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Alvernia JE, Simon E, Khandelwal K, Ramos CD, Perkins E, Kim P, Mertens P, Messina R, Luzardo G, Diaz O. Anatomical study of the thoracolumbar radiculomedullary arteries, including the Adamkiewicz artery and supporting radiculomedullary arteries. J Neurosurg Spine 2023; 38:233-241. [PMID: 36152330 DOI: 10.3171/2022.5.spine2214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this paper was to identify and characterize all the segmental radiculomedullary arteries (RMAs) that supply the thoracic and lumbar spinal cord. METHODS All RMAs from T4 to L5 were studied systematically in 25 cadaveric specimens. The RMA with the greatest diameter in each specimen was termed the artery of Adamkiewicz (AKA). Other supporting RMAs were also identified and characterized. RESULTS A total of 27 AKAs were found in 25 specimens. Twenty-two AKAs (81%) originated from a left thoracic or a left lumbar radicular branch, and 5 (19%) arose from the right. Two specimens (8%) had two AKAs each: one specimen with two AKAs on the left side and the other specimen with one AKA on each side. Eight cadaveric specimens (32%) had 10 additional RMAs; among those, a single additional RMA was found in 6 specimens (75%), and 2 additional RMAs were found in each of the remaining 2 specimens (25%). Of those specimens with a single additional RMA, the supporting RMA was ipsilateral to the AKA in 5 specimens (83%) and contralateral in only 1 specimen (17%). The specimens containing 2 additional RMAs were all (100%) ipsilateral to their respective AKAs. CONCLUSIONS The segmental RMAs supplying the thoracic and lumbar spinal cord can be unilateral, bilateral, or multiple. Multiple AKAs or additional RMAs supplying a single anterior spinal artery are common and should be considered when dealing with the spinal cord at the thoracolumbar level.
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Affiliation(s)
- Jorge E Alvernia
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
- 2Brain and Spine Associates, Monroe, Louisiana
| | - Emile Simon
- 3Department of Neurosurgery, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France
- 4Laboratory of Anatomy, Faculty of Medicine Lyon Est, Claude Bernard University Lyon 1, Lyon, France
| | | | - Cara D Ramos
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Eddie Perkins
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Patrick Kim
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Patrick Mertens
- 3Department of Neurosurgery, Hospices Civils de Lyon, Hôpital Neurologique Pierre Wertheimer, Bron, France
- 4Laboratory of Anatomy, Faculty of Medicine Lyon Est, Claude Bernard University Lyon 1, Lyon, France
| | - Raffaella Messina
- 5Division of Neurosurgery University "Aldo Moro" of Bari, Italy; and
| | - Gustavo Luzardo
- 1Department of Neurosurgery, University of Mississippi, Jackson, Mississippi
| | - Orlando Diaz
- 6Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
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Small JE, Pérez Pérez VH. The Dominant Anterior Thoracic Artery of the Spinal Cord. AJNR Am J Neuroradiol 2023; 44:111-114. [PMID: 36581455 PMCID: PMC9835921 DOI: 10.3174/ajnr.a7737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/25/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Dominant radiculomedullary arteries such as the artery of lumbar enlargement and the artery of cervical enlargement are well-documented. However, variability exists as to the size, number, and location of other radiculomedullary arteries contributing supply to the anterior spinal artery. The aim of this anatomic study was to document the prevalence and characteristics of the dominant anterior thoracic artery in cadaveric specimens. MATERIALS AND METHODS Microsurgical dissection of cadaveric human spinal cord specimens (n = 50) was conducted. The artery of lumbar enlargement was injected with colored latex until the small-caliber arterial vessels were filled. The dominant anterior thoracic artery was identified, injected, and filled with diluted industrial paint. The course, diameter, and location of the dominant anterior thoracic artery, artery of lumbar enlargement, and artery of cervical enlargement were documented. RESULTS The artery of lumbar enlargement was identified between T3 and L2 in all 50 specimens (100%), and the artery of cervical enlargement was identified in 84% of specimens (42/50). At least 1 dominant anterior thoracic artery distinct from the artery of lumbar enlargement and the artery of cervical enlargement was identified between T1 and T11 in 47 of the 50 specimens (94%). The most frequent origin of the dominant anterior thoracic artery was at the level of T4 on the left. The average size of the dominant anterior thoracic artery was 0.446 mm (range, 0.300-0.759 mm on the left and 0.270-0.569 mm on the right). CONCLUSIONS A dominant anterior thoracic artery is present in 94% of individuals. Variations of the arterial supply to the anterior thoracic cord are of great importance due to their implications for ischemic events as well as surgical and endovascular procedures.
