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Artery of Adamkiewicz: a meta-analysis of anatomical characteristics

  • Dominik Taterra
  • Bendik Skinningsrud
  • Przemysław A. Pękala
  • Wan Chin Hsieh
  • Roberto Cirocchi
  • Jerzy A. Walocha
  • R. Shane Tubbs
  • Krzysztof A. TomaszewskiEmail author
  • Brandon Michael Henry
Open Access
Spinal Neuroradiology

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.

Keywords

Adamkiewicz artery Anatomy Great anterior radiculomedullary artery Thoracoabdominal aneurysm Aortic aneurysm 

Introduction

The artery of Adamkiewicz (AKA), also known as the great anterior radiculomedullary artery, is a major artery that joins the anterior spinal artery in the lower one-third of the spinal cord (Fig. 1) [1]. Because of its large role in feeding the spinal cord, many reports have stressed the importance of reattaching the intercostal or lumbar arteries to the AKA in the event of spinal cord ischemia following vascular and endovascular surgery (Fig. 2). Identification of the AKA preoperatively helps surgeons to determine the appropriate range of aortic lesions that require graft replacement [2]. Therefore, accurate localization and detailed anatomical knowledge of the AKA are important when planning surgical and interventional radiological treatments of thoracoabdominal diseases and spinal lesions in order to help reduce the risk of postoperative ischemic spinal complications and paraplegia.
Fig. 1

Vasculature of the spinal cord—the artery of Adamkiewicz (great radicular a.)

Fig. 2

Intraoperative image of the artery of Adamkiewicz

The AKA is the most dominant anterior radiculomedullary artery and is responsible for the arterial blood supply to the spinal cord from T8 to the conus medullaris [3]. Its origin is highly variable and extends from the mid-thoracic level to the lumbar levels, including the bilateral T3-T12 intercostal arteries [4] and L1-L4 lumbar arteries [5]. It typically arises from the T8–L1 neural foramina [6] from the left intercostal or lumbar arteries [7]. The AKA has a diameter of 0.8–1.3 mm, and the distal portion of this artery, together with the anterior spinal artery, forms a characteristic “hairpin” turn [8] (Fig. 3). Various techniques have been devised to preoperatively identify the location and anatomy of this artery. Such techniques include computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), with the latter considered the gold standard [9].
Fig. 3

Cadaveric dissection of the artery of Adamkiewicz

The most important cause of injury to the AKA is iatrogenic, and in part, this is a factor of the high degree of variability in the anatomical location of this artery [10]. Preoperative AKA identification and its subsequent reconstruction or preservation may aid in reducing the incidence of postoperative neurological deficits and improving the outcomes of thoracolumbar surgical procedures. To this end, the aim of this study was to provide comprehensive data on the prevalence and anatomical characteristics of the AKA.

Materials and methods

Search strategy

A search of all major electronic databases (PubMed, EMBASE, ScienceDirect, China National Knowledge Infrastructure (CNKI), SciELO, BIOSIS, and Web of Science) was performed in order to identify potential articles. The following search terms were employed: artery of Adamkiewicz, arteria radicularis magna (ARM), radicularis magna, great radicular artery of Adamkiewicz, major anterior segmental medullary artery, great anterior segmental medullary artery, artery of the lumbar enlargement, arteria radicularis anterior magna, and great anterior radiculomedullary artery. A search through the references of the initially selected articles was conducted to identify any potential studies that were omitted. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines throughout this meta-analysis (Supplement 1).

Eligibility assessment

An eligibility assessment was conducted by two independent reviewers. Studies were included in this meta-analysis if they (1) provided complete data on the prevalence of the AKA or (2) provided data on the anatomy of AKA. The following exclusion criteria were employed: case, case-series, conference abstracts, letters to editors, and studies not published in peer-reviewed journals. Studies that were originally published in languages other than English were translated by medical professionals who are fluent both in English and the original language of the manuscript. All differences of opinion among the reviewers concerning the eligibility of the studies were resolved by consensus through consultation with the author of the respective study.

