block that will just temporarily block the nerve sensation telling your body that a particular neck joint hurts. Again, this would be a temporary relief neck that can be used to diagnose some joint pain and also progress to a more invasive procedure where the actual nerve is burned. This is called a radiofrequency ablation. Again this does not directly treat ALL injuries. 

Surgery:

Sometimes surgery can be recommended for ALL injury that has led to disk injury causing nerve impingement if conservative measures fail. The most common type of surgery for neck problems is a core decompression and fusion surgery. In this procedure, the doctor can come from the front or the back of the neck and remove disk material, replace it with bone or a spacer and fuse the cervical bones together with screws and plates. Sometimes remove any bone spurs that may be impinging on the nerve.

Fusion is certainly a big surgery with much higher risks than injections, and can be associated with significant complications. Typical complications can include infection, nerve injury, failure of the bones to fuse and hardware misplacement.

Also, even if the surgery does go well, it is almost a guarantee that in 2-5 years, patients will develop adjacent segment disease.  This a condition where additional pressure was placed on disk and facets above and below the fusion, so this would cause added pain and problems in those areas. Often then can lead to more surgeries. 

Surgery is definitely needed if there is some spinal cord or actual nerve root injury. However, this is not the majority of cases. To use surgery only to treat pain should only be a last resort option. 

Regenerative Options:

Prolotherapy: prolotherapy is the injection of an irritant solution that causes small damage to tissue thus initiating a healing response. The most common solution is a hypertonic dextrose solution. This is basically sugar water solution that has a higher osmolality than your body’s tissues so it causes stress to the tissue by drawing water out of the cells initiating stress/injury then a healing response. The healing response is small so it often requires multiple treatments but can work very well for mild ligament and tendon injuries. 

Platelet Rich Plasma (PRP): PRP is made from taking your own blood, centrifuging (spinning it) to separate the components and concentrating the platelets. The concentrated platelets can then be injected into areas of tissue injury to initiate a healing response. Platelets have growth factors, cytokines, proteins, exosomes, etc that mediate that healing response. PRP can be used to treat mild to moderate ligament tears of the ALL and other structures. 

Bone marrow concentrate (BMAC): bone marrow concentrate contains stem cells as well as many other cells that can be powerful healing cells. Similarly, to PRP, bone marrow can be collected, spun down and concentrated then injected into the patient’s damaged tissue as well. BMAC containing stem cells is a more powerful healing agent and can be used for more moderate to severe ligament injuries of the ALL and other structures. 

At the Centeno-Schultz Clinic, we are experts in the diagnosis and treatment of orthopedic musculoskeletal problems including neck pain. We have 15 years of experience treating the various neck problems such as the disk, facets, ligaments, spinal nerves, tendons, etc. commonly with a patient’s own PRP or stem cells.  In 2005, we were the first clinic in the world to inject stem cells into disks and we have been extensively using regenerative methods such as PRP and bone marrow concentrate containing stem cells that contain growth factors that can improve the blood flow, reduce inflammation, accelerate healing and repair musculoskeletal tissues, thus resulting in less pain, improved function and without the risk of steroid injections or major surgeries. We use a functional spine unit approach instead of pain generator approach.  This means we look at the neck as a whole treating all structures that are injured including the ALL when appropriate. This is in contrast to the pain generator approach that tries to identify 1-2 painful joints or nerves and the goal is just to block the pain with meds or nerve ablation to stop pain only.  Our registry data had shown positive results from our comprehensive approach Regenexx Patient Outcome Data | Centeno-Schultz Clinic (centenoschultz.com) as well as published research (4-7).

In addition, we have created many interventional orthopedic procedures to address many of the body’s musculoskeletal structures. I authored a textbook describing many of these procedures, Atlas of Interventional Orthopedics. 

Here at the Centeno Schultz Clinic, I have also pioneered and refined injecting the ALL ligament in which 99% of injectors would not even attempt to perform due to the complexity. I developed a technique utilizing ultrasound and fluoroscopy in combination to safely inject the C2-T1 area ALL ligaments. To sufficiently perform the injections, an intimate working knowledge of the spinal anatomy along with years of x-ray and ultrasound guided injections to master excellent ultrasound needle visualization skills, and spatial orientation skill are required to perform this procedure. This is a complex, highly skilled injection that your family doctor, orthopedic surgeon, or traditional pain doctor cannot perform.

Below are some images of anterior longitudinal ligament injection.

Ultrasound image of the needle directed under the carotid artery and jugular vein towards the ALL. 

Lateral X Ray (fluoroscopy image) of the needle in the ALL ligament, confirmed with contrast injection showing accurate flow in multiple sections of the ALL.

Don’t Take Neck Whiplash Injuries Lightly, Get Yourself Checked Now

Neck pain after whiplash injury can be a progressive condition that can continue to worsen over time if you do not take action. Damage to the anterior longitudinal ligament can be a major contributor to neck pain and cause damage to other structures. If conservative measures are not helping then you want to be evaluated by a board certified musculoskeletal specialist such as a PMR doctor (physiatrist), sports medicine doctor, or pain physician for a thorough evaluation, diagnostic imaging, and a comprehensive treatment plan. Taking pills and hoping that it will go away is not effective. Dependence on medication also poses significant risks, including increasing your risk for heart attack, GI bleed, kidney and liver problems and dependence or addiction. Diagnosing the problem early allows for easier, less invasive treatment options to help you. Specialized reparative injections to treat the ALL and other injured structures such as those that we pioneered at the Centeno-Schultz clinic work well to help heal patients. Schedule an in person or telemedicine consultation with a musculoskeletal board-certified fellowship-trained physician and learn about your regenerative treatment options. Act now while the issue is small and treatment is available.

You want to get your life and level of activity back to normal as soon as possible.

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References

1. Pastakia K, Kumar S. Acute whiplash associated disorders (WAD). Open Access Emerg Med. 2011;3:29-32. Published 2011 Apr 27. doi:10.2147/OAEM.S17853.
2. Stemper BD, Yoganandan N, Pintar FA, Rao RD. Anterior longitudinal ligament injuries in whiplash may lead to cervical instability. Med Eng Phys. 2006;28(6):515–524. doi:10.1016/j.medengphy.2005.09.011
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. Williams C, Jerome M, Fausel C, et al. (October 08, 2021) Regenerative Injection Treatments Utilizing Platelet Products and Prolotherapy for Cervical Spine Pain: A Functional Spinal Unit Approach. Cureus 13(10): e18608. doi:10.7759/cureus.18608
5. Centeno CJ, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005 Jan;8(1):67-72. PMID: 16850045.
6. Ashley Smith, Ben Andruski, George Deng, Robert Burnham, Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of short-term outcomes, Interventional Pain Medicine, Volume 1, Issue 2, 2022, 100078, ISSN 2772-5944. Cervical facet joint platelet-rich plasma in people with chronic whiplash-associated disorders: A prospective case series of short-term outcomes – ScienceDirect
7. Lam KHS, Hung CY, Wu TJ. Ultrasound-Guided Cervical Intradiscal Injection with Platelet-Rich Plasma with Fluoroscopic Validation for the Treatment of Cervical Discogenic Pain: A Case Presentation and Technical Illustration. J Pain Res. 2020;13:2125-2129. Published 2020 Aug 20. doi:10.2147/JPR.S264033. Ultrasound-Guided Cervical Intradiscal Injection with Platelet-Rich Plasma with Fluoroscopic Validation for the Treatment of Cervical Discogenic Pain: A Case Presentation and Technical Illustration – PMC (nih.gov)