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Affiliation(s)
- J E Small
- From Lahey Hospital and Medical Center (J.E.S.), Burlington, Massachusetts
| | - V H Pérez Pérez
- Instituto de Ciencias Forenses (V.H.P.P), TSJ Ciudad de México, Centro Medico Siglo XXI, Mexico City, Mexico
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Younger DS. Spinal cord motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:3-42. [PMID: 37620076 DOI: 10.1016/b978-0-323-98817-9.00007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Spinal cord diseases are frequently devastating due to the precipitous and often permanently debilitating nature of the deficits. Spastic or flaccid paraparesis accompanied by dermatomal and myotomal signatures complementary to the incurred deficits facilitates localization of the insult within the cord. However, laboratory studies often employing disease-specific serology, neuroradiology, neurophysiology, and cerebrospinal fluid analysis aid in the etiologic diagnosis. While many spinal cord diseases are reversible and treatable, especially when recognized early, more than ever, neuroscientists are being called to investigate endogenous mechanisms of neural plasticity. This chapter is a review of the embryology, neuroanatomy, clinical localization, evaluation, and management of adult and childhood spinal cord motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Arvind V, Nevzati E, Ghaly M, Nasim M, Farshad M, Guggenberger R, Sciubba D, Spiessberger A. Primary extradural tumors of the spinal column: A comprehensive treatment guide for the spine surgeon based on the 5 th Edition of the World Health Organization bone and soft-tissue tumor classification. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:336-360. [PMID: 35068816 PMCID: PMC8740815 DOI: 10.4103/jcvjs.jcvjs_115_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In 2020, the World Health Organization (WHO) published the 5th version of the soft tissue and bone tumor classification. Based on this novel classification system, we reviewed the current knowledge on all tumor entities with spinal manifestations, their biologic behavior, and most importantly the appropriate treatment options as well as surgical approaches. METHODS All tumor entities were extracted from the WHO Soft-Tissue and Bone Tumor Classification (5th Edition). PubMed and Google Scholar were searched for the published cases of spinal tumor manifestations for each entity, and the following characteristics were extracted: Growth pattern, ability to metastasize, peak age, incidence, treatment, type of surgical resection indicated, recurrence rate, risk factors, 5-year survival rate, key molecular or genetic alterations, and possible associated tumor syndromes. Surgical treatment strategies as well as nonsurgical treatment recommendations are presented based on the biologic behavior of each lesion. RESULTS Out of 163 primary tumor entities of bone and soft tissue, 92 lesions have been reported along the spinal axis. Of these 92 entities, 54 have the potential to metastasize. The peak age ranges from conatal lesions to 72 years. For each tumor entity, we present recommended surgical treatment strategies based on the ability to locally destruct tissue, to grow, recur after resection, undergo malignant transformation as well as survival rates. In addition, potential systemic treatment recommendations for each tumor entity are outlined. CONCLUSION Based on the 5th Edition of the WHO bone and soft tumor classification, we identified 92 out of 163 tumor entities, which potentially can have spinal manifestations. Exact preoperative tissue diagnosis and interdisciplinary case discussions are crucial. Surgical resection is indicated in a significant subset of patients and has to be tailored to the specific biologic behavior of the targeted tumor entity based on the considerations outlined in detail in this article.
