Spinal Dura Attachments into the Ligamentum Nuchae

Why This Anatomy May Matter in Headache and Neck Pain

In the proceedings of the 2000 International Conference of Spinal Manipulation, Kenin, Humphreys, Hubbard, and Cramer reported important findings regarding connective tissue attachments between the spinal dura and the posterior cervical structures.

Their study, Attachments from the Spinal Dura to the Ligamentum Nuchae: Incidence, MRI Appearance, and Strength of Attachment, explored whether consistent anatomical connections exist in the cranio-cervical region — and whether these attachments can be visualized on MRI.

Background: Why Look at the Dura?

The spinal dura mater is not just a passive membrane. It surrounds the spinal cord and is sensitive to mechanical tension. As early as 1929, Von Lanz described posterior attachments to the dura in the upper cervical region.

More recently, interest has grown around the concept of the myodural bridge — connective tissue linking suboccipital muscles to the dura. Such connections may provide a mechanical pathway between cervical motion and dural tension.

These findings may help explain mechanisms underlying:

• Cervicogenic headaches

• Neck pain of unclear origin

• Vertigo

• Whiplash-associated disorders

(Hack et al., 1995; Bogduk, 2001)

Kenin and colleagues evaluated:

• 30 cadaveric cervical spines

• MRI correlation in 4 specimens

They identified a consistent connective tissue complex arising from the substance of the ligamentum nuchae between the occiput and axis.

This complex gave rise to three bridges:

1. Two attaching directly to the posterior spinal dura (between C1–C2)

2. One linking the Rectus capitis posterior minor muscle to the Ligamentum nuchae

Key Findings

The authors reported:

• The ligamentum nuchae–dura attachments between C1–C2 are robust and consistent

• The rectus capitis posterior minor connection typically exists

• These dural attachments can be identified on MRI

The ability to visualize these structures radiologically is particularly significant. It suggests that clinicians may one day correlate imaging findings with symptom patterns in headache and cervical injury patients.

Clinical Implications

The upper cervical spine plays a unique biomechanical role. It supports:

• Cranial motion

• Proprioceptive input

• Vertebral artery passage

• Dural tension dynamics

If tension in the ligamentum nuchae or suboccipital musculature transmits directly to the dura, this could:

• Alter nociceptive signaling

• Contribute to cervicogenic headache

• Influence symptoms following flexion-extension injuries

The concept of muscular-dural connections has been supported by earlier anatomical work describing the myodural bridge (Hack et al., 1995).

A Balanced Perspective

While this study demonstrated consistent anatomical attachments, it did not directly prove causation in headache or neck pain. However, identifying these structures:

• Strengthens anatomical plausibility

• Provides imaging correlation

• Encourages further clinical research

As upper cervical biomechanics continue to be studied, these findings help bridge anatomy with clinical symptom patterns.

Conclusion

Kenin et al. (2000) documented robust connective tissue attachments between the ligamentum nuchae and the posterior spinal dura at C1–C2, along with MRI confirmation of their presence.

These findings provide anatomical support for the idea that cervical soft tissue tension may influence dural mechanics — a concept with potential relevance in cervicogenic headache, vertigo, and whiplash-associated disorders.

Understanding these attachments may deepen our appreciation of the mechanical relationships at the cranio-cervical junction.

References

Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med Rehabil Clin N Am. 2003;14(3):455–472.

Hack GD, Koritzer RT, Robinson WL, Hallgren RC, Greenman PE. Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine (Phila Pa 1976). 1995;20(23):2484–2486.

Kenin S, Humphreys BK, Hubbard B, Cramer GD. Attachments from the spinal dura to the ligamentum nuchae: Incidence, MRI appearance, and strength of attachment. Proceedings of the 2000 International Conference on Spinal Manipulation. 2000;Sept:202–204.

Attachments from the Spinal Dura to the Ligamentum Nuchae: Incidence, MRI Appearance, and Strength of Attachment, Kenin S, Humphreys BK, Hubbard B, Cramer GD

Proceedings of the 2000 International Conference of Spinal Manipulation   2000;Sept:202-4

Abstract: The identification of attachments to the posterior spinal dura from the surrounding tissues in the cranio-cervical region by Von Lanz in 1929, may provide the key towards a better understanding of underlying mechanisms involved in chronic benign headaches as well as neck pain of unknown etiology.   The recent findings of connective tissue attachments to the cervical spinal dura from muscles, ligament, and osseous elements have sparked increasing interest among clinicians and anatomists.   However, studies of a large number of specimens or those evaluating the MRI appearance of these attachments have never been published.   This study evaluated these attachments in 30 cadaveric spines and then correlated the MRI appearance of the attachments to their anatomic appearance on 4 of the specimens.

This study identified a consistent connective tissue complex arising from within the substance of the ligamentum nuchae, between the occiput and axis, giving rise to 3 connective tissue bridges.   Two of the connective tissue bridges attached to the posterior spinal dura while the third linked the rectus capitis posterior minor muscle to the ligamentum nuchae.   Of significance were: (1) The attachment between the ligamentum nuchae and dura between C1-C2 are quite robust.   (2) The attachments between the rectus capitis posterior minor and ligamentum nuchae usually exist.   (3) The attachments between the ligamentum nuchae and dura mater can be identified on MRI scans.   These attachments may have clinical significance in cervicogenic headache, vertigo, and flexion-extension (whiplash) injuries, making their MRI appearance clinically important.