Cardinal ligament

Last revised by Dr Daniel J Bell on 12 Jul 2022

The cardinal ligaments, also known as transverse cervical ligaments or Mackenrodt ligaments, are paired structures that act to support the pelvic organs of the female pelvis. These along with the uterosacral and pubocervical ligaments, provide support to prevent pelvic organ prolapse 1

The cardinal ligaments originate at the border of the greater sciatic foramen before “inserting” at the lateral aspect of the superior vagina and cervix 1. Along with the uterosacral ligaments, they act to suspend the uterus, cervix, and upper vagina. This can be demonstrated by the cardinal ligaments being in a relatively vertical orientation when an individual is standing upright - resisting the effect of gravity on the structures it supports 1,2

While referred to as a "ligament", the cardinal ligament is rather a condensation of connective tissue rather than a discrete ligamentous structure in the traditional sense 1,2.

The cardinal ligament consists primarily of vascular, neural, and areolar tissue containing fat with a network of connective tissue separating the different elements 2.

They are comprised of both a vascular component (located cranially) and a neural component (located caudally) 2,4:

The ureter crosses the cardinal ligament at the point where the ligament passes inferior to the uterine vessels 4.

Cardinal ligaments are best demonstrated on coronal T2-weighted MRI imaging. Vessels appear as dot-shaped structures with low T2 signal intensity, while areas of high T2 signal intensity correlate with adipose and connective tissue 3.  

Given the position of the uterine vessels and ureter relative to the cardinal ligament, manipulation of the structure during pelvic surgery can result in ureteric or uterine artery injury 4

Should the cardinal ligament become lax, the vaginal apex may position directly above the levator hiatus leading to an increased risk of prolapse due to the loss of suspensory support 1

The cardinal ligament was first named by the German surgeon Josef Kocks in 1880 4. The German gynecologist Alwin Mackenrodt (1859-1925) later named the structure the “transverse cervical ligament” in 1895 and since then has also been known as "Mackenrodt ligament" 4.

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