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Transligamentous Cervical Annular Tears

Dr. Lisa S. Apfel MD - Spine and Neurosurgery Dr. Lisa S. Apfel MD - Spine and Neurosurgery
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Degenerative Bones, Joints, and Spine Care (A - Z)

Transligamentous cervical annular tears are a specific type of injury to the annulus fibrosus—the tough, fibrous outer ring of the intervertebral disc in the neck—where the tear extends through the entire thickness of the annulus and penetrates the posterior longitudinal ligament, potentially allowing disc material or fluid to leak into the space around the spinal cord and nerve roots bonepit.comRadiopaedia. This full-thickness radial tear is classified as Grade 3 (contrast extending beyond the outer annulus into the epidural space) in the original Dallas discogram system and is sometimes referred to as a “free fragment” or transligamentous leak bonepit.com. Such tears can cause neck pain, nerve irritation, and—in severe cases—spinal cord compression.

Anatomy of the Annulus Fibrosus in the Cervical Spine

  1. Structure: The annulus fibrosus is composed of 15–25 concentric lamellae of fibrocartilage, with collagen fibers oriented at alternating angles to resist torsion and axial loads Radiopaedia.
  2. Location: It forms the peripheral ring of each intervertebral disc from C2–C3 through C7–T1 in the cervical spine, encircling the gelatinous nucleus pulposus NCBI.
  3. Origin/Insertion: Sharpey’s fibers anchor the outermost lamellae of the annulus into the adjacent vertebral endplates and ring apophyses, securing the disc to the vertebrae above and below Radiopaedia.
  4. Blood Supply: Blood vessels supply only the outer one-third of the annulus; nutrients reach inner layers by diffusion through the endplates and peripheral rete NCBINCBI.
  5. Nerve Supply: Sensory nerve fibers, primarily from the sinuvertebral nerve (a branch of the spinal nerve), penetrate the outer third of the annulus, making tears in this region painful NCBI.

Six Functions:

  1. Containment of Nucleus Pulposus: Prevents the gelatinous core from bulging outward NCBI.

  2. Load Transmission: Distributes compressive forces evenly across the disc NCBI.

  3. Shock Absorption: Damps axial impacts during daily activities ScienceDirect.

  4. Motion Guidance: Directs and limits flexion/extension, lateral bending, and rotation NCBI.

  5. Spinal Stability: Maintains intervertebral alignment under load PMC.

  6. Protective Barrier: Shields the spinal cord and nerve roots from disc material extrusion bonepit.com.

Types of Annular Tears

  1. Radial Fissures (Dallas Grades 1–3):

    • Grade 1: Tear in the inner third of the annulus.

    • Grade 2: Tear extends to the middle third.

    • Grade 3: Full-thickness tear reaching the outer third but contained by the posterior longitudinal ligament bonepit.com.

  2. Concentric (Circumferential) Tears: Delamination between lamellae, often circumferentially around the disc Desert Institute for Spine Care.

  3. Transligamentous (Grade 4+): Full-thickness radial tear with contrast leaking into the epidural space—true transligamentous bonepit.com.

  4. Peripheral Rim Lesions: Tears parallel to the vertebral rim, usually at the outermost annulus Desert Institute for Spine Care.

