Artery of Adamkiewicz |
| The
spinal cord depends on a surprisingly fragile network of blood vessels,
and among these, one artery stands out for the outsized role it plays
in keeping the lower spinal cord alive. Known as the artery of
Adamkiewicz, or by its older name arteria radicularis magna, this
vessel is the single largest contributor of blood to the anterior
spinal artery along the thoracolumbar region. While the spinal cord as
a whole receives blood from multiple small radicular branches coming
off the aorta, most of these vessels regress during development,
leaving only a handful of dominant feeders. In the vast majority of
people, one vessel clearly outranks the others in size and importance,
and it is this vessel that carries the name of the nineteenth-century
physician who first described it in detail. Anatomically, the artery arises from an intercostal or lumbar branch of the descending aorta, most often on the left side, and enters the spinal canal through an intervertebral foramen alongside an exiting spinal nerve root. Once inside the canal, it turns sharply upward, forming what is often described as a hairpin or "candy-cane" curve, before merging with the anterior spinal artery. This anterior spinal artery, in turn, supplies roughly the front two-thirds of the spinal cord, an area responsible for motor function and for the pathways carrying pain and temperature sensation. Because the artery of Adamkiewicz is so often the dominant supply to this region in the lower thoracic and lumbar cord, any interruption of its flow can produce a strikingly consistent pattern of injury: sudden weakness or paralysis below the level of damage, along with loss of bladder and bowel control, while the sense of touch and joint position often remains intact, since those pathways travel through a different part of the cord that receives blood from other vessels. What makes this artery clinically important is not just its role in normal physiology but its extraordinary variability from person to person. Its point of origin can be as high as the mid-thoracic spine or as low as the upper lumbar region, and while it favors the left side in the great majority of individuals, a meaningful minority have it entering from the right, or in rare cases have more than one such vessel altogether. This unpredictability means that a surgeon cannot simply assume where the artery will be based on textbook averages. A vessel that supplies such a large portion of the spinal cord, yet whose location differs so much between patients, becomes a genuine hazard whenever an operation approaches the aorta, the vertebral column, or the tissues surrounding the spinal canal. In adults, this concern arises most often during surgery on the thoracic or abdominal aorta, where aneurysm repair or stent placement can interrupt segmental arteries feeding the spinal cord and cause devastating paralysis if the artery of Adamkiewicz is sacrificed without warning. But the same anatomical hazard extends squarely into pediatric surgery, and in some ways it becomes even more consequential in children because of the types of tumors that develop close to the spine early in life. Posterior thoracic and paraspinal masses, most commonly neuroblastic tumors such as neuroblastoma, ganglioneuroblastoma, and ganglioneuroma, frequently arise directly beside or even within the neural foramina through which this artery passes. Some of these tumors grow in a distinctive dumbbell shape, extending from the chest cavity into the spinal canal through the very foramen the artery uses to reach the cord. Operating to remove such a tumor completely, without leaving behind malignant tissue that could recur, means working in immediate proximity to a vessel whose injury could leave a child permanently paralyzed or incontinent. This is precisely why identifying the artery before surgery has become such a central concern in the care of children with these tumors. Surgeons and radiologists have several imaging tools available, including computed tomography angiography and magnetic resonance angiography, both of which are noninvasive and can often reveal the vessel's course without exposing a child to the risks of a catheter-based procedure. Yet for decades, the recognized gold standard for visualizing spinal blood supply has been catheter spinal angiography, a more invasive test in which contrast is injected directly into the small arteries feeding the spinal cord. Because it directly opacifies the vessel rather than relying on indirect signals, angiography tends to succeed in locating the artery more consistently than cross-sectional imaging alone, particularly in small children where vessel caliber is tiny and imaging resolution is more limited. Encouragingly, when this invasive test has been used in children, it has proven remarkably safe, with essentially no reported complications directly attributable to the procedure itself, even in infants weighing only a few kilograms. The payoff for this extra effort appears to be real. When surgeons know beforehand exactly where the artery enters the spinal canal, they can plan their operative approach, choose which side to work from, decide how aggressively to dissect near the foramen, and adjust their technique to avoid the vessel entirely, or deliberately preserve it if the tumor surrounds it. Children who underwent successful preoperative identification of the artery experienced markedly fewer neurological complications after surgery compared to those in whom the vessel's location remained unknown, and in some reported groups, no child with a properly identified artery went on to develop paralysis or other neurologic sequelae afterward. This does not mean imaging guarantees complete removal of every tumor, since some masses so thoroughly encase the artery that surgeons choose to leave a small remnant of tumor behind rather than risk the child's mobility and continence, a trade-off that speaks to how seriously this single blood vessel is regarded in the operating room. Beyond the tumor setting, the same anatomical hazard occasionally intersects with other procedures performed near the spine, including epidural injections, vertebral fracture treatments, and instrumented spinal fusion, all of which carry a small but recognized risk of catastrophic cord injury if a needle, screw, or cement inadvertently damages this vessel or its branches. Across every context in which it appears, the lesson remains the same: a structure barely a millimeter wide, tucked into an unpredictable location along the spine, can determine whether a patient walks away from surgery or spends the rest of their life dealing with paralysis, making careful preoperative attention to the artery of Adamkiewicz one of the most important anatomical considerations in modern pediatric surgical oncology and spine care. References: 1- Taterra D, Skinningsrud B, Pekala PA, Hsieh WC, Cirocchi R, Walocha JA, Tubbs RS, Tomaszewski KA, Henry BM. Artery of Adamkiewicz: a meta-analysis of anatomical characteristics. Neuroradiology. 61(8):869-880, 2019 2- Piola FPF, Nogueira-Barbosa MH, Maranho DAC, Martins AA, Barbosa MF, Herrero CFPS. Identification of the Artery of Adamkiewicz Using Multidetector Computed Tomography Angiography (MCTA). Rev Bras Ortop (Sao Paulo). 55(1):70-74, 2020 3- Slavkov D. Artery of Adamkiewicz. Korean J Neurotrauma. 18(2):399-403, 2022 4- Zarfati A, Guérin F, Dioguardi Burgio M, Fuchs J, Sarnacki S, Losty PD, Pio L. Preoperative Identification of Adamkiewicz Artery in Pediatric Posterior Thoracic Tumors: Fact or Fiction? A Systematic Review from the International Society of Pediatric Surgical Oncology (IPSO). J Pediatr Surg. 59(12):161985, 2024 5- Lindeire S, Hauser JM. Anatomy, Back, Artery of Adamkiewicz. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan–. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|