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13 Cardinal and Uterosacral Ligament Lines of Action: Mri

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13 Cardinal and Uterosacral Ligament Lines of Action: Mri 13 Chen L1, Ramanah R1, Hsu Y2, Ashton-Miller J1, DeLancey J1 1. University of Michigan, 2. University of Utah CARDINAL AND UTEROSACRAL LIGAMENT LINES OF ACTION: MRI BASED 3D TECHNIQUE DEVELOPMENT AND PRELIMINARY FINDINGS IN NORMAL WOMEN Hypothesis / aims of study The cardinal and uterosacral ligaments play a critical role in utero-vaginal support. Based on cadaveric dissection and cross- sectional anatomy the histological makeup and connections of these structures is known. However, the biomechanical understanding of their lines of action in living women, a critical factor necessary to understand their functional role, is not. The aim of this study is to quantify geometrical relationship between ligaments in living women using a newly developed a MRI based 3D technique. Study design, materials and methods Supine MRI scans of volunteers with normal support on POP-Q (all points at least 1 cm above the hymen) examination were obtained from an IRB approved study of pelvic organ support. 3-D models were constructed using the 3-D Slicer© software from a convenience sample of 10 women with normal support in whom axial and coronal proton density MR scans clearly showed ligament anatomy. The landmarks of genital insertions for both ligaments were marked. The uterosacral insertions to sacrum and cardinal attachments to pelvic side wall at the top of the great sciatic foramen were identified. The 3-D lines-of- action of the four ligaments were determined by connecting center of the origin and insertion points. The length and curvature of the ligaments were assessed using the best fit the curve of ligaments which were constructed at the cross-sectional plane defined by the line-of-action using Imageware v.12© (UGS, Plano, TX ) software (Figure1). Ut Sac Sac Ut Ut Ut CL US US CL CL US US PB Vag Vag PS CL β CL Sac γ Ut Δ α Cx Ut US CL US L Cx Vag PS PS Vag S A S L L A A C 3 Quarter View B View from Back View from Top D View from Left Figure 1A. 3D model showing the Pubic Bone (PB), Sacrum (Sac), Uterus (Ut), Vagina (Vag) and Cardinal ligaments (CL) and Uterosacral ligament (US) in three quarter view. 1B. Methodology to identify origin-insertion line and best fit curve for the cardinal ligament viewing from back (L to left and S to superior direction). Red dots are the landmarks identified for origins and insertions. Blue line connects the centre of landmarks to establish the line-of-action. The angle between cardinal ligament was measured as α. The red lines represent the best fit curves of the ligaments on the cross-section. The length of the curve is L and the tangent direction difference was measured as Δ. 1C. Uterosacral ligament line-of-action and best fit curve were similarly shown, the angle between uterosacral ligament βwas measured in axial plane ( View from top, L to left and A to anterior direction). 1D. shows the angles γbetween cardinal and uterosacral ligament in sagittal plane viewing from left. The blue lines represent the line-of-action of the ligaments. The angles between the cardinal and uterosacral ligament on each side, and the angle between the cardinals, angle between uterosacrals were measured. We also estimate how angle variation affects ligament tension with an arbitrary 1N “pelvic load” deflected by the levator plate (45 degree in normal women), Results Figure 2 shows the mean and range of the projection angles between origin-insertion-line of ligament in axial, coronal and sagittal planes. Two extreme examples (Figure 2E and 2F) show the variation of ligament tension on cardinal and uterosacral ligament. Table1 shows the length and curvature of the best fit curve to the ligaments. Angles between CL Angles between US Angles between CL and US Figure 2. Results of angular relationship on left side 45.2°(mean)±17.7°(s.d.) 44.7°(mean)±25.1°(s.d.) 66.3°(mean)±11.0°(s.d.) between ligaments and its variation in normal CL Cx US CL women. Panels A - D shows the projected Sac angle between two cardinals, two uterosacrals, and cardinal and uterosacral on each side. Solid line shows the average orientation and the dash US S A S line shows the range of the angles. Cx Cx L L Cx A A B Sac Back View Top View C Left View represents the cervix. Sac presents sacrum. Angles between CL and US Panels E,F show two examples of how angle on right side T =0.82 CL variation (47.6°and 96.3°) between ligaments 72.7°(mean)±13.5°(s.d.) TCL=0. 87 CL affect the ligament tensions ( Tcl and Tus) for 1N Sac pelvic load ( T = 1 ) . Tus=0.22 US S T=1 T=1 Tus=0.60 Cx A Right View E F D Table 1 Length and curvature measurements (N=10) Best Fit Curve Tangent Direction Length (mm) Difference (°) Mean ± SD & Mean ± SD & ( Minimum ~ ( Minimum~ Maximum ) Maximum ) Cardinal 56.4 ± 12.2 97.7 ± 33.4 Ligament (L) ( 41.7 ~ 76.1 ) ( 47.8 ~ 135.7) Cardinal 58.9 ± 11.5 118.6 ± 17.5 Ligament (R) ( 42 ~ 73.6 ) ( 96 ~ 155.8 ) Uterosacral 24.9 ± 9.9 52.8 ± 20.5 Ligament (L) ( 11.2 ~ 46.8 ) ( 29.8 ~ 99.0 ) Uterosacral 31.9 ± 8.1 52.5 ± 34.6 Ligament (R) ( 19.6 ~ 44.1 ) ( 13.3 ~ 104.8 ) Interpretation of results This technique, for the first time, quantifies the very different lines of action angles for the cardinal and uterosacral ligaments in living women with normal support. The cardinal is relatively vertical in the standing position, while the uterosacral is more dorsally directed. These are somewhat similar to the two different operative approaches with abdominal sacral colpopexy (ASC) being similar to cardinal vector and sacrospinous or uterosacral suspension (SSLS and USLS) being similar to the uterosacral vector. Further consideration of these vectors and operative failure should be considered; SSLS prone to cystocele and ASC being prone to rectocele postoperatively. These data can now be used in biomechanical models to see how different angles affect ligament stresses; are there geometries that are more favorable to good support. Concluding message Cardinal is relatively vertical in standing position while the uterosacral is more dorsally directed. There is considerable variation in the angles for the cardinal and uterosacral ligaments in normal women and these angles affect ligament tension for any given load. The load supported by each ligament can be expected to vary depending on the angle between ligaments. References 1. DeLancey, J. O.: Anatomic aspects of vaginal eversion after hysterectomy. American Journal of Obstetrics & Gynecology, 1992;166: t 2. Range, R. L. and Woodburne, R. T.: The gross and microscopic anatomy of the transverse cervical ligaments. American Journal of Obstetrics & Gynecology, 1964;90: 460 3. Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JO. Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol. 2004 Mar;103(3):447-51 Specify source of funding or grant We sincerely appreciate the funding resources R01 HD38665, P50 HD 44406 to make this research possible. Is this a clinical trial? No What were the subjects in the study? HUMAN Was this study approved by an ethics committee? Yes Specify Name of Ethics Committee Institutional Review Board Was the Declaration of Helsinki followed? Yes Was informed consent obtained from the patients? Yes .
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