Data extraction

Two reviewers carried out data extraction independently. The following data was extracted: publication year, country of origin, study type (cadaveric, CTA, MRA, DSA), prevalence data of AKA, number of AKAs per patient, laterality of the AKA, origin of the AKA based on the vertebral level, side of origin, and morphometric data. In cases of incomplete data, the authors of the original articles were contacted for clarification.

Quality assessment

The AQUA tool [11] was used by the reviewers to evaluate quality and reliability of the included studies. In brief, the tool was devised to probe for potential risk of bias. Five domains were evaluated in the analysis: (1) objective(s) and subject characteristics, (2) study design, (3) methodology characterization, (4) descriptive anatomy, and (5) reporting of results; and each domain was categorized as either of “Low,” “High,” or “Unclear” risk of bias. Decision was made that a “No” answer in whichever signaling question within each of the categories arbitrated the domain to be of “High” risk of bias, whereas all answers “Yes” suggested that it presented a “Low” risk of bias. “Unclear” option was chosen when the study with incoherent data did not permit for a clear scrutiny.

Statistical analysis

The prevalence analysis was conducted using MetaXL version 5.8 by EpiGear Pty Ltd. (Wilston, Queensland, Australia). Morphometric analysis using Comprehensive Meta-Analysis version 3.3 yielded the pooled mean diameter of the AKA. Single and multi-categorical pooled prevalence rates were calculated using a random effects model. Heterogeneity was assessed using a chi-squared test and the I2 statistic. For the I2 statistic, the values of 0–40% indicated that heterogeneity might not be important; values of 30–60% could indicate moderate heterogeneity; values of 50–90% could indicate substantial heterogeneity; and values of 75–100% indicated considerable heterogeneity. A p value below 0.10 for Cochran’s Q suggested significant heterogeneity [12].

An analysis of the subgroups was conducted to determine the source of heterogeneity. The difference between the groups was considered to be insignificant if the confidence intervals (CIs) of specific rates overlapped [13]. Subgroups according to study type, gender, and geographical location were analyzed.

Results

Study identification and characteristics of included studies

The study identification process is presented in Fig. 4. An initial search yielded 747 entries. After thorough analysis, 627 entries were excluded. In total, 120 articles were analyzed, and 60 studies were included in this meta-analysis.
Fig. 4

Flow diagram of included studies

The characteristics of the included studies are presented in Table 1. A total of 60 studies (4317 subjects with AKA) published between 1989 [14] and 2017 [15] were included [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62]. The studies originated from North America, Asia and Europe, and from ten different countries.
Table 1

Characteristics of included studies

Study

Country

Type of study

Number of subjects

% prevalence of AKA (no. of subjects with AKA)

Alleyne 1998

USA

Cadaveric

10

90.0 (9)

Amako 2011

Japan

CTA

110

100.0 (110)

Bachet 1996

France

CTA

36

77.8 (28)

Backes 2008

Netherlands

MRA

85

100.0 (85)

Biglioli 2004

Italy

Cadaveric

51

100.0 (51)

Bley 2010

Germany

MRA

68

88.2 (60)

Boll 2006

USA

MDCT angiography

100

100.0 (100)

Bowen 1996

USA

MRA

6

100.0 (6)

Champlin 1994

USA

DSA

61

32.8 (20)

Charles 2011

France

DSA

100

96.0 (96)

Fanous 2015

USA

DSA

34

70.6 (24)

Fereshetian 1989

USA

DSA

12

75.0 (9)

Furukawa 2010

Japan

CTA

37

100.0 (37)

Gailloud 2013

USA

DSA

50

92.0 (46)

Guzinski 2017

Poland

MSCT

200

21.5 (43)

Heinemann 1998

Germany

DSA

46

65.2 (30)

Hyodoh 2005

Japan

MRA

50

84.0 (42)

Hyodoh 2007

Japan

MRA (double subtraction maximum intensity projection)

170

82.4 (140)