  5. Transverse (Horizontal) Tears: Fissures that run horizontally through lamellae.

Causes

  1. Age-Related Degeneration: Discs stiffen and dehydrate, making tears more likely NCBISpine-health.

  2. Degenerative Disc Disease: Loss of proteoglycans and water content weakens annular fibers PMC.

  3. Repetitive Microtrauma: Cumulative small stresses from work or sports BEST Health System.

  4. High-Impact Sports: Football, rugby, gymnastics cause acute stresses BEST Health System.

  5. Heavy Manual Labor: Frequent lifting, bending, twisting NJ Spine & Orthopedic.

  6. Whole-Body Vibration: Truck driving or machinery operation accelerates wear ADR Spine.

  7. Obesity: Increased axial load on discs Spine-health.

  8. Smoking: Impairs nutrient diffusion, speeds degeneration Spine-health.

  9. Genetic Predisposition: Polymorphisms (e.g., GDF5, ASPN) linked to disc degeneration PMCBioMed Central.

  10. Vascular Compromise: Reduced blood supply to endplates and outer annulus NCBIADR Spine.

  11. Diabetes Mellitus: Microvascular disease impairs disc cell metabolism ADR Spine.

  12. Inflammatory Cytokines: Local cytokine release degrades extracellular matrix PMCNature.

  13. Rheumatoid Arthritis: Cervical arthropathy accelerates adjacent disc degeneration UW RadiologyBonati.

  14. Whiplash/Trauma: Sudden hyperextension or flexion injuries BEST Health SystemVSI® (Virginia Spine Institute).

  15. Falls/Accidents: Direct impact can rupture annular fibers BEST Health SystemVSI® (Virginia Spine Institute).

  16. Osteophyte Formation: Alters biomechanics, strains annulus PMC.

  17. Vitamin D Receptor Polymorphisms: Linked to reduced disc signal and degeneration PMC.

  18. Dehydration of Nucleus Pulposus: Less shock absorption increases annular stress BioMed Central.

  19. Annular Lamellae Irregularities: Age-related bifurcation/interdigitation weaken fibers BioMed Central.

  20. Occupational Vibration: Chronic vibration exposure in industrial jobs ADR Spine.

Symptoms

  1. Neck Pain: Localized or diffuse aching.

  2. Radicular Arm Pain: Shooting pain along a nerve root.

  3. Paresthesia: Numbness or tingling in arm/hand.

  4. Muscle Weakness: In affected myotomes.

  5. Spasm: Muscle tightness in neck/shoulder.

  6. Reduced Range of Motion: Difficulty turning or bending neck.

  7. Pain Aggravated by Movement: Especially flexion/extension.

  8. Cough/Sneeze-Induced Pain: Valsalva maneuvers increase pain.

  9. Headaches: Often at base of skull (cervicogenic).

  10. Night Pain: Wakes patient from sleep.

  11. Shoulder Blade Pain: Referred discomfort under scapula.

  12. Nerve Root Distribution Pain: Follows dermatomal patterns.

  13. Weak Grip Strength: Involvement of C7–T1 roots.

  14. Sensory Loss: Hypoesthesia in dermatomes.

  15. Balance Issues: If mild cord compression.

  16. Dizziness: Cervical vertigo from proprioceptive disturbance.

  17. Muscle Atrophy: Chronic denervation of paraspinals.

  18. Reflex Changes: Diminished biceps or triceps reflex.

  19. Myelopathic Signs: Clonus, Hoffmann’s if cord involvement.

  20. Autonomic Symptoms: Rarely, bowel/bladder changes in severe myelopathy.

Diagnostic Tests

  1. MRI T2-Weighted (High-Intensity Zone): Visualizes annular fissures RadiopaediaPubMed.

  2. Gadolinium-Enhanced MRI: Highlights inflamed annular tissue Radiology Assistant.

  3. Fluoroscopic Discography: Provokes pain and outlines tear bonepit.com.

  4. CT Discography: Combines contrast with CT for detailed bony and annular assessment bonepit.com.

  5. Plain Radiographs (X-Ray): Detects osteophytes, disc space narrowing Verywell HealthRadiology Key.

  6. Flexion-Extension X-Rays: Evaluates segmental instability Verywell HealthRadiology Key.

  7. CT Myelography: Assesses nerve root and cord compression PubMed.

  8. Spurling’s Test: Neck compression reproduces radicular pain PhysiopediaAAFP.

  9. Cervical Distraction Test: Relief of pain with traction suggests radiculopathy AAFPNCBI.

  10. Valsalva Maneuver: Increases intradiscal pressure, provoking pain NCBI.

  11. Shoulder Abduction Relief Test (Bakody’s Sign): Lifts arm reduces pain NCBI.

  12. Upper Limb Neurodynamic Tests: Nerve gliding reproduces symptoms Vrije Universiteit Amsterdam.

  13. Neck Tornado Test: Rotational compression elicits radicular pain Int J Med Sci.

