Anatomy, Back, Artery Of Adamkiewicz


Article Author:
Sayi Lindeire


Article Editor:
Joshua Hauser


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
12/6/2018 4:09:30 PM

Introduction

The spinal cord relies on 3 main arteries for vascular supply. The anterior spinal artery supplies the anterior two-thirds, and the 2 posterolateral spinal arteries supply the posterior third of the spinal cord.

The anterior spinal artery originates from the 2 vertebral arteries at the level of the foramen magnum. It is supplied by anterior segmental medullary vessels from the aorta, the biggest of which is the artery of Adamkiewicz, also referred to as the arteria radicularis magna or the great anterior radiculomedullary artery.

The anatomic course of the artery of Adamkiewicz can be traced starting from the descending aorta. Here, approximately 8 to 10 segmental (either intercostal or lumbar) arteries branch off and split into anterior and posterior branches. The posterior branch then 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, and the largest anterior radiculomedullary artery is named the artery of Adamkiewicz. The artery of Adamkiewicz then passes through the intervertebral foramen and enters the spinal canal adjacent to the exiting spinal nerve (usually ventral or slightly rostrolateral to the dorsal root ganglion/ventral ramus. It then travels with the ventral root to the ventral (anterior) surface of the spinal cord, ascends, makes a classic “hairpin” arch, then directs toward and joins the anterior spinal artery. [1][2][3][4]

The artery of Adamkiewicz typically arises from the left side of the aorta between T8 and L2 (usually T9 to T12, although the artery of Adamkiewicz is found above T8 in about 15% of people), and has been documented as having a diameter anywhere from 0.6 to 1.8 mm. Variants include the artery of Adamkiewicz arising from the right side of the aorta or level outside of T8 through L2, differences in the angle of how the artery of Adamkiewicz joins the anterior spinal artery and the presence of more than one artery of Adamkiewicz. Of note, collateral circulation is possible if the artery of Adamkiewicz has progressive occlusion; collaterals usually arise from the muscular branch or other intercostal or lumbar arteries.[3][5]

Structure and Function

The Artery of Adamkiewicz is the major arterial supply of the anterior spinal artery. [6][2]

Blood Supply and Lymphatics

The artery of Adamkiewicz arises from the descending aorta.[1][2]

Surgical Considerations

The location of the artery of Adamkiewicz is very important for many surgical procedures since lack of flow to this vessel can cause ischemia to the spinal cord (discussed in the Clinical Significance section). Several surgical subspecialties must consider its location, to include vascular surgery (thoracoabdominal aortic aneurysm repair), orthopedics (thoracolumbar spine surgery), neurosurgery (resection of intramedullary tumors), as well as urology and pediatric surgery (retroperitoneal dissections).[5]

Anatomical evaluation of the artery of Adamkiewicz is often performed preoperatively via computerized tomographic or magnetic resonance angiography to avoid neurological complications, and there are several documented cases of change in surgical approach if the artery of Adamkiewicz and planned approach are on the same side. Care must be taken to distinguish the artery of Adamkiewicz from the anterior radiculomedullary vein, which is very similar in shape and may follow a very close course to the artery of Adamkiewicz. To avoid confusing the 2, it is imperative to trace the artery from the aorta (termed the “continuity technique”). Of note, preoperative imaging may be difficult in patients with bony abnormalities (scoliosis, osteophytes, narrowing of intervertebral foramen), or patients with extensive arterial disease.[3][6][7]

Clinical Significance

Anterior cord syndrome (also called anterior spinal artery syndrome) most commonly occurs due to an interrupted supply of the anterior spinal artery or the Artery of Adamkiewicz (its major supplier), which has a less efficient supply compared to the 2 posterolateral spinal arteries. This commonly is caused by atherosclerotic disease, trauma (surgical instrumentation or direct injury by a disc or bone fragment), hypotension (for example, from blood loss in open surgery like bowel resection), vasculitic disorders. Anterior cord syndrome can also be caused by muscular disorders including spinal muscular atrophy and multiple sclerosis, as well as infectious causes including poliomyelitis and West Nile virus.

This syndrome affects the anterior two-thirds of the spinal cord, which includes the majority 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. This results in bilateral loss of motor function (flaccid paralysis at level of lesion and spastic paralysis below the lesion) from loss of the corticospinal tract and anterior horn, bilateral loss of pain and temperature one level below the lesion from loss of the spinothalamic tract, and sexual dysfunction and urinary and fecal incontinence from loss of descending autonomic tracts. Sensations of touch, vibration, and proprioception remain intact since the posterior white matter columns are spared. Motor recovery occurs in less than half of patients with anterior cord syndrome, and treatment is generally supportive and focuses on addressing the underlying cause. Successful recovery involves enrolling patients in physical therapy, occupational therapy, and mental health support.[8][9][10] 