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Affiliation(s)
- Varun Arvind
- Department of Orthopedic Surgery, Icahn School of Medicine – The Mount Sinai Hospital, New York, USA
| | - Edin Nevzati
- Department of Neurosurgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Maged Ghaly
- Department of Radiation Oncology, North Shore University Hospital, Manhasset, USA
| | - Mansoor Nasim
- Department of Pathology, North Shore University Hospital, Manhasset, USA
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Roman Guggenberger
- Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Sciubba
- Department of Neurosurgery, North Shore University Hospital, Manhasset, USA
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Abstract
The arterial supply of the spinal cord is provided by the spinal branch of the cervical, thoracic, and lumbar intersegmental arteries. While supply is initially provided at each embryonic segment, only a few prominent anterior radiculomedullary arteries remain at the adult stage, including the arteries of the cervical and lumbosacral enlargements as well as a constant upper thoracic contributor. The spinal cord is surrounded by the vasocorona, an arterial network that includes several longitudinal anastomotic chains, notably the anterior and posterior spinal arteries, which respectively supply the central and peripheral components of the intrinsic vascularization. The intrinsic venous circulation is also divided into central and peripheral components. The perimedullary venous system includes several longitudinal anastomotic chains interconnected by the coronary plexus. The radiculomedullary veins loosely follow the spinal nerve roots on their way to the epidural plexus. Their point of passage through the thecal sac forms an important valve-like structure, the antireflux mechanism.
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Affiliation(s)
- Lydia Gregg
- Division of Interventional Neuroradiology and Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philippe Gailloud
- Division of Interventional Neuroradiology and Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Dmytriw AA, Kapadia A, Enriquez-Marulanda A, Parra-Fariñas C, Kühn AL, Nicholson PJ, Waqas M, Renieri L, Michelozzi C, Foreman PM, Phan K, Yang IH, Tutino VM, Ogilvy CS, Radovanovic I, Harrigan MR, Siddiqui AH, Levy EI, Limbucci N, Cognard C, Krings T, Pereira VM, Thomas AJ, Marotta TR, Griessenauer CJ. Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion. J Neurosurg 2020; 134:961-970. [PMID: 32217800 DOI: 10.3171/2020.1.jns193293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Coverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction. METHODS A multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome. RESULTS Sixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage. CONCLUSIONS FD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.
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Affiliation(s)
- Adam A Dmytriw
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto.,2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anish Kapadia
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto.,2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Alejandro Enriquez-Marulanda
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carmen Parra-Fariñas
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Anna Luisa Kühn
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Patrick J Nicholson
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Muhammad Waqas
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Leonardo Renieri
- 6Department of Interventional Neuroradiology, University of Florence, Italy
| | | | - Paul M Foreman
- 4Orlando Health, Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Kevin Phan
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - I-Hsiao Yang
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,8Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Vincent M Tutino
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Christopher S Ogilvy
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Ivan Radovanovic
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mark R Harrigan
- 7Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Adnan H Siddiqui
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Elad I Levy
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Nicola Limbucci
- 6Department of Interventional Neuroradiology, University of Florence, Italy
| | - Christophe Cognard
- 9Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Timo Krings
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vitor Mendes Pereira
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Thomas R Marotta
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- 10Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania; and.,11Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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Saravi B, Wittmann K, Krause S, Puttfarcken L, Siepe M, Göbel U, Beyersdorf F, Kari FA. Analysis of spinal cord blood supply combining vascular corrosion casting and fluorescence microsphere technique: A feasibility study in an aortic surgical large animal model. Clin Anat 2020; 34:527-535. [PMID: 32115761 DOI: 10.1002/ca.23586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Spinal cord ischemia after cardiovascular interventions continues to be a devastating problem in modern surgery. The role of intraspinal vascular networks and anterior radiculomedullary arteries (ARMA) in preventing spinal cord ischemia is poorly understood. MATERIALS AND METHODS Landrace pigs (n = 30, 35.1 ± 3.9 kg) underwent a lateral thoracotomy. Fluorescent microspheres were injected into the left atrium and a reference sample was aspirated from the descending aorta. Repeated measurements of spinal cord and renal cortical blood flow from the left and right kidneys with three different microsphere colors in five pigs were taken to validate reproducibility. Spinal cord blood flow to the upper thoracic (T1-T4), mid-thoracic (T5-T8), lower thoracic (T9-T13), and lumbar (L1-L3) levels were determined. After euthanasia, we carried out selective vascular corrosion cast and counted the left and right ARMAs from levels T1-T13. RESULTS Blood flow analysis of the left and right kidneys revealed a strong correlation (r = .94, p < .001). We detected more left than right ARMAs, with the highest prevalence at T4 (p < .05). The mean number of ARMAs was 8 ± 2. Their number in the upper thoracic region ranged from 2 to 7 (mean of 5 ± 1), while in the lower thoracic region they ranged from 0 to 5 (mean of 3 ± 1 [p < .001]). CONCLUSIONS This study shows that combining fluorescence microsphere technique and vascular corrosion cast is well suited for assessing the blood flow and visualizing the arteries at the same time.
