Chapter

Spinal vascular anatomy and implications

3 for treatment of arteriovenous malformations

Paul Singh and Y. Pierre Gobin

Spinal vascular anatomy

Arterial system
Spinal vascular anatomy incorporates not only the vascular sup-
ply to the cord but also that to the adjacent structures which share
common networks for blood supply, including the nerve roots,
dura, and paraspinal musculature. It is important to understand
the complex anatomical detail of the spinal column and its
anomalies prior to undergoing extensive diagnostic or therapeu-
tic spinal vascular procedures. Because vessel origins vary with
progression from the cervical to the thoracic, lumbar, and sacral
levels, this chapter starts by outlining the arteriovenous system
macroscopically (Fig. 3.1).
Superficially, the anterior two-thirds of the spinal cord is
supplied by the anterior spinal artery (ASA) and the posterior
one-third is supplied by the posterior spinal arteries (PSAs).
These vessels also anastomose over the peripheral cord to form
a pial plexus, the vasocorona (Fig. 3.2) [1].
Deeper in the spinal cord, the ASA feeds into the sulcal
arteries, which propagate into the anterior median fissure.
These central arteries then centrifugally supply the gray matter.
The vasocorona has perforators that centripetally supply the
white matter of the peripheral spinal cord (rami perforantes) [2].
Neuroanatomically, when incorporating the extrinsic and
intrinsic systems, the ASA supplies the anterior commissure,
dorsal nucleus of Clarke, corticospinal tract, spinothalamic
tract, and the anterior portions of fasciculi cuneatus and gracilis.
The PSAs supply the posterior horns, parts of the corticospinal
tracts, and the posterior third of the spinal cord [1].

Segmental arteries
The level of each segmental artery corresponds to the spinal
level it supplies rather than its site of origin from the aorta. In
the upper thoracic spine, the segmental arteries can exit the
aorta up to two levels caudal to the vertebral levels they supply.
The midthoracic segmental arteries generally exit just below
their corresponding vertebral levels, and the lumbar segmental
vessels arise typically at their respective vertebral levels. The
Fig. 3.1. Arteries supplying the spinal cord. (1) Basilar artery;
(2) vertebral artery; (3) anterior spinal artery; (4) anterior radiculomedullary
artery; (5) posterior spinal arteries; (6) ascending cervical artery; (7) deep
cervical artery; (8) subclavian artery; (9) posterior radiculomedullary artery; (10)
segmental arteries (intercostal arteries); (11) great anterior radiculomedullary
artery (artery of Adamkiewicz); (12) segmental arteries (lumbar arteries);
(13) rami cruciantes. (Reprinted from Santillan et al. 2012 [1], with permission
from BMJ Publishing Group.)

Comprehensive Management of Arteriovenous Malformations of the Brain and Spine, ed. Robert F. Spetzler, Douglas S. Kondziolka,
Randall T. Higashida, and M. Yashar S. Kalani. Published by Cambridge University Press. © Cambridge University Press 2015.

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 Section 1: Development, anatomy, and physiology of AVMs

1
6
7

3
4

2
Fig. 3.3. Posterior and anterior spinal cord arteries. (1) Posterior spinal arteries;
(2) anterior spinal artery; (3) spinal branch; (4) anterior radiculomedullary artery;
(5) posterior radiculomedullary artery; (6) central (sulcal) arteries; (7)
vasocorona. (Reprinted from Santillan et al. 2012 [1], with permission from BMJ
Publishing Group.)

Fig. 3.2. Segmental arteries supplying the spinal cord. (1) Posterior spinal
arteries; (2) anterior spinal artery; (3) anterior radiculomedullary artery; (4)
medial musculocutaneous branch; (5) lateral musculocutaneous branch; (6 &
7) retrocorporeal arteries; (8) posterior (spinal) branch; (9) anterior
branch; (10 & 11) trunk of the segmental (intercostal or lumbar) artery;
(12) aorta. (Reprinted from Santillan et al. 2012 [1], with permission from
BMJ Publishing Group.)

lower lumbar and sacral supply originates from branches of the

internal iliac arteries.
Because the aorta is located anterior to the spinal cord, the
left segmental arteries generally exit the aorta posteriorly
and the right segmental arteries originate medially [3]. Each
segmental artery has a ventral, dorsal, and spinal branch. The
spinal branch enters the intervertebral foramen and splits into
(1) the retrocorporeal (anterior spinal canal) and prelaminar
(posterior spinal canal) arteries, and (2) a radicular artery. The
radicular artery supplies nerve roots and dura at every level as
the radiculoradial or radiculomeningeal arteries. At certain
levels, the radicular artery supplies the spinal cord via branches
known as the radiculomedullary arteries. The anterior
radiculomedullary arteries supply the ASA and the posterior
radiculomedullary arteries supply the PSAs (Fig. 3.3) [4].