  14. Hoffmann’s Sign: Flick of finger induces thumb/index flexion (UMN sign) NCBI.

  15. Babinski’s Sign: Upward toe extension suggests cord involvement NCBIPhysiopedia.

  16. Sustained Clonus: ≥ 3 beats indicates UMN lesion Orthobullets.

  17. Lhermitte’s Sign: Neck flexion causes electric shock sensation Orthobullets.

  18. Romberg Test: Balance loss with eyes closed indicates proprioceptive issues Orthobullets.

  19. EMG/NCS: Identifies nerve root dysfunction NCBIWikipedia.

  20. Somatosensory Evoked Potentials: Assesses conduction through dorsal columns (if cord involvement).

Non-Pharmacological Treatments

  1. Rest & Activity Modification: Limiting aggravating movements Hospital for Special Surgery.

  2. Soft Cervical Collar: Short-term immobilization for comfort Hospital for Special Surgery.

  3. Relative Bed Rest: During acute flare-ups (≤1 week) AAFP.

  4. Ergonomic Adjustments: Proper workstation and posture UpToDate.

  5. Therapeutic Exercises: Strengthening and stretching by a PT AAFP.

  6. Manual Therapy: Spinal manipulation or mobilization Wikipedia.

  7. Mechanical Traction: Intermittent cervical traction Medscape.

  8. Manual Traction: Therapist-applied traction Medscape.

  9. Home Traction Devices: Over-door or pneumatic traction Medscape.

  10. Moist Heat Packs: Improves circulation and relaxes muscles Medscape.

  11. Cold Packs: Reduces inflammation and pain Medscape.

  12. TENS: Transcutaneous electrical stimulation for pain relief UpToDate.

  13. Ultrasound Therapy: Deep tissue heating UpToDate.

  14. Dry Needling: Targeted trigger point release UpToDate.

  15. Massage Therapy: Myofascial release and relaxation AAFP.

  16. Biofeedback: Teaches muscle control and relaxation MedCentral.

  17. Cognitive Behavioral Therapy: Addresses pain perception MedCentral.

  18. Mindfulness/Stress Reduction: Lowers muscle tension MedCentral.

  19. Acupuncture: May reduce pain and improve function MedCentral.

  20. Neural Mobilization: Nerve gliding exercises Verywell Health.

  21. Chin Tuck Exercises: Improves neck posture Verywell Health.

  22. Neck Extension Exercises: Strengthens posterior muscles Verywell Health.

  23. Lateral Flexion (Side Tilts): Stretches lateral muscles Verywell Health.

  24. Isometric Strengthening: Resists flexion, extension, side-bending Verywell Health.

  25. Shoulder/Scapular Stabilization: e.g., shoulder circles Verywell Health.

  26. Movement-Based Therapies: Pilates, Feldenkrais, etc. UpToDate.

  27. Ergonomic Pillow Support: Maintains neutral neck at night Hospital for Special Surgery.

  28. Weight Management: Reduces axial load on cervical spine Spine-health.

  29. Smoking Cessation: Improves disc nutrition Spine-health.

  30. Patient Education: Self-management and posture awareness UpToDate.

Pharmacological Treatments

  1. Ibuprofen (NSAID) AAFP

  2. Naproxen (NSAID) AAFP

  3. Diclofenac (NSAID) AAFP

  4. Celecoxib (COX-2 inhibitor) AAFP

  5. Cyclobenzaprine (muscle relaxant) AAFP

  6. Tizanidine (muscle relaxant) AAFP

  7. Baclofen (muscle relaxant) AAFP

  8. Methocarbamol (muscle relaxant) AAFP

  9. Codeine (opioid analgesic) AAFP

  10. Oxycodone (opioid analgesic) AAFP

  11. Morphine (opioid analgesic) AAFP

  12. Hydrocodone (opioid analgesic) AAFP

  13. Gabapentin (anticonvulsant for neuropathic pain) AAFP

  14. Carbamazepine (anticonvulsant) AAFP

  15. Amitriptyline (tricyclic antidepressant) AAFP

  16. Nortriptyline (tricyclic antidepressant) AAFP

  17. Duloxetine (SNRI) AAFP

  18. Venlafaxine (SNRI) AAFP

  19. Epidural Methylprednisolone (steroid injection) NCBI

  20. Lidocaine Injection (nerve root block) Maryland Health Experts

Surgical Treatments

  1. Anterior Cervical Discectomy & Fusion (ACDF): Removes the disc and fuses vertebrae WikipediaSpine-health.

  2. Cervical Disc Arthroplasty: Artificial disc replacement preserves motion Verywell Health.

  3. Posterior Cervical Foraminotomy: Opens the neural foramen without fusion Verywell Health.

  4. Anterior Cervical Corpectomy & Fusion: Removes vertebral body and disc, then fuses Wikipedia.

  5. Posterior Cervical Decompression & Fusion: Laminectomy with fusion to stabilize Wikipedia.

  6. Cervical Laminoplasty: Hinged opening of lamina to decompress cord WikipediaPMC.