Hyodoh 2009

Japan

MRA

82

81.7 (67)

Jaspers 2007

Netherlands

MRA

20

100.0 (20)

Kawaharada 2002

Japan

MRA

40

72.5 (29)

Kawaharada 2004

Japan

MRA

120

82.5 (99)

Kawaharada 2007

Japan

MRA

83

85.5 (71)

Kieffer 1989

France

Arteriography

45

88.9 (40)

Kieffer 2002

France

Arteriography

480

87.3 (419)

Koshino 1999

Japan

Cadaveric

102

88.2 (90)

Kovacs 2009

Germany

CT

51

70.6 (36)

Kroszczynski 2013

USA

Cadaveric

24

95.8 (23)

Kudo 2003

Japan

MDCT

19

68.4 (13)

Matsuda 2010

Japan

MRA and CTA

50

94.0 (47)

Matsuda 2010a

Japan

MRA and CTA

60

80.0 (48)

Melissano 2009

Italy

MDCT

67

67.2 (45)

Mordasini 2012

Switzerland

MRA

24

83.3 (20)

Morishita 2003

Japan

Cadaveric

55

100.0 (55)

Murthy 2010

USA

Spinal angiography

248

46.4 (115)

Nakayama 2008

Japan

CTA

80

56.3 (45)

Nijenhuis 2004

Netherlands

MRA

8

100.0 (8)

Nijenhuis 2007

Netherlands

MRA and CTA

39

100.0 (39)

Nijenhuis 2007a

Netherlands

MRA

60

100.0 (60)

Nishida 2014

Japan

CT

33

75.8 (25)

Nishii 2013

Japan

CTA

160

81.9 (131)

Nojiri 2007

Japan

CTA

27

100.0 (27)

Ogino 2006

Japan

MRA

92

70.7 (65)

Ou 2007

France

CTA

40

95.0 (38)

Polaczek 2014

Poland

Cadaveric

28

100.0 (28)

Rodriguez-Baeza 1991

Spain

Cadaveric

30

100.0 (30)

Schurink 2007

Netherlands

MRA

9

100.0 (9)

Sukeeyamonon 2010

Thailand

MDCT angiography

73

71.2 (52)

Takagi 2015

Japan

MRA and MDCTA

117

89.7 (105)

Takase 2002

Japan

MDCT

70

90.0 (63)

Takase 2007

Japan

MDCT

10

90.0 (9)

Tanaka 2016

Japan

MRA and CTA

1252

87.5 (1096)

Uotani 2008

Japan

CTA

32

78.1 (25)

Utsunomiya 2008

Japan

CTA

80

62.5 (50)

Williams 1991

USA

Retrograde femoral artery catherization

47

55.3 (26)

Yamada 2000

Japan

MRA

26

69.2 (18)

Yingbin 2013

China

MDCT

217

55.8 (121)

Yoshioka 2003

Japan

MRA and CTA

30

90.0 (27)

Yoshioka 2006

Japan

MRA and CTA

30

96.7 (29)

Zhao 2009

China

MDCTA

51

35.3 (18)

Quality assessment

The majority of studies included in this meta-analysis, evaluated by the AQUA tool, revealed domain one (objective(s) and subject characteristics) and domain three (methodology characterization) to be at “High” risk of bias, owing to missing demographic data of the research group and no information regarding experience of the researchers. All studies had a “Low” risk of bias found in domain two (study design) and domain five (reporting of results), and almost all studies had a “Low” risk of bias found in domain four (descriptive anatomy). The AQUA tool evaluation can be found in Table 2.
Table 2