Anterior spinal artery

At the cervical level, the ASA originates from a medial branch
of each intracranial vertebral artery, which join together in
the midcervical spine (C2–C4)(Fig. 3.4). This vessel descends
over the central sulcus of the anterior cord all the way to the
conus medullaris [5]. En route, it acquires multiple feeders. In
Fig. 3.4. Selective right vertebral artery catheter angiogram (frontal view)
demonstrates the artery of cervical enlargement (arrow) supplying the anterior
spinal artery (arrowheads). (Reprinted from Santillan et al. 2012 [1], with
permission from BMJ Publishing Group.)

30
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 Chapter 3: Spinal vascular anatomy and implications for treatment
Fig. 3.5. Selective left vertebral artery catheter angiogram (frontal view)
shows the anterior spinal artery (arrowheads) originating from the left
vertebral artery (arrow) distal to the posterior inferior cerebellar artery origin.
(Reprinted from Santillan et al. 2012 [1], with permission from BMJ
Publishing Group.)
the cervical spine, the most prominent feeder is the artery of
cervical enlargement, which is typically a branch of the deep
cervical artery from the costocervical trunk at the C4–C8 level
(Fig. 3.5) [6].
Additional arterial supply can arise from branches of
the vertebral artery (usually around C3), the thyrocervical
trunk (C4–C6), and the costocervical trunk (C6–C8)
(Fig. 3.1) [2].
In the thoracolumbar spine, multiple anterior radiculo-
medullary feeders (usually six on average) from segmental
branches directly from the aorta give supply to the ASA
[2,7]. It is worth delineating the course of these arteries
from the aorta to the spinal cord. In the thoracic spine,
caudally from the T3 level, there are, on average, 10 pairs of
segmental arteries exiting from the aorta. Above T3, a
supreme intercostal artery emanates from the aorta and can
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divide into multiple segmental artery branches in order to
supply the upper thoracic spine.
In the lumbar spine, there are normally four pairs of
lumbar segmental arteries from L1–L4 (Fig. 3.2) [3].
Although there is much variability in the exact segmental
arteries supplying the ASA, the anterior great radiculomedullary
artery (artery of Adamkiewicz [AKA]), is a large feeder that
originates from a segmental branch from T8 to L2 in
the majority of individuals, although it can exit higher or
lower than these levels [8]. It is typically found on the left
side, taking a “hairpin” turn cranially prior to its downward
course (Fig. 3.6) [3].
The lower lumbar segmental arteries, specifically at L4 and
L5, can originate below the level of the aorta (i.e., the common
iliac arteries and the median sacral artery), which are normally
seen at the aortic bifurcation (Fig. 3.7).
Posterior spinal artery
At the level of the foramen magnum, two PSAs originate
from branches of the vertebral arteries or posterior inferior
cerebellar arteries. As mentioned above, the PSAs supply
the posterior one-third of the spinal cord, specifically the
posterior columns, dorsal lateral columns, and dorsal gray
matter. Each PSA descends along the posterolateral surface
of the spinal cord, receiving arterial feeders from 6 to 11
posterior radiculomedullary arteries as they descend caudally
[5]. It should be noted that, unlike the ASA, the PSAs are
discontinuous in their course (Fig. 3.8).
Venous system
The venous anatomy of the spinal cord is more variable than
that of the arterial system. It is convenient to subdivide the
anatomy of the venous side into a similar manner to the
arterial side: into an intrinsic system and an extrinsic
system (Fig. 3.9).
Intrinsic system
Venous drainage is not directly analogous to the arterial anat-
omy. Drainage is more regional with a central and peripheral
venous system. The peripheral, or radial, veins originate in the
capillaries at the gray–white junction and are directed centrifu-
gally. The central, or sulcal, veins drain from the medial aspects
of both halves of the spinal cord, specifically from the anterior
horns, anterior commissure, and the white matter in the ante-
rior funiculus [1].
Extrinsic system
Unlike the intrinsic system, it is convenient to correlate
the superficial extrinsic venous system with the arterial
system. The anterior median spinal vein is the closest
corollary to the ASA and descends ventrally, receiving
venous drainage from the sulcal veins and veins of the
31
 Section 1: Development, anatomy, and physiology of AVMs
A B
ventral fissure. Posteriorly, there is usually a dominant
posterior median vein, but smaller posterolateral veins
often accompany this vessel [1]. These veins receive drain-
age from the peripheral veins of the spinal cord. The
anterior and posterior median spinal veins subsequently
drain into the anterior and posterior radiculomedullary
veins, respectively, which then drain into epidural venous
plexi. There are, on average, 8–14 anterior radiculomedul-
lary veins [9] and 5–10 posterior radiculomedullary veins
[5]. The largest anterior draining vein is the great anterior
radiculomedullary vein, which drains the anterior thoraco-
lumbar spine and is the closest corollary to AKA, given
its proximity to the AKA. It is usually found from T11 to
L3 (Fig. 3.10). It should be noted that venous drainage is
normally difficult to visualize, except when injecting
the AKA. The venous phase must appear within 10 sec-
onds, otherwise it should be considered an abnormal find-
ing and a spinal dural arteriovenous fistula must be
suspected.
On average, three tortuous posterior median spinal veins
and the anterior median spinal vein descend towards the
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Fig. 3.6. Two lower thoracic selective catheter
spinal angiograms (frontal views) depicting the
typical “hairpin” turn of the artery of Adamkiewicz
(arrow), which supplies the anterior spinal artery
(arrowheads). The hemivertebral blush is noted in
(A), confirming the midline position of the anterior
spinal artery. (Reprinted from Santillan et al. 2012 [1],
with permission from BMJ Publishing Group.)
epidural venous plexus via the posterior and anterior radiculo-
medullary veins [1].
On axial views, the epidural venous plexi are best rep-
resented diagrammatically with the anterior external verte-
bral venous plexus and basivertebral vein draining the
vertebral body and the anterior internal vertebral venous
plexus draining the epidural space. Posterior external and
internal venous plexi are also present at each level. The
internal venous plexi communicate with the aforemen-
tioned radiculomedullary veins and with the external
venous plexi via the intervertebral veins in a valveless
system (Fig. 3.11).
