Intraforaminal location of thoracolumbar anterior medullary arteries

Andrzej C. Kroszczynski, Kevin Kohan, Marek Kurowski, Todd R. Olson, Sherry A. Downie

Research output: Contribution to journalArticle

27 Citations (Scopus)

Abstract

Background: Transforaminal epidural steroid injection (TFESI) is a widely utilized interventional pain technique for radicular pain. Although the six o'clock position of the pedicle in the so-called "safe triangle" has been used as a target location, there have been a number of reported catastrophic complications of this procedure, including paraplegia. The mechanism of this has been attributed to the intravascular injection of steroids. The goal of this study was to examine the intraforaminal location of thoracolumbar medullary arteries which would help guide pain physicians in developing safer techniques and guidelines. Methods: Twenty-four (24) embalmed cadavers were dissected and examined for the presence and distribution of thoracolumbar anterior medullary arteries. Access to the anterior surface of the spinal cord was made via anterior corpectomy from C2 to S5. Each medullary artery's course was determined by dissection from its origin, the anterior spinal artery, through the intervertebral foramen. The foramen was subsequently opened in the coronal plane, and the intraforaminal location of the artery, its diameter, and its relation to other foraminal structures were examined and measured. Results: In the thoracolumbar foramina (T4-L2), 39 anterior medullary arteries were found, including 23 great medullary arteries (Adamkiewicz artery). One Adamkiewicz artery was found to be located in the left S2 foramen and was not included in the statistical analysis. Of the analyzed 39 anterior medullary arteries, 29 (74%) were located in the upper 1/3 of the foramen, 9 (23%) were located in the middle, and 1 (3%) artery was located in the lower 1/3. In relation to the dorsal root ganglion-ventral root complex, 21 (54%) arteries were located anterosuperiorly, 16 (41%) anteriorly, and 2 (5%) anteroinferiorly. The average intraforaminal artery diameter was 1.20mm (0.84-1.91mm). At thoracolumbar levels, the artery is almost always (92%±15%) located anterosuperior to the nerve. At typical thoracic levels, it is less often anterosuperior (38%±19%), but more often anterior to the nerve. Conclusions: At thoracolumbar levels, if needles were to encounter an artery, they are most likely to do so if placed anterosuperior to the nerve. Encountering an artery anterosuperior to the nerve is less likely at typical thoracic levels, but the likelihood is far from negligible. Pain physicians should be cognizant of this when considering optimal needle placement during transforaminal epidural steroid injections.

Original languageEnglish (US)
Pages (from-to)808-812
Number of pages5
JournalPain Medicine (United States)
Volume14
Issue number6
DOIs
StatePublished - Jun 2013

Fingerprint

Arteries
Epidural Injections
Pain
Steroids
Needles
Thorax
Physicians
Spinal Nerve Roots
Paraplegia
Spinal Ganglia
Cadaver
Dissection
Spinal Cord
Guidelines

Keywords

  • Artery of adamkiewicz
  • Epidural
  • Medullary artery
  • Safe triangle intraforaminal
  • Transforaminal

ASJC Scopus subject areas

  • Clinical Neurology
  • Anesthesiology and Pain Medicine

Cite this

Intraforaminal location of thoracolumbar anterior medullary arteries. / Kroszczynski, Andrzej C.; Kohan, Kevin; Kurowski, Marek; Olson, Todd R.; Downie, Sherry A.

In: Pain Medicine (United States), Vol. 14, No. 6, 06.2013, p. 808-812.

Research output: Contribution to journalArticle

Kroszczynski, Andrzej C. ; Kohan, Kevin ; Kurowski, Marek ; Olson, Todd R. ; Downie, Sherry A. / Intraforaminal location of thoracolumbar anterior medullary arteries. In: Pain Medicine (United States). 2013 ; Vol. 14, No. 6. pp. 808-812.
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title = "Intraforaminal location of thoracolumbar anterior medullary arteries",
abstract = "Background: Transforaminal epidural steroid injection (TFESI) is a widely utilized interventional pain technique for radicular pain. Although the six o'clock position of the pedicle in the so-called {"}safe triangle{"} has been used as a target location, there have been a number of reported catastrophic complications of this procedure, including paraplegia. The mechanism of this has been attributed to the intravascular injection of steroids. The goal of this study was to examine the intraforaminal location of thoracolumbar medullary arteries which would help guide pain physicians in developing safer techniques and guidelines. Methods: Twenty-four (24) embalmed cadavers were dissected and examined for the presence and distribution of thoracolumbar anterior medullary arteries. Access to the anterior surface of the spinal cord was made via anterior corpectomy from C2 to S5. Each medullary artery's course was determined by dissection from its origin, the anterior spinal artery, through the intervertebral foramen. The foramen was subsequently opened in the coronal plane, and the intraforaminal location of the artery, its diameter, and its relation to other foraminal structures were examined and measured. Results: In the thoracolumbar foramina (T4-L2), 39 anterior medullary arteries were found, including 23 great medullary arteries (Adamkiewicz artery). One Adamkiewicz artery was found to be located in the left S2 foramen and was not included in the statistical analysis. Of the analyzed 39 anterior medullary arteries, 29 (74{\%}) were located in the upper 1/3 of the foramen, 9 (23{\%}) were located in the middle, and 1 (3{\%}) artery was located in the lower 1/3. In relation to the dorsal root ganglion-ventral root complex, 21 (54{\%}) arteries were located anterosuperiorly, 16 (41{\%}) anteriorly, and 2 (5{\%}) anteroinferiorly. The average intraforaminal artery diameter was 1.20mm (0.84-1.91mm). At thoracolumbar levels, the artery is almost always (92{\%}±15{\%}) located anterosuperior to the nerve. At typical thoracic levels, it is less often anterosuperior (38{\%}±19{\%}), but more often anterior to the nerve. Conclusions: At thoracolumbar levels, if needles were to encounter an artery, they are most likely to do so if placed anterosuperior to the nerve. Encountering an artery anterosuperior to the nerve is less likely at typical thoracic levels, but the likelihood is far from negligible. Pain physicians should be cognizant of this when considering optimal needle placement during transforaminal epidural steroid injections.",
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AU - Kurowski, Marek