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Affiliation(s)
| | - Karin Wittmann
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sonja Krause
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luisa Puttfarcken
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Göbel
- Anesthesiology and Intensive Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fabian A Kari
- Cardiovascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Abstract
This article reviews the arterial and venous anatomy of the spine and spinal cord. Special emphasis is placed on vessels critical to the conduct and interpretation of spinal angiography, notably the intersegmental artery and its cranial and caudal derivatives: the vertebral, supreme intercostal, and sacral arteries.
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Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, 1800 East Orleans Street, Baltimore, MD 21287, USA.
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Taterra D, Skinningsrud B, Pękala PA, Hsieh WC, Cirocchi R, Walocha JA, Tubbs RS, Tomaszewski KA, Henry BM. Artery of Adamkiewicz: a meta-analysis of anatomical characteristics. Neuroradiology 2019. [DOI: 10.1007/s00234-019-02207-y –] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Taterra D, Skinningsrud B, Pękala PA, Hsieh WC, Cirocchi R, Walocha JA, Tubbs RS, Tomaszewski KA, Henry BM. Artery of Adamkiewicz: a meta-analysis of anatomical characteristics. Neuroradiology 2019; 61:869-880. [PMID: 31030251 PMCID: PMC6620248 DOI: 10.1007/s00234-019-02207-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/01/2019] [Indexed: 12/03/2022]
Abstract
PURPOSE The artery of Adamkiewicz (AKA) provides the major blood supply to the anterior thoracolumbar spinal cord and iatrogenic injury or inadequate reconstruction of this vessel during vascular and endovascular surgery can result in postoperative neurological deficit due to spinal cord ischemia. The aim of this study was to provide comprehensive data on the prevalence and anatomical characteristics of the AKA. METHODS An extensive search was conducted through the major electronic databases to identify eligible articles. Data extracted included study type, prevalence of the AKA, gender, number of AKA per patient, laterality, origin based on vertebral level, side of origin, morphometric data, and ethnicity subgroups. RESULTS A total of 60 studies (n = 5437 subjects) were included in the meta-analysis. Our main findings revealed that the AKA was present in 84.6% of the population, and patients most frequently had a single AKA (87.4%) on the left side (76.6%) originating between T8 and L1 (89%). CONCLUSION As an AKA is present in the majority of the population, caution should be taken during vascular and endovascular surgical procedures to avoid injury or ensure proper reconstruction. All surgeons operating in the thoracolumbar spinal cord should have a thorough understanding of the anatomical characteristics and surgical implications of an AKA.
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Affiliation(s)
- Dominik Taterra
- International Evidence-Based Anatomy Working Group, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31-034, Kraków, Poland
| | - Bendik Skinningsrud
- International Evidence-Based Anatomy Working Group, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31-034, Kraków, Poland
| | - Przemysław A Pękala
- International Evidence-Based Anatomy Working Group, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31-034, Kraków, Poland
| | - Wan Chin Hsieh
- International Evidence-Based Anatomy Working Group, Kraków, Poland
- First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Roberto Cirocchi
- Department of Surgical Sciences, Radiology and Dentistry, University of Perugia, Perugia, Italy
| | - Jerzy A Walocha
- International Evidence-Based Anatomy Working Group, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31-034, Kraków, Poland
| | | | - Krzysztof A Tomaszewski
- International Evidence-Based Anatomy Working Group, Kraków, Poland.
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski KrakowUniversity, Kraków, Poland.
