Adamkiewicz Artery in Pediatric Posterior Thoracic Tumors |
| Posterior
thoracic tumors in pediatric patients, particularly those of neurogenic
origin such as neuroblastomas and ganglioneuromas, pose unique surgical
challenges due to their proximity to the Artery of Adamkiewicz (AKA).
This artery, the primary blood supply to the anterior spinal cord, is
often located between the T8 and L1 vertebral levels and exhibits
significant anatomical variability. Inadvertent injury to the AKA
during tumor resection can lead to catastrophic outcomes, including
anterior spinal cord ischemia, paraparesis, or paraplegia.
Consequently, accurate preoperative identification of the AKA is
critical to surgical planning and patient safety. Recent advancements in imaging techniques, particularly spinal angiography (SA) and Magnetic Resonance Angiography (MRA), have revolutionized preoperative evaluation for pediatric patients with posterior thoracic tumors. These modalities allow detailed mapping of the spinal vasculature, enabling surgeons to plan resections that minimize the risk of vascular injury. Studies have demonstrated that incorporating these imaging techniques into preoperative protocols not only improves surgical outcomes but also reduces the incidence of neurologic complications. One study involving 36 pediatric patients evaluated the utility of preoperative spinal angiography. Among these patients, SA identified the AKA in all cases, demonstrating its reliability in mapping vascular anatomy. In four cases where the AKA was in close proximity to the tumor, surgical plans were modified, with three patients undergoing non-surgical management, such as radiation therapy, to mitigate risk. Importantly, no complications arose from the SA procedure itself, highlighting its safety and efficacy as a preoperative tool. Another key finding from recent research is the significant reduction in neurologic complications when SA is employed. A retrospective analysis comparing outcomes before and after the routine use of SA in pediatric posterior thoracic tumor resections revealed a marked decrease in the incidence of postoperative spinal ischemia. Prior to implementing routine SA, one patient in the study cohort developed paraplegia following resection. Post-SA implementation, no such complications were observed, underscoring the role of detailed preoperative vascular mapping in enhancing patient safety. In addition to spinal angiography, Magnetic Resonance Angiography (MRA) has shown promise as a non-invasive alternative for visualizing the AKA. A case report highlighted the successful use of MRA in a 14-month-old child with a thoracic neuroblastoma. The imaging identified the precise location of the AKA, allowing the surgical team to avoid critical vascular structures during resection. MRA's non-invasive nature and ability to provide high-resolution images make it particularly suitable for pediatric patients, where minimizing procedural risks is paramount. Despite these advancements, challenges remain in achieving consistent and accurate preoperative identification of the AKA. The artery's variability in origin, pathway, and laterality necessitates a tailored approach for each patient. Moreover, the choice of imaging modality—whether SA, MRA, or a combination—often depends on institutional resources and expertise. While spinal angiography remains the gold standard for AKA visualization, its invasive nature, and associated risks, though minimal, must be carefully weighed against the benefits in each case. The integration of imaging findings into surgical decision-making has profound implications for treatment strategies. In cases where the AKA is identified in close proximity to the tumor, surgeons may opt for partial resections, alternative surgical approaches, or adjunctive therapies such as radiation. This tailored approach not only preserves spinal cord function but also improves overall outcomes by reducing the likelihood of tumor recurrence or residual disease. Studies also emphasize the importance of interdisciplinary collaboration in managing these complex cases. The involvement of pediatric surgeons, interventional radiologists, and neuro-oncologists ensures a comprehensive evaluation of risks and benefits, facilitating informed decision-making. Multidisciplinary tumor boards play a pivotal role in this process, integrating imaging findings with clinical and pathological data to devise individualized treatment plans. Further research is needed to refine imaging techniques and establish standardized protocols for preoperative evaluation of the AKA. Emerging technologies, such as advanced MRI sequences and 3D vascular mapping, hold promise for enhancing the accuracy and accessibility of preoperative imaging. Additionally, longitudinal studies assessing long-term outcomes in patients undergoing surgery with preoperative AKA identification will provide valuable insights into the efficacy of these strategies. In conclusion, the preoperative identification of the Adamkiewicz Artery is a critical component of surgical planning for pediatric posterior thoracic tumors. Techniques such as spinal angiography and Magnetic Resonance Angiography enable precise vascular mapping, significantly reducing the risk of spinal ischemia and associated neurologic complications. By incorporating these modalities into preoperative protocols and fostering interdisciplinary collaboration, healthcare teams can optimize surgical outcomes and improve the quality of life for pediatric patients with these challenging tumors. Continued advancements in imaging technology and research will further enhance the safety and efficacy of these interventions, paving the way for improved standards of care in pediatric oncology. References: 1- Boglino C, Martins AG, Ciprandi G, Sousinha M, Inserra A: Spinal cord vascular injuries following surgery of advanced thoracic neuroblastoma: an unusual catastrophic complication. Med Pediatr Oncol. 32(5):349-52, 1999 2- Nordin AB, Fallon SC, Jea A, Kim ES: The use of spinal angiography in the management of posterior mediastinal tumors: case series and review of the literature. J Pediatr Surg. 48(9):1871-7, 2013 3- Schmidt A, Hempel JM, Ellerkamp V, Warmann SW, Ernemann U, Fuchs J: The Relevance of Preoperative Identification of the Adamkiewicz Artery in Posterior Mediastinal Pediatric Tumors. Ann Surg Oncol. 29(1):493-499, 2022 4- Clark RA, Jacobson JC, Murphy JT: Preoperative spinal angiography decreases risk of spinal ischemia in pediatric posterior thoracic tumor resection. Pediatr Surg Int. 38(10):1427-1434, 2022 5- Almeida AI, Vasconcelos-Castro S, Sampaio L: Successful technical note-Identification of the Adamkievicz artery with 1.5 Tesla MR angiography in a 14-month-old child. Radiol Case Rep. 18(1):188-191, 2022 5- 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 |
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