AU - Olson, Todd R.

AU - Downie, Sherry A.

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N2 - Background: Transforaminal epidural steroid injection (TFESI) is a widely utilized interventional pain technique for radicular pain. Although the six o'clock position of the pedicle in the so-called "safe triangle" has been used as a target location, there have been a number of reported catastrophic complications of this procedure, including paraplegia. The mechanism of this has been attributed to the intravascular injection of steroids. The goal of this study was to examine the intraforaminal location of thoracolumbar medullary arteries which would help guide pain physicians in developing safer techniques and guidelines. Methods: Twenty-four (24) embalmed cadavers were dissected and examined for the presence and distribution of thoracolumbar anterior medullary arteries. Access to the anterior surface of the spinal cord was made via anterior corpectomy from C2 to S5. Each medullary artery's course was determined by dissection from its origin, the anterior spinal artery, through the intervertebral foramen. The foramen was subsequently opened in the coronal plane, and the intraforaminal location of the artery, its diameter, and its relation to other foraminal structures were examined and measured. Results: In the thoracolumbar foramina (T4-L2), 39 anterior medullary arteries were found, including 23 great medullary arteries (Adamkiewicz artery). One Adamkiewicz artery was found to be located in the left S2 foramen and was not included in the statistical analysis. Of the analyzed 39 anterior medullary arteries, 29 (74%) were located in the upper 1/3 of the foramen, 9 (23%) were located in the middle, and 1 (3%) artery was located in the lower 1/3. In relation to the dorsal root ganglion-ventral root complex, 21 (54%) arteries were located anterosuperiorly, 16 (41%) anteriorly, and 2 (5%) anteroinferiorly. The average intraforaminal artery diameter was 1.20mm (0.84-1.91mm). At thoracolumbar levels, the artery is almost always (92%±15%) located anterosuperior to the nerve. At typical thoracic levels, it is less often anterosuperior (38%±19%), but more often anterior to the nerve. Conclusions: At thoracolumbar levels, if needles were to encounter an artery, they are most likely to do so if placed anterosuperior to the nerve. Encountering an artery anterosuperior to the nerve is less likely at typical thoracic levels, but the likelihood is far from negligible. Pain physicians should be cognizant of this when considering optimal needle placement during transforaminal epidural steroid injections.

AB - Background: Transforaminal epidural steroid injection (TFESI) is a widely utilized interventional pain technique for radicular pain. Although the six o'clock position of the pedicle in the so-called "safe triangle" has been used as a target location, there have been a number of reported catastrophic complications of this procedure, including paraplegia. The mechanism of this has been attributed to the intravascular injection of steroids. The goal of this study was to examine the intraforaminal location of thoracolumbar medullary arteries which would help guide pain physicians in developing safer techniques and guidelines. Methods: Twenty-four (24) embalmed cadavers were dissected and examined for the presence and distribution of thoracolumbar anterior medullary arteries. Access to the anterior surface of the spinal cord was made via anterior corpectomy from C2 to S5. Each medullary artery's course was determined by dissection from its origin, the anterior spinal artery, through the intervertebral foramen. The foramen was subsequently opened in the coronal plane, and the intraforaminal location of the artery, its diameter, and its relation to other foraminal structures were examined and measured. Results: In the thoracolumbar foramina (T4-L2), 39 anterior medullary arteries were found, including 23 great medullary arteries (Adamkiewicz artery). One Adamkiewicz artery was found to be located in the left S2 foramen and was not included in the statistical analysis. Of the analyzed 39 anterior medullary arteries, 29 (74%) were located in the upper 1/3 of the foramen, 9 (23%) were located in the middle, and 1 (3%) artery was located in the lower 1/3. In relation to the dorsal root ganglion-ventral root complex, 21 (54%) arteries were located anterosuperiorly, 16 (41%) anteriorly, and 2 (5%) anteroinferiorly. The average intraforaminal artery diameter was 1.20mm (0.84-1.91mm). At thoracolumbar levels, the artery is almost always (92%±15%) located anterosuperior to the nerve. At typical thoracic levels, it is less often anterosuperior (38%±19%), but more often anterior to the nerve. Conclusions: At thoracolumbar levels, if needles were to encounter an artery, they are most likely to do so if placed anterosuperior to the nerve. Encountering an artery anterosuperior to the nerve is less likely at typical thoracic levels, but the likelihood is far from negligible. Pain physicians should be cognizant of this when considering optimal needle placement during transforaminal epidural steroid injections.

KW - Artery of adamkiewicz

KW - Epidural

KW - Medullary artery

KW - Safe triangle intraforaminal

KW - Transforaminal

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