The AQUA tool—tabular display

Study

Risk of bias

Objective(s) and study characteristics

Study design

Methodology characterization

Descriptive anatomy

Reporting of results

Alleyne 1998

High

Low

High

Low

Low

Amako 2011

Low

Low

High

Low

Low

Bachet 1996

High

Low

High

High

Low

Backes 2008

High

Low

High

Low

Low

Biglioli 2004

Low

Low

High

High

Low

Bley 2010

Low

Low

High

Low

Low

Boll 2006

High

Low

High

High

Low

Bowen 1996

High

Low

High

Low

Low

Champlin 1994

High

Low

High

Low

Low

Charles 2011

High

Low

High

Low

Low

Fanous 2015

High

Low

High

Low

Low

Fereshetian 1989

High

Low

High

Low

Low

Furukawa 2010

High

Low

High

Low

Low

Gailloud 2013

High

Low

High

Low

Low

Guzinski 2017

High

Low

High

Low

Low

Heinemann 1998

High

Low

High

Low

Low

Hyodoh 2005

High

Low

High

High

Low

Hyodoh 2007

High

Low

High

Low

Low

Hyodoh 2009

High

Low

High

High

Low

Jaspers 2007

High

Low

High

Low

Low

Kawaharada 2002

High

Low

High

Low

Low

Kawaharada 2004

High

Low

High

Low

Low

Kawaharada 2007

High

Low

High

Low

Low

Kieffer 1989

High

Low

High

High

Low

Kieffer 2002

High

Low

High

Low

Low

Koshino 1999

High

Low

High

Low

Low

Kovacs 2009

High

Low

High

Low

Low

Kroszczynski 2013

High

Low

High

Low

Low

Kudo 2003

High

Low

High

Low

Low

Matsuda 2010

High

Low

High

High

Low

Matsuda 2010a

High

Low

High

High

Low

Melissano 2009

High

Low

Low

High

Low

Mordasini 2012

High

Low

Low

High

Low

Morishita 2003

High

Low

High

Low

Low

Murthy 2010

Unclear

Low

High

Low

Low

Nakayama 2008

High

Low

Low

Low

Low

Nijenhuis 2004

High

Low

Unclear

Low

Low

Nijenhuis 2007

High

Low

High

Low

Low

Nijenhuis 2007a

High

Low

High

Low

Low

Nishida 2014

High

Low

Low

High

Low

Nishii 2013

High

Low

Low

High

Low

Nojiri 2007

High

Low

High

Low

Low

Ogino 2006

High

Low

High

High

Low

Ou 2007

High

Low

Unclear

High

Low

Polaczek 2014

High

Low

High

Low

Low

Rodriguez-Baeza 1991

High

Low

High

Low

Low

Schurink 2007

High

Low

High

Low

Low

Sukeeyamonon 2010

High

Low

Low

High

Low

Takagi 2015

High

Low

Low

Low

Low

Takase 2002

High

Low

High

Low

Low

Takase 2007

High

Low

High

High

Low

Tanaka 2016

High

Low

High

Low

Low

Uotani 2008

High

Low

High

Low

Low

Utsunomiya 2008

High

Low

High

Low

Low

Williams 1991

High

Low

High

Low

Low

Yamada 2000

High

Low

High

Low

Low

Yingbin 2013

High

Low

High

Low

Low

Yoshioka 2003

High

Low

High

Low

Low

Yoshioka 2006

High

Low

High

Low

Low

Zhao 2009

High

Low

High

Low

Low

Prevalence of the artery of Adamkiewicz

A total of 60 studies (n = 5437 subjects) reported data on the prevalence of the AKA. The pooled prevalence estimate (PPE) of the AKA was 84.6% (95% CI 79.7–89.0) (Table 3).
Table 3

Overall prevalence of AKA

Subgroup

Number of studies (number of subjects)

Pooled prevalence of AKA: % (95% CI)

I2 % (95% CI)

Cochran’s Q, p value

Overall

60 (5437)

84.6 (79.7–89.0)

95.3 (94.5–95.9)

< 0.001

Gender

Males

15 (515)

93.7 (83.3–100.0)

94.0 (91.6–95.7)

< 0.001

Females

14 (345)

90.4 (68.9–100.0)

96.4 (95.2–97.4)

< 0.001

Type of study

Cadaveric

7 (300)

97.5 (92.4–100.0)

72.2 (38.8–87.1)