  7. Cervical Laminectomy: Removal of lamina to relieve pressure Wikipedia.

  8. Microdiscectomy (Open Discectomy): Microsurgical removal of herniated disc material Wikipedia.

  9. Full Endoscopic ACDF: Minimally invasive anterior approach Wikipedia.

  10. Percutaneous Disc Decompression (Nucleoplasty): Image-guided removal of nucleus pulposus Main Line Spine.

Prevention Strategies

  1. Maintain Good Posture & Ergonomics: Avoid sustained awkward neck positions Verywell Health.

  2. Safe Lifting Techniques: Bend at knees, keep load close NJ Spine & Orthopedic.

  3. Regular Neck & Core Exercises: Strengthen supporting musculature Verywell Health.

  4. Avoid Repetitive Neck Flexion/Extension: Use ergonomic tools NJ Spine & Orthopedic.

  5. Healthy Weight Management: Reduces mechanical stress on discs Spine-health.

  6. Smoking Cessation: Preserves disc nutrition Spine-health.

  7. Stay Hydrated: Supports disc hydration and resilience BioMed Central.

  8. Use Supportive Pillows: Maintains neutral cervical alignment at night Hospital for Special Surgery.

  9. Take Frequent Breaks: Change posture during prolonged sitting UpToDate.

  10. Stress Management: Prevents chronic muscle tension MedCentral.

When to See a Doctor

Seek medical evaluation if you experience:

  • Neck pain persisting beyond six weeks despite conservative care Verywell Health

  • Severe arm weakness or numbness interfering with daily activities

  • Signs of spinal cord involvement (e.g., balance issues, clonus, Hoffmann’s sign) Orthobullets

  • Sudden onset of bladder or bowel dysfunction

  • High fever, unexplained weight loss, or trauma-related symptoms
    Early consultation ensures timely imaging, diagnosis, and management to prevent permanent nerve or cord injury.

FAQs

  1. What exactly is a transligamentous cervical annular tear?
    It’s a full-thickness tear of the fibrous ring of a cervical disc that extends through the posterior longitudinal ligament, allowing disc material or fluid to escape into the epidural space bonepit.com.

  2. How is it different from a simple annular tear?
    Simple (intraligamentous) tears stop at the outer annulus; transligamentous tears breach the ligament and can cause more severe nerve irritation bonepit.com.

  3. What symptoms should I expect?
    Neck pain, arm radiating pain, tingling, and sometimes muscle weakness in the arm or hand Radiopaedia.

  4. Can it heal without surgery?
    Many improve with conservative care—PT, traction, and medications—within 8–12 weeks; about 85% of cases resolve without surgery NCBI.

  5. What imaging is best for diagnosis?
    MRI with T2-weighted sequences showing a high-intensity zone is the Gold Standard; discography may be used for confirmation Radiopaedia.

  6. Is discography painful or risky?
    It can cause temporary pain and carries small risks of infection and disc damage; it’s reserved when MRI is inconclusive bonepit.com.

  7. When is surgery recommended?
    After 6–12 weeks of failed conservative therapy, progressive neurological deficits, or myelopathic signs AAFP.

  8. What is the difference between annular tear and disc herniation?
    An annular tear is a fissure in the disc wall; herniation is when nucleus pulposus bulges or extrudes Radiopaedia.

  9. Can tears cause headaches?
    Yes—cervicogenic headaches often arise from C2–C3 disc pathology Radiopaedia.

  10. Do all tears show up on MRI?
    No; small fissures may be missed, and a high-intensity zone is seen in only ~50% of painful discs Radiopaedia.

  11. What is the long-term outlook?
    Many remain symptom-free after conservative or surgical treatment, though some may have recurrent pain ScienceDirect.

  12. Can an annular tear lead to myelopathy?
    Rarely; if a large fragment compresses the cord, myelopathic signs (e.g., clonus, Hoffmann’s) can occur Orthobullets.

  13. Is exercise safe during recovery?
    Yes—supervised strengthening and stretching under a PT’s guidance is beneficial AAFP.

  14. How can I prevent future tears?
    Maintain good posture, strong neck/core muscles, healthy weight, and avoid smoking Spine-health.

  15. Are annular tears more common in older adults?
    Yes—degenerative changes over age 40–50 increase tear risk Spine-health.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 04, 2025.