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11
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Amato ACM, Parga Filho JR, Stolf NAG. Predictors of Adamkiewicz artery and anterior spinal artery detection through computerized tomographic angiography. SAGE Open Med 2017; 5:2050312117711599. [PMID: 28616230 PMCID: PMC5459350 DOI: 10.1177/2050312117711599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/02/2017] [Indexed: 11/16/2022] Open
Abstract
Background: The detection of the Adamkiewicz artery and the anterior spinal artery has been associated with the ability to prevent adverse spinal cord outcomes after aortic surgical procedures. Yet, to our knowledge, no previous studies have attempted to use modern predictive models to identify the most important variables in determining artery detectability. Aims: To develop a model to predict the odds of visualizing the Adamkiewicz artery or anterior spinal artery in patients undergoing computerized tomographic angiography. Methods: We conducted a prospective, cross-sectional study. Outcomes of interest were the non-detection of the Adamkiewicz artery and anterior spinal artery, and their corresponding level of origin. Axial images were inspected in high definition in search of two dense spots characterizing the Adamkiewicz artery and anterior spinal artery. A multiplanar three-dimensional reconstruction was then performed using the OsiriX® software. Results: A total of 110 participants were part of this analysis. When evaluating risks for the Adamkiewicz artery being undetectable, significant factors could be classified into three broad categories: risk factors for arterial disease, established arterial disease, and obesity. Factors in the former category included metabolic syndrome, hypertension, and smoking status, while factors in the arterial disease included descending aortic aneurysm, mural thrombi, aortic aneurysm without a dissection, and aortic disease in general. In relation to anterior spinal artery not being detectable, significant risk factors included hypertension, smoking status, and metabolic syndrome, while those associated with arterial disease involved aortic disease and arterial thrombi. When evaluating the importance of individual clinical factors, the presence of higher body mass index was the single most important risk factor. Conclusion: Arterial disease, established arterial disease, and increased body mass index are risk factors in the detection of Adamkiewicz artery and anterior spinal artery. Specific diagnostic protocols should be in place for patients with these underlying conditions, thus enhancing the likelihood of detection when the Adamkiewicz artery is indeed present.
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Affiliation(s)
- Alexandre Campos Moraes Amato
- Post-Graduate Program, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jose Rodrigues Parga Filho
- Cardiovascular Magnetic Resonance and Computed Tomography Sector, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Noedir Antonio Groppo Stolf
- School of Medicine, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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12
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Gregg L, Sorte DE, Gailloud P. Intraforaminal Location of Thoracolumbar Radicular Arteries Providing an Anterior Radiculomedullary Artery Using Flat Panel Catheter Angiotomography. AJNR Am J Neuroradiol 2017; 38:1054-1060. [PMID: 28209578 DOI: 10.3174/ajnr.a5104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/12/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flat panel catheter angiotomography performed during the selective injection of intersegmental arteries offers a multiplanar assessment of the intraforaminal course of the radicular arteries providing an anterior radiculomedullary artery. Injury of anterior radiculomedullary arteries during transforaminal epidural steroid injections can result in spinal cord damage. Evaluations of the intraforaminal location of these arteries have so far been limited to anteroposterior views or the examination of cadaveric material. This study documents the in vivo intraforaminal location of thoracolumbar arteries providing an anterior radiculomedullary artery with flat panel catheter angiotomography. MATERIALS AND METHODS Ninety-four flat panel catheter angiotomography acquisitions obtained during the selective injection of intersegmental arteries providing an anterior radiculomedullary artery were reviewed. Measurements obtained from sagittal reconstructions were converted into a scatterplot visualization. Patients' age, sex, and side and level of the injection were recorded. RESULTS The location of radicular arteries could be ascertained in 78 of 94 flat panel catheter angiotomography acquisitions (33 women and 45 men, 22-82 years of age). Fifty-three acquisitions (67.9%) were on the left side, and 25 (32.1%), on the right, between T2 and L3. The arteries were found in the anterosuperior quadrant of the neural foramen in 75 cases (96.2%), in the posterosuperior quadrant in 2 cases (2.6%), and in the anteroinferior quadrant in 1 case (1.3%). None were located in the posteroinferior quadrant. No differences in location were observed with age, sex, side of injection, or vertebral level. CONCLUSIONS Avoiding needle placement in the superior half of the neural foramen, specifically the anterosuperior quadrant, can reduce the risk of spinal cord injury during transforaminal epidural steroid injection.