0.001

CTA

9 (602)

88.1 (74.0–97.6)

94.4 (91.4–96.4)

< 0.001

MRA

16 (943)

88.3 (81.9–93.4)

85.1 (77.3–90.3)

< 0.001

DSA

6 (303)

75.4 (49.1–94.9)

94.9 (91.2–97.0)

< 0.001

Country of origin

Japan

27 (3017)

85.3 (81.0–89.2)

87.5 (83.0–90.8)

< 0.001

USA

10 (592)

79.5 (57.0–95.7)

96.3 (94.7–97.4)

< 0.001

France

5 (701)

89.8 (83.8–94.6)

69.0 (20.4–87.9)

0.012

Netherlands

6 (221)

99.4 (98.2–100.0)

0.0 (0.0–0.0)

0.972

The subgroup analysis of gender differences showed that the AKA was slightly more prevalent in males (93.7% [95% CI 83.3–100.0]) than females (90.4% [95% CI 68.9–100.0]), although not significantly.

Seven cadaveric studies (n = 300) yielded the highest PPE of the AKA (97.5% [95% CI 92.4–100.0]) among the different study types. This was followed by MRA, CTA, and DSA studies with PPEs of 88.3%, 88.1%, and 75.4%, respectively (Table 3).

The subgroup analysis of geographical origin showed that the AKA was most prevalent in the Netherlands, with a PPE of 99.4% (95% CI 98.2–100.0); France with a PPE of 89.8% (95% CI 83.8–94.6); and Japan, with a PPE of 85.3 (95% CI 81.0–89.2). It was least prevalent in the USA, with a PPE of 79.5% (95% CI 57.0–95.7).

Number of arteries of Adamkiewicz per patient

An analysis of 20 studies (n = 1329 subjects with AKAs) showed that the majority of patients (87.4% [95% CI 83.4–91.9]) had one AKA. Patients presented with two AKAs in 11.3% (95% CI 7.5–15.8) of cases, three AKAs in 0.8% (95% CI 0.0–2.5) of cases, and four AKAs in 0.5% (95% CI 0.0–1.6) of cases.

In patients with two AKAs, the majority (73.3% [95% CI 47.3–93.4]) presented unilaterally as duplications. A total of 26.7% (95% CI 6.6–52.7; I2 66.2%, 95% CI 12.0–87.0; p = 0.019) of patients with two AKAs had bilateral configuration.

Origin of the artery of Adamkiewicz

A total of 56 studies (n = 3316 patients with AKA) analyzed the side of origin of AKA. The results showed that 76.6% (95% CI 73.2–79.9) of AKAs originated from the left side, while 23.4% (95% CI 20.1–26.8; I2 78.5%, 95% CI 72.5–83.2; p < 0.001) from the right side. The analysis of 43 studies (n = 2834 patients with AKA) showed that 89% of arteries originated between T8 and L1 (Table 4). AKA most frequently originated at the level of T9 with PPE of 22.2% (95% CI 18.9–25.4), followed by T10 and T11 with PPE of 21.7% (95% CI 18.5–25.0) and 18.7% (95% CI 15.6–21.8), respectively.
Table 4

Origin of AKA (vertebral levels)

Number of studies (number of subjects with AKA)

T3: % (95% CI)

T4: % (95% CI)

T5: % (95% CI)

T6: % (95% CI)

T7: % (95% CI)

T8: % (95% CI)

T9: % (95% CI)

T10: % (95% CI)

T11: % (95% CI)

T12: % (95% CI)

L1: % (95% CI)

L2: % (95% CI)

L3: % (95% CI)

L4: % (95% CI)

L5: % (95% CI)

I2: % (95% CI)

Cochran’s Q, p value

43 (2834)

0.5 (0.1–1.3)

0.7 (0.2–1.6)

0.8 (0.2–1.7)

0.8 (0.2–1.8)

2.2 (1.2–3.5)

7.3 (5.3–9.4)

22.2 (18.9–25.4)

