RELATIONSHIP OF THE DURA, HOFMANN LIGAMENTS, BATSON PLEXUS, AND A FIBROVASCULAR MEMBRANE LYING ON THE POSTERIOR SURFACE OF THE VERTEBRAL BODIES AND ATTACHING TO THE DEEP LAYER OF THE POSTERIOR LONGITUDINAL LIGAMENT - AN ANATOMICAL, RADIOLOGIC, AND CLINICAL-STUDY

With the advent of computed tomography (CT) and magnetic resonance imaging (MRI), visualization of soft tissue structures in the spinal canal, which were previously undetectable, is possible. This study was undertaken to more accurately identify these soft tissue layers and to determine factors such as when is a disc contained and when is it not; in discography, when the disc leaks, into what layer is the contrast going; or when a nuclear fragment creeps upward or downward, just where is it. The works of Fick, Dommisse, Kikuchi, Schellinger, Hofmann, Batson, and Parke were studied. The professors of anatomy of four major medical schools were consulted along with several neuroradiologists and embryologists. Forty lumbar spines were dissected (20 fresh, 20 preserved). Magnetic resonance imaging scans were taken. Photographs and photomicrographs were made. A fibrous membrane, first mentioned by Fick, can be identified lying anterior to the posterior longitudinal ligament and attaching to the deep layer of the posterior longitudinal ligament. It has been given relatively little attention in the past. This membrane has about one fourth the toughness of the dura and is made up largely of fibrous tissue. The veins of Batson lie on its dorsal surface and pierce it to go ventral to this membrane and enter the vertebral body. Batson's plexus crosses the disc space. The peridural membrane extends from one side to the other, spanning the width of the vertebral body and encircling the bony canal around the outside of the dura. There is a potential space between it and the dura. It does not cross the disc space. A probe can easily be passed posterior or anterior to it, between it and the posterior longitudinal ligament or between it and the vertebral body. We also identified Hofmann's ligament anterior to the dura, attaching the dura to the posterior longitudinal ligament. Laterally, tiny attachments between this fibrovascular membrane and the circumneural sheaths of the spinal nerves can be observed as the nerves enter the foramina. The posterior longitudinal ligament (PLL) is very tough and strong and seldom ruptures. The annulus frequently ruptures. Fragments of nucleus pulposus can creep out at the vertebral rim and get under the PLL and the peridural membrane. Hematoma can form by the same route and have the exact appearance as a sequestrated disc. There is no periosteum inside the vertebral canal. With MRI, hematomas can be differentiated from an extruded fragment, They may cause symptoms similar to an extruded disc but will probably heal with time. Infection in the vertebral body may sometimes come posteriorly into the premembranous space but is blocked by the membrane and seldom breaks through into the epidural space. Knowledge of structures in the vertebral canal adds to our ability to interpret CT scans, MRI scans, and discograms. During surgery, one often wonders what tissue layer is being cut when an incision is made into the layers that are overlying a disc fragment that has crept caudally or cranially from its disc level of origin. Often this tissue layer appears far too thin and fragile to be the PLL. We know now that it is probably this fibrous membrane with the veins of Batson on its posterior surface.