Subarachnoid hemorrhage, which typically occurs intracranially, can also originate from the spine (less than 1% of all cases). Etiologies include arteriovenous malformations and fistulae, as well as isolated spinal artery aneurysms. Spinal subarachnoid hemorrhage should be on the differential diagnosis of patients who present with sudden-onset back pain, myelopathy, and radiculopathy.[11]

Other Issues

Transforaminal epidural steroid injections are commonly used to treat radicular pain, and there have been case reports of spinal cord infarction and acute paraplegia following this procedure. Typically, a posterior approach with a subpedicular technique is utilized. The needle tip is placed in the “safe triangle” in the superior aspect of the neural foramen, where it is immediately superior and lateral to the targeted nerve, which decreases the chance of traumatic injury to the nerve. While this method avoids injury to the nerve root, disruption of blood supply to the anterior spinal cord can occur with this procedure in the thoracic or upper lumbar spine if the needle tip is in the vicinity of the AKA, or other anterior medullary arteries. Case reports have suggested that acute paraplegia was due to direct needle injury, induced vasospasm, or embolization. Thus, it has been proposed that when epidural injections are performed at L3 and above, the needle should be placed in the inferior foramen instead.[4][12]


  • Image 2206 Not availableImage 2206 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anatomy, Back, Artery Of Adamkiewicz - Questions

Take a quiz of the questions on this article.

Take Quiz
The artery of Adamkiewicz is found above the T8 level in what percentage of the population?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The artery of Adamkiewicz typically arises from which vertebral level?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is false about the artery of Adamkiewicz?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common origin of the artery of Adamkiewicz?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient who has developed anterior spinal syndrome as results of occlusion of the artery of Adamkiewicz, which of the following clinical features will not be present?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anatomy, Back, Artery Of Adamkiewicz - References

References

Microsurgical anatomy of the Adamkiewicz artery-anterior spinal artery junction., N'da HA,Chenin L,Capel C,Havet E,Le Gars D,Peltier J,, Surgical and radiologic anatomy : SRA, 2015 Dec 1     [PubMed]
Predictors of Adamkiewicz artery and anterior spinal artery detection through computerized tomographic angiography., Amato ACM,Parga Filho JR,Stolf NAG,, SAGE open medicine, 2017     [PubMed]
MR angiography and CT angiography of the artery of Adamkiewicz: state of the art., Yoshioka K,Niinuma H,Ehara S,Nakajima T,Nakamura M,Kawazoe K,, Radiographics : a review publication of the Radiological Society of North America, Inc, 2006 Oct     [PubMed]
Detection of the Adamkiewicz artery in computed tomography of the thorax and abdomen., Guziński M,Bryl M,Ziemińska K,Wolny K,Sąsiadek M,Garcarek JS,, Advances in clinical and experimental medicine : official organ Wroclaw Medical University, 2017 Jan-Feb     [PubMed]
Intraforaminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz): a retrospective review., Murthy NS,Maus TP,Behrns CL,, Pain medicine (Malden, Mass.), 2010 Dec     [PubMed]
Charles YP,Barbe B,Beaujeux R,Boujan F,Steib JP, Relevance of the anatomical location of the Adamkiewicz artery in spine surgery. Surgical and radiologic anatomy : SRA. 2011 Jan     [PubMed]
Klakeel M,Thompson J,Srinivasan R,McDonald F, Anterior spinal cord syndrome of unknown etiology. Proceedings (Baylor University. Medical Center). 2015 Jan     [PubMed]
Yadav N,Pendharkar H,Kulkarni GB, Spinal Cord Infarction: Clinical and Radiological Features. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2018 Aug 6     [PubMed]
Bican O,Minagar A,Pruitt AA, The spinal cord: a review of functional neuroanatomy. Neurologic clinics. 2013 Feb     [PubMed]
Tanaka H,Ogino H,Minatoya K,Matsui Y,Higami T,Okabayashi H,Saiki Y,Aomi S,Shiiya N,Sawa Y,Okita Y,Sueda T,Akashi H,Kuniyoshi Y,Katsumata T, The impact of preoperative identification of the Adamkiewicz artery on descending and thoracoabdominal aortic repair. The Journal of thoracic and cardiovascular surgery. 2016 Jan     [PubMed]
Aljuboori Z,Sharma M,Simpson J,Altstadt T, Surgical Management of Ruptured Isolated Aneurysm of Artery of Adamkiewicz: Interesting Report and Overview of Literature. World neurosurgery. 2018 Mar     [PubMed]
Kroszczynski AC,Kohan K,Kurowski M,Olson TR,Downie SA, Intraforaminal location of thoracolumbar anterior medullary arteries. Pain medicine (Malden, Mass.). 2013 Jun     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Orthopaedic. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Orthopaedic, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Orthopaedic, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Orthopaedic. When it is time for the Surgery-Orthopaedic board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Orthopaedic.