21.7 (18.5–25.0)

18.7 (15.6–21.8)

12.2 (9.7–14.8)

6.9 (5.0–9.0)

3.8 (2.4–5.5)

1.1 (0.4–2.1)

0.5 (0.1–1.3)

0.5 (0.1–1.2)

74.7 (66.0–81.2)

< 0.001

Continuity of the artery of Adamkiewicz

A total of seven studies (n = 375 patients with AKAs) were included in an analysis of the continuity of the AKA from the aorta to the anterior spinal artery. The results showed that AKA continued from the aorta to the anterior spinal artery in 71.3% of patients (95% CI 45.8–91.6; I2 95.6%, 95% CI 92.8–97.2; p < 0.001).

Morphometric analysis of the artery of Adamkiewicz

Five studies (n = 324 patients with AKA) analyzed the morphometric data of the AKA. The analysis showed a pooled mean diameter of 1.09 mm (95% CI 0.69–1.50; I2 36.2%; p < 0.001).

Discussion

Because the AKA originates from the lumbar arteries, it may be prudent to preserve the blood flow from the lumbar arteries when a thoracoabdominal aortic repair is planned [5, 63]. Concomitant or previous abdominal aortic repair and extensive thoracic aorta exclusion by means of multiple stent grafts are associated with a significantly higher risk of paraplegia [64]. After the interruption of most of the intercostal and lumbar arteries, the residual collateral blood supply is marginal, and in some cases, the spinal cord may become extremely prone to injury due to arterial hypotension or low cardiac output from any cause [65]. During aortic repair, preservation, reattachment, or reconstruction of the intercostal or lumbar arteries can maintain the blood supply to the spinal cord [66, 67]. Depending on the number of intercostal or lumbar arteries that require reconstruction, the ischemic duration may be prolonged during reconstruction. In our study, in patients with an AKA present, 11.3% had two AKAs, with bilateral AKAs present in 26.7% of these patients. The preoperative identification of the AKA and its anatomical characteristics allows for superior surgical planning, such that the surgical time and postoperative spinal complication risk are decreased [31]. Therefore, AKA identification is of interest for surgeons aiming to reconstruct intercostal or lumbar arteries in order to prevent postoperative spinal ischemic complications [3].

With respect to the continuity between the radicular arteries (including the AKA) and the anterior spinal arteries, the AKA continued from the aorta to the anterior spinal artery in 71.3% of the patients in our study. When this continuity is present, blood may drain away from the spinal cord through the anterior spinal arteries and the radicular arteries, acting as stealing channels by rerouting the blood to be distal to an aortic obstruction [5]. During aortic cross-clamping, back-bleeding from the ostia of the posterior intercostal and lumbar arteries may be a clinical manifestation of such rerouting of blood when continuity between the AKA and the anterior spinal arteries is present. This steal phenomenon may further worsen spinal cord ischemia, causing irreversible neurological injuries if the ischemia time is longer than 20 to 30 min [68].

The detection of the AKA can be difficult because of the various possible levels of origins of the artery, its small size, the amount of time needed to obtain the angiogram, and complications that can occur during surgical procedures [14, 26]. In our study, the pooled mean diameter of the AKA was 1.09 mm. Various techniques have been devised to preoperatively identify the location and anatomy of the AKA, such as CTA [55], MRA [7], and DSA [9]. These techniques can be used to identify both the level and the laterality of the artery, which can affect a surgeon’s approach to an aneurysm or spinal lesion. We have included three DSA images with injected contrast into left radicular artery at the level of T4 (Fig. 5), T8 (Fig. 6), and T11 (Fig. 7). In our meta-analysis, cadaveric studies had the highest prevalence of an AKA (97.5%), and among the different imaging modalities, MRA and CTA had the highest prevalence rates (88.3% and 88.1%, respectively), while DSA had the lowest prevalence rate (75.4%). In spite of its apparent success in detecting an AKA, MRA has been shown to be inferior to DSA in terms of evaluating vessel continuity, sharpness, and background homogeneity [7]. Furthermore, compared with CTA, a more limited field of view is a major disadvantage of MRA [61]. As a result, MRA may fail to depict the clinically important collateral vessels to the AKA in some patients, when a collateral source is the internal thoracic artery or the thoracodorsal artery [69]. Despite DSA studies reporting a lower prevalence rate of the AKA than MRA and CTA in our meta-analysis, DSA remains the “gold standard” for identifying spinal cord vasculature as it is both safe and efficient [9]. A possible reason for this discrepancy could be the small number of patients included in our DSA analysis as compared to the number of patients included in our MRA and CTA analyses.
Fig. 5