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  157. Thoracic Posture and Mobility in Mechanical Neck[rxharun.com]
  158. Thoracic_and_Lumbar_Spine_ROM_exercise_programme_done_2019[rxharun.com]
  159. spine-5-fh-thoracic-spine-anatomy[rxharun.com]
  160. Clinical examination of the thoracic spine[rxharun.com]
  161. TIMS-Managing-Thoracic-Back-Pain-July-2024[rxharun.com]
  162. Cervical-and-Thoracic-Spine-Disorders-[rxharun.com]

PDF Document For This Disease Conditions

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  2. https://pubmed.ncbi.nlm.nih.gov/27887750/
  3. https://www.ncbi.nlm.nih.gov/books/NBK537139/
  4. https://www.ncbi.nlm.nih.gov/books/NBK537236/
  5. https://www.ncbi.nlm.nih.gov/books/NBK537140/
  6. https://pubmed.ncbi.nlm.nih.gov/30335291/
  7. https://pubmed.ncbi.nlm.nih.gov/30725921/
  8. https://pubmed.ncbi.nlm.nih.gov/30725824/
  9. https://www.ncbi.nlm.nih.gov/books/NBK559006/
  10. https://pubmed.ncbi.nlm.nih.gov/30725825/
  11. https://en.wikipedia.org/wiki/Muscle
  12. https://en.wikipedia.org/wiki/List_of_skeletal_muscles_of_the_human_body
  13. https://medlineplus.gov/ency/imagepages/19841.htm
  14. https://www.britannica.com/science/human-muscle-system
  15. https://training.seer.cancer.gov/anatomy/muscular/types.html
  16. https://www.britannica.com/science/human-muscle-system
  17. https://www.sciencedirect.com/topics/medicine-and-dentistry/skeletal-muscle
  18. https://academic.oup.com/nar/article/32/5/1792/2380623
  19. https://onlinelibrary.wiley.com/journal/10974598
  20. https://medlineplus.gov/skinconditions.html
  21. https://en.wikipedia.org/wiki/Category:Kidney_diseases
  22. https://kidney.org.au/your-kidneys/what-is-kidney-disease/types-of-kidney-disease
  23. https://www.niddk.nih.gov/health-information/kidney-disease
  24. https://www.kidney.org/kidney-topics/chronic-kidney-disease-ckd
  25. https://www.kidneyfund.org/all-about-kidneys/types-kidney-diseases
  26. https://www.aad.org/about/burden-of-skin-disease
  27. https://www.usa.gov/federal-agencies/national-institute-of-arthritis-musculoskeletal-and-skin-diseases
  28. https://www.cdc.gov/niosh/topics/skin/default.html
  29. https://www.mayoclinic.org/diseases-conditions/brain-tumor/symptoms-causes/syc-20350084
  30. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep
  31. https://www.cdc.gov/traumaticbraininjury/index.html
  32. https://www.skincancer.org/
  33. https://illnesshacker.com/
  34. https://endinglines.com/
  35. https://www.jaad.org/
  36. https://www.psoriasis.org/about-psoriasis/
  37. https://books.google.com/books?
  38. https://www.niams.nih.gov/health-topics/skin-diseases
  39. https://cms.centerwatch.com/directories/1067-fda-approved-drugs/topic/292-skin-infections-disorders
  40. https://www.fda.gov/files/drugs/published/Acute-Bacterial-Skin-and-Skin-Structure-Infections—Developing-Drugs-for-Treatment.pdf
  41. https://dermnetnz.org/topics
  42. https://www.aaaai.org/conditions-treatments/allergies/skin-allergy
  43. https://www.sciencedirect.com/topics/medicine-and-dentistry/occupational-skin-disease
  44. https://aafa.org/allergies/allergy-symptoms/skin-allergies/
  45. https://www.nibib.nih.gov/
  46. https://www.nei.nih.gov/
  47. https://en.wikipedia.org/wiki/List_of_skin_conditions
  48. https://en.wikipedia.org/?title=List_of_skin_diseases&redirect=no
  49. https://en.wikipedia.org/wiki/Skin_condition
  50. https://oxfordtreatment.com/
  51. https://www.nidcd.nih.gov/health/
  52. https://consumer.ftc.gov/articles/w
  53. https://www.nccih.nih.gov/health
  54. https://catalog.ninds.nih.gov/
  55. https://www.aarda.org/diseaselist/
  56. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets
  57. https://www.nibib.nih.gov/
  58. https://www.nia.nih.gov/health/topics
  59. https://www.nichd.nih.gov/
  60. https://www.nimh.nih.gov/health/topics
  61. https://www.nichd.nih.gov/
  62. https://www.niehs.nih.gov
  63. https://www.nimhd.nih.gov/
  64. https://www.nhlbi.nih.gov/health-topics
  65. https://obssr.od.nih.gov/
  66. https://www.nichd.nih.gov/health/topics
  67. https://rarediseases.info.nih.gov/diseases
  68. https://beta.rarediseases.info.nih.gov/diseases
  69. https://orwh.od.nih.gov/

References

 

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