The intervertebral veins subsequently drain into segmental
veins, which empty into the ascending lumbar and azygos
systems before entering the superior vena cava (Fig. 3.9)
[10,11].
When discussing the normal anatomy of the spinal venous
system, it is necessary to discuss physiological mechanisms
behind the venous drainage in the lower spinal cord. Many
theories exist as to how autoregulation of venous pressure occurs
in the spinal cord to prevent venous reflux under the umbrella of
 Chapter 3: Spinal vascular anatomy and implications for treatment
Fig. 3.7. Selective median sacral artery angiogram (frontal view) originating
from the aorta (white arrows). Bilateral L5 segmental arteries are seen originating
from this vessel (black arrows).
A B
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the “anti-reflux mechanism.” Early theories ascribed this to the
presence of radicular venous valves, but these valves are not
found universally in cadaveric studies. Other structures to
explain the anti-reflux mechanism have been discovered that
will help to control venous pressure, including intravenous intra-
dural folds, narrowing of radicular veins upon their entrance to
the dura, increased smooth muscle fibers in these veins to assist
in regulating waves in pressure, and a tortuous course to assist in
siphoning increases in venous pressure [12,13].
Embryology
Embryologically, bilateral capillary networks on the ventro-
lateral surface of the cord connect with segmental branches
of the aorta. These networks slowly transform into longitu-
dinal systems that eventually form the ASA by the end of the
second embryological month [5]. At this stage, there are 31
pairs of segmental arteries feeding the ASA. By the end of
the fourth embryological month, variable regression of these
vessels leaves four to eight ventral arteries supplying the
ASA, with the artery of cervical enlargement and the AKA
being the dominant vessels [14]. This variable segmental
artery regression also leads to the origination of the vertebral
arteries, thyrocervical trunks, and costocervical trunks in the
cervical region and the iliac arteries in the lumbar region
[15]. Venous networks are forming as these arterial anasto-
moses develop early in the embryo. It is thought that many
vascular malformations can originate at this critical time,
three to six weeks after gestation [16]. The premise of
Fig. 3.8. Selective catheter spinal angiograms showing the
differences between the anterior (A) and posterior (B)
radiculomedullary arteries. (A) The hairpin curve formed
when the anterior radiculomedullary artery (arrow) joins the
anterior spinal artery (arrowheads) is round. (B) The posterior
radiculomedullary artery (arrow) makes a sharper turn
when reaching the posterior spinal artery (arrowheads).
(Reprinted from Santillan et al. 2012 [1], with permission from
BMJ Publishing Group.)
33
 Section 1: Development, anatomy, and physiology of AVMs
Fig. 3.9. Venous drainage of the spinal cord. (1) Right vertebral vein; (2) anterior
median vein; (3) right deep cervical vein; (4) left vertebral vein; (5) subclavian vein
(6) left deep cervical vein; (7) internal jugular vein; (8) left subclavian vein;
(9) superior vena cava; (10) accessory hemiazygos vein; (11) intercostal veins; (12)
posterior radiculomedullary vein; (13) anterior radiculomedullary vein;
(14) azygos vein; (15) hemiazygos vein; (16) lumbar veins. (Reprinted from
Santillan et al. 2012 [1], with permission from BMJ Publishing Group.)
variable arterial regression in altering the vascular supply of
the spinal cord at any given level underscores the need for an
exhaustive angiogram of all potential feeding vessels for
spinal vascular anomalies (Fig. 3.12). There are fewer data
on the embryological development of the venous system [5].
Spinal anastomoses
Knowledge of spinal anastomotic networks is essential for
an adequate characterization of spinal vascular lesions
and subsequent treatment of these abnormalities. Failure
to do so may result in inaccurate false-negative spinal
angiograms or incompletely treated arteriovenous malfor-
mations [17].
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Arterial anastomoses
Extradural anastomoses
The extradural anastomoses are divided into intraspinal
and extraspinal systems. The extraspinal system, also known as
the paravertebral anastomotic network, is a longitudinal network
that runs along the lateral aspect of the vertebral bodies and is
best defined in the cervical spine where the vertebral artery,
ascending cervical artery, and deep cervical arteries can commu-
nicate [18]. It is also evident between adjacent segmental arteries.
The intraspinal system, or retrocorporeal arterial network, is
primarily a transverse network that connects the right and left
segmental arteries and is best recognized as a diamond-shaped
network located in the dorsal epidural space posterior to the
vertebral bodies [15].
Pial anastomoses
The pial arterial network, also known as the vasocorona, is an
arterioarterial connection between the anterior and posterior
spinal systems that is not visualized on a normal spinal
angiogram because of the small caliber of these vessels,
although it visible in high-flow lesions such as arteriovenous
malformations [15].
Conus anastomoses
Commonly referred to as the “arterial basket” the conus
anastomosis is the anastomotic arcade located at the conus
medullaris that connects the ASA to two PSAs via the rami
cruciantes [15]. Radicular arteries from the cauda equina
also go through this network because of the abundant
vascular arterial supply [15].
Venous anastomoses
Although not uniform in their anatomy, venous anastomoses
can be subdivided into central–peripheral and transmedul-
lary types. The central–peripheral type connects sulcal and
radial veins and the transmedullary type is a midline anasto-
mosis of the left and right median veins [18]. The latter is
a larger, more important, network that can sometimes be
visualized on MRI as well as angiography. It should be
noted that the transmedullary system is largest in the
cervicothoracic spine [5].
Although a thorough investigation of all potential spinal
anastomoses is needed to diagnose a treatable lesion, occasion-
ally angiography must look beyond the spine itself. One addi-
tional pathological anastomosis is the type 5 craniocervical
dural arteriovenous fistula, which can clinically present as
dysfunction of the upper cord or lower brainstem and radio-
graphically with edema in the cervical spine and/or brainstem.
The existence of these fistulae underlines the need not only for a
spinal angiogram but also for cerebral angiography when
searching for treatable lesions [19–23].
 Chapter 3: Spinal vascular anatomy and implications for treatment

