Russian Roulette of Thoracic Spinal Endoscopy: The Importance of Preoperative Identification of Adamkiewicz System

Thoracic endoscopic spine surgery is gaining traction. During thoracic decompression, the arterial Adamkewicz system (AKA) can be encountered, with potentially severe implications if injured. This chapter outlines a diagnostic protocol and patient selection for the surgery based on a study examining surgical risks tied to the radicular magna artery. The authors share insights from fifteen patients with thoracic herniated discs and spinal stenosis who underwent preoperative CTA. This assessed the anatomical relationship of the Magna radicular artery to the surgical area. The Adamkiewicz artery's prevalent locations were T10/11 (15.4%), T11/12 (23.1%), and T9/10 (30.8%). Patients were grouped into three categories based on their pathology's proximity to the AKA foraminal entry. In five instances, the Magna radicular artery entered the spinal canal near the nerve root at the surgery site, prompting a surgical approach adjustment. The authors advocate for CTA evaluation to gauge surgical risks and adapt thoracic discectomy techniques based on the magna radicular artery's closeness to the pathology.