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Affiliation(s)
- L Gregg
- From the Division of Interventional Neuroradiology (L.G., D.E.S., P.G.)
- Department of Art as Applied to Medicine (L.G.), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D E Sorte
- From the Division of Interventional Neuroradiology (L.G., D.E.S., P.G.)
| | - P Gailloud
- From the Division of Interventional Neuroradiology (L.G., D.E.S., P.G.)
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Eckart Sorte D, Pardo CA, Gailloud P. Angiographic suppression of the artery of Adamkiewicz by venous hypertension resolving after embolization in a case of spinal epidural arteriovenous fistula. J Neurointerv Surg 2015; 7:e31. [DOI: 10.1136/neurintsurg-2014-011308.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2014] [Indexed: 11/04/2022]
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Gailloud P, Gregg L, Galan P, Becker D, Pardo C. Periconal arterial anastomotic circle and posterior lumbosacral watershed zone of the spinal cord. J Neurointerv Surg 2014; 7:848-53. [PMID: 25280570 DOI: 10.1136/neurintsurg-2014-011408] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/10/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND The existence of spinal cord watershed territories was suggested in the 1950s. Segmental infarcts within the junctional territories of adjacent radiculomedullary contributors and isolated spinal gray matter ischemia constitute two well-recognized types of watershed injury. This report describes the existence of another watershed territory related to the particular configuration of the spinal vasculature in the region of the conus medullaris. METHODS The anatomical bases underlying the concept of a posterior lumbosacral watershed zone are demonstrated with angiographic images obtained in a 16-year-old child. The clinical importance of this watershed zone is illustrated with MRI and angiographic data of three patients with a conus medullaris infarction. RESULTS In all three cases of spinal ischemia an intersegmental artery providing a significant radiculomedullary contribution for the lower cord was compromised by a compressive mechanism responsible for decreased spinal cord perfusion (diaphragmatic crus syndrome in two cases, disk herniation in one). The ischemic injury, located at the junction of the anterior and posterior spinal artery territories along the dorsal aspect of the conus medullaris, was consistent with a watershed mechanism. This zone is at risk because of the caudocranial direction of flow within the most caudal segment of the posterior spinal arterial network which, from a functional standpoint, depends on the anterior spinal artery. CONCLUSIONS The posterior thoracolumbar watershed zone of the spinal cord represents an area at increased risk of ischemic injury, particularly in the context of partial flow impairment related to arterial compression mechanisms.
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Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lydia Gregg
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Peter Galan
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Becker
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Sorte DE, Pardo CA, Gailloud P. Angiographic suppression of the artery of Adamkiewicz by venous hypertension resolving after embolization in a case of spinal epidural arteriovenous fistula. BMJ Case Rep 2014; 2014:bcr-2014-011308. [PMID: 25028420 DOI: 10.1136/bcr-2014-011308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A case of complete angiographic suppression of the artery of Adamkiewicz and anterior spinal artery in a patient with a spinal epidural arteriovenous fistula (AVF) is reported. Slow flow AVFs typically present with progressive myelopathy secondary to spinal venous hypertension (SVH). The lack of a normal venous phase during angiography and its restoration after treatment is commonly observed with these lesions, yet a similar phenomenon seems exceptional at the arterial level. Right T11 intercostal artery angiograms obtained before and after treatment of a left L4 epidural AVF documented the initial suppression of the artery of Adamkiewicz and anterior spinal artery, and their normal appearance immediately after correction of the SVH by embolization. This report confirms that SVH can angiographically suppress prominent and functionally important spinal arteries, re-emphasizing the potential role played by secondary arterial changes in SVH induced myelopathy. This hemodynamic phenomenon also represents a potential pitfall during diagnostic and therapeutic endovascular procedures.
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Affiliation(s)
- Danielle Eckart Sorte
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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