A B Fig. 3.10. Selective spinal angiography

demonstrating the greater anterior radicular vein.
Left T11 angiograms with a prolonged injection of
contrast to better visualize the angioanatomy at the
conus medullaris. (A) Late arterial phase. In this
particular patient, all three radiculomedullary
arteries of the conus medullaris are seen: (1) the
artery of Adamkiewicz; (2 & 2’) the right and left
posterior radiculomedullary arteries; (3) the right
retrocorporeal artery; (4) transmedian anastomosis
of the retrocoporeal arteries (note how the right
retrocorporeal arteries fill via this anastomosis on
this left intercostal artery angiogram); (5) capillary
blush of the conus medullaris. (B) Late venous phase
(10–12 seconds). (6) The greater anterior radicular
vein is well visualized; (7) narrowing at the dural
passage that has been identified as a potential anti-
reflux mechanism; (8) epidural vein. Note also other
veins following the nerve roots of the filum
terminale.

Fig. 3.11. Veins of the spinal cord in axial views.

(1) Anterior external vertebral venous plexus;
(2) basivertebral vein; (3) anterior internal vertebral venous
plexus; (4) intervertebral vein; (5) anterior and posterior
radicular veins; (6) posterior internal vertebral venous
plexus; (7) posterior external vertebral venous plexus;
(8) posterior spinal vein; (9) posterior central vein; (10) pial
venous plexus; (11) anterior central vein; (12) anterior
spinal vein.

A B C Fig. 3.12. Embryological development of the arterial system. (A)

Metameric stage with individual arteries supplying each spinal level.
(B) Formation of longitudinal anastomoses. (C) Segmental regression
and fusion of arteries with formation of a central artery.

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 Section 1: Development, anatomy, and physiology of AVMs
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