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Anatomy, Back, Artery of Adamkiewicz
Introduction
The spinal cord receives its vascular supply from 3 main arteries. The anterior spinal artery supplies the anterior 2/3, while the 2 posterolateral spinal arteries supply the posterior 3rd.[1] The anterior spinal artery originates from the 2 vertebral arteries at the level of the foramen magnum. Anterior segmental medullary vessels from the aorta provide additional supply, with the largest being the artery of Adamkiewicz, also known as the arteria radicularis magna or the great anterior radiculomedullary artery (see Image. Artery of Adamkiewicz).
The artery of Adamkiewicz serves as the primary arterial supply to the anterior spinal artery along the lower thoracic, lumbar, and sacral segments of the spinal cord. Injury to this artery can cause neurologic deficits, including fecal and urinary incontinence and impaired motor function, while sensory function is typically preserved (see Image. Spinal Cord Fasciculi).[2]
Identifying the location of this blood vessel preoperatively is essential in thoracoabdominal aortic surgery to minimize the risk of ischemic spinal cord injury. Understanding this artery's anatomy and function is essential for preventing ischemic spinal cord injury during surgical procedures, particularly thoracoabdominal aortic repair.
Structure and Function
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Structure and Function
The artery of Adamkiewicz originates from the descending aorta, where 8 to 10 segmental arteries, either intercostal or lumbar, branch off and divide into anterior and posterior branches. The posterior branch further divides into 3: the radiculomedullary artery, the muscular branch, and the dorsal somatic branch. The radiculomedullary artery then splits into the main anterior and smaller posterior radiculomedullary arteries. The largest anterior radiculomedullary artery is the artery of Adamkiewicz.
The blood vessel passes through the intervertebral foramen and enters the spinal canal adjacent to the exiting spinal nerve, typically ventral or slightly rostrolateral to the dorsal root ganglion or ventral ramus. The artery then courses with the ventral root to the anterior surface of the spinal cord, ascends, forms a characteristic hairpin arch, and joins the anterior spinal artery.[3][4]
The artery of Adamkiewicz most often arises from the left side of the aorta between T8 and L2, typically between T9 and T11, but it is located above T8 in approximately 15% of individuals.[5][6] The vessel's diameter ranges from 0.6 to 1.8 mm. Anatomical variations include origin from the right side of the aorta or outside the T8 to L2 range, differences in the angle at which it joins the anterior spinal artery, and the presence of more than 1 artery of Adamkiewicz. Collateral circulation can develop if the artery of Adamkiewicz undergoes progressive occlusion, with collaterals usually arising from the muscular branch or other intercostal or lumbar arteries.[7] Other physiological variants are explained below (see Physiologic Variants).
Embryology
The artery of Adamkiewicz develops from segmental arteries that originate from the dorsal aorta during embryogenesis, supplying the spinal cord and contributing to the anterior spinal artery network. Vasculogenesis and angiogenesis, guided by hypoxia and vascular endothelial growth factor, shape the vascular system around the spinal cord.[8] Some intersegmental arteries evolve into radiculomedullary arteries, with the artery of Adamkiewicz being the largest and most critical for lower spinal cord perfusion. Developmental remodeling leads to variability in its origin and course, as most segmental arteries regress, leaving the artery of Adamkiewicz as the dominant blood supply.[9][10][11]
Physiologic Variants
The artery of Adamkiewicz typically originates between T9 and T11 but can arise as high as T3 or as low as L4. The blood vessel shows left-sided dominance in 77% to 91.5% of cases, though a right-sided origin occurs in up to 20%. Duplication is rare, with 1 study reporting it in 6 of 50 specimens, while another found none, suggesting population-specific variability.[12] The artery of Adamkiewicz may also arise from the intercostobronchial trunk, a variant critical to consider during bronchial artery embolization.[13]
Variants outside T8 to L2 or origins from the intercostobronchial trunk increase surgical risk, necessitating preoperative imaging such as computed tomography angiography. A 2020 Brazilian study found artery of Adamkiewicz distribution similar to global patterns but cautioned against generalizing across ethnic groups.