Digital subtraction angiography image of the artery of Adamkiewicz from left T4 radicular artery injection

Fig. 6

Digital subtraction angiography image of the artery of Adamkiewicz from left T8 radicular artery injection

Fig. 7

Digital subtraction angiography image of the artery of Adamkiewicz from left T11 radicular artery injection

Future studies should examine the blood supply and the collateral circulation of the spinal cord in the presence of degenerative atherosclerotic or dissecting aneurysm, or after a surgical or endovascular aortic procedure. In these patients, the disease and the surgical procedure may occlude several segmental arteries and promote collateral vessels enlargement, significantly altering the normal patterns of blood supply to the spinal cord [5].

Our meta-analysis was limited by the high amount of heterogeneity between the studies. However, the number of included studies and their large sample sizes mitigate this limitation. As cadaveric dissection is the gold standard for anatomical considerations, more cadaveric studies should assess prevalence of AKA, especially performed on subjects poorly represented in our meta-analysis, such as Africa, South America, and Oceania.

Because of the lower prevalence of AKA in radiological studies, surgeons should keep in mind that these results might be false negative. In this case, the risk of iatrogenic injury to the AKA during thoracolumbar surgical procedures is increased. More accurate imaging methods should be developed to assess the true prevalence of AKA.

To ensure spinal cord safety, preoperative AKA identification and its subsequent reconstruction or preservation are effective adjuncts for more secure protection of the spinal cord, along with other adequate management strategies.

Conclusions

Our main findings revealed that the AKA was found to be present in the vast majority of the general population (84.6%), most often as a single vessel (87.4%) originating between T8 and L1 (89%) on the left side (76.6%). Based on our anatomical findings, we recommend that efforts should be made to identify and subsequently reconstruct or preserve the AKA to prevent postoperative neurological deficit due to spinal cord ischemia in vascular and endovascular surgical procedures in the thoracolumbar spinal cord.

Notes

Acknowledgements

KAT was supported by the Polish Ministry of Higher Education grant for young scientists.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

For this type of meta-analysis study formal consent is not required.

Informed consent

NA

Supplementary material

234_2019_2207_MOESM1_ESM.doc (64 kb)
ESM 1 (DOC 64 kb)

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© The Author(s) 2019

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • Dominik Taterra
    • 1
    • 2
  • Bendik Skinningsrud
    • 1
    • 2
  • Przemysław A. Pękala
    • 1
    • 2
  • Wan Chin Hsieh
    • 1
    • 3
  • Roberto Cirocchi
    • 4
  • Jerzy A. Walocha
    • 1
    • 2
  • R. Shane Tubbs
    • 5
  • Krzysztof A. Tomaszewski
    • 1
    • 6
    Email author
  • Brandon Michael Henry
    • 1
  1. 1.International Evidence-Based Anatomy Working GroupKrakówPoland
  2. 2.Department of AnatomyJagiellonian University Medical CollegeKrakówPoland
  3. 3.First Faculty of MedicineCharles UniversityPragueCzech Republic
  4. 4.Department of Surgical Sciences, Radiology and DentistryUniversity of PerugiaPerugiaItaly
  5. 5.Seattle Science FoundationSeattleUSA
  6. 6.Faculty of Medicine and Health SciencesAndrzej Frycz Modrzewski KrakowUniversityKrakówPoland

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