Surgical Considerations
The location of the artery of Adamkiewicz is crucial for many surgical procedures, as loss of flow to this vessel can cause spinal cord ischemia, as discussed in the Clinical Significance section (see Clinical Significance below). Surgical subspecialists must consider its location, including those performing vascular surgery for thoracoabdominal aortic aneurysm repair, orthopedic surgery for thoracolumbar spine procedures, neurosurgery for intramedullary tumor resection, and urological and pediatric surgery for retroperitoneal dissections.
Anatomical evaluation of the artery of Adamkiewicz is often performed preoperatively using computerized tomographic or magnetic resonance angiography to prevent neurological complications. Documented cases show adjustments in surgical approach when the artery of Adamkiewicz and the planned incision site are on the same side. Distinguishing the artery of Adamkiewicz from the anterior radiculomedullary vein is essential, as the 2 structures have similar shapes and often follow close courses. To avoid misidentification, tracing the artery from the aorta using the continuity technique is recommended. Preoperative imaging may be challenging in patients with bony abnormalities such as scoliosis, osteophytes, or narrowed intervertebral foramina, as well as in individuals with extensive arterial disease.[14][15][16]
Clinical Significance
Anterior cord syndrome, also "called anterior spinal artery syndrome," most commonly results from an interrupted supply to the anterior spinal artery or its major supplier, the artery of Adamkiewicz, which has a less efficient supply than the 2 posterolateral spinal arteries. Common causes include atherosclerotic disease, trauma from surgical instrumentation or direct injury by a disc or bone fragment, hypotension from blood loss during open surgery such as bowel resection, and vasculitic disorders. Muscular disorders, including spinal muscular atrophy and multiple sclerosis, as well as infectious causes such as poliomyelitis and West Nile virus, can also contribute to anterior cord syndrome.[17]
This syndrome affects the anterior 2/3 of the spinal cord, including most of the anterior and lateral white matter funiculi, the central gray matter, the bilateral lateral and anterior horns, and the bases of the posterior horns. Damage results in bilateral motor loss, with flaccid paralysis at the lesion level and spastic paralysis below due to corticospinal tract and anterior horn involvement. Bilateral pain and temperature sensation loss occur 1 level below the lesion due to spinothalamic tract disruption.
Sexual dysfunction and urinary and fecal incontinence arise from descending autonomic tract damage. Touch, vibration, and proprioception remain intact because the posterior white matter columns are spared. Motor recovery occurs in less than 50% of patients, and treatment is primarily supportive, addressing the underlying cause. Rehabilitation involves physical therapy, occupational therapy, and mental health support.[18][19]
Subarachnoid hemorrhage, typically intracranial, can also originate from the spine in fewer than 1% of cases. Etiologies include arteriovenous malformations, fistulae, and isolated spinal artery aneurysms. Spinal subarachnoid hemorrhage should be considered in patients presenting with sudden-onset back pain, myelopathy, and radiculopathy.[20]
Other Issues
Transforaminal epidural steroid injections are commonly used to treat radicular pain, with case reports documenting spinal cord infarction and acute paraplegia following this procedure. A posterior approach using a subpedicular technique is typically employed. The needle tip is positioned in the superior aspect of the neural foramen within the "safe triangle," where it lies immediately superior and lateral to the targeted nerve, reducing the risk of traumatic nerve injury.
Although this method avoids direct nerve root injury, disruption of blood supply to the anterior spinal cord can occur when the procedure is performed in the thoracic or upper lumbar spine, particularly if the needle tip is near the artery of Adamkiewicz or other anterior medullary arteries. Case reports suggest acute paraplegia may result from direct needle injury, vasospasm, or embolization. To mitigate this risk, some have proposed placing the needle in the inferior foramen when performing epidural injections at L3 and above.[21][22]
Media
(Click Image to Enlarge)
Spinal Cord Fasciculi. The illustration depicts the principal fasciculi of the spinal cord.
Henry Vandyke Carter, Public Domain, via Wikimedia Commons
(Click Image to Enlarge)
Artery of Adamkiewicz. This illustration shows the anatomic relationships of the artery of Adamkiewicz and its branches with the T9 vertebra, anterior spinal artery, posterior intercostal artery, and aorta.
StatPearls Illustration
References
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