Last Updated: June 22, 2021
The spinal cord circulation is derived from segmental branches arising from the vertebral arteries, as well as multiple radicular arteries arising from segmental vessels in parallel, including the descending cervical, deep cervical, intercostal, lumbar, and sacral arteries. The venous drainage of the spinal cord is more symmetric and redundant when compared to the arterial system with both minimal anterior to posterior and right to left segmental variation.
Figure 1: Axial CT Angiogram neck with contrast. This image demonstrates the most common variant of the aortic arch – an aberrant right subclavian artery (green arrow). This artery variation typically traverses posteriorly to the trachea/esophagus and can result in dysphagia for the patient called dysphagia luscoria. The other vessel origins from the aortic arch are as follows: left subclavian artery (yellow arrow), left common carotid artery (blue arrow), and the brachiocephalic trunk (purple).
Figure 2: CT Angiogram of the neck – maximal intensity projection 3-D reformat, posterior oblique view. This image demonstrates a common variant in which the left vertebral artery arises from the aortic arch (green), creating a four vessel aortic arch. The other artery origins from the aortic arch are as follows: left subclavian artery (yellow arrow), left common carotid artery (blue arrow), and the brachiocephalic trunk (purple). There is a conventional origin of the right vertebral artery origin from the left subclavian artery (red arrow).
Figure 3: Conventional cerebral angiogram with digital subtraction images to review the posterior circulation in the anterior-posterior projection. The catheter is injecting angiographic contrast through the left vertebral artery (yellow arrow) which demonstrates the most distal branch, the posterior inferior cerebellar artery (green arrow). Other artery branches that are included in the image: anterior inferior cerebellar artery (purple arrow), basilar artery (blue arrow), superior cerebellar artery (red arrow), and posterior cerebral artery (pink arrow).
Figure 4: Conventional cerebral angiogram with digital subtraction images of the posterior circulation in the lateral projection. Again the catheter is injecting angiographic contrast into the left vertebral artery (yellow arrow). The distal most branch from the vertebral artery is the posterior inferior cerebellar artery (green arrow). The basilar artery is marked with the blue arrow.
Figure 5: Axial MRI of the thoracic spine at the T11 vertebral body level with contrast. There are only a couple of arteries that can be identified on MRI lining the spinal cord. Anteriorly, one can typically see the anterior spinal artery (green arrow) while posteriorly, one can typically see one or two of the posterior spinal arteries (yellow arrow). The vessels along the lateral aspect of the spinal canal is the internal vertebral venous plexus (blue arrow).
Figure 6: Conventional spinal angiogram utilizing digital subtraction angiography. These images demonstrate the supreme intercostal origin of the cervical spinal artery (blue arrows) which is occasionally visualized but can be difficult to catherize at times.
Figure 7: Conventional angiogram of the spinal arteries. The spinal arteries can opacify a single lumbar level, however, on occasion there may be a common trunk which supplies two levels. This image demonstrates a common trunk (green arrow) that supplies the T11 spinal artery (blue arrow) in addition to supplying the T12 spinal artery (yellow arrow).
Figure 8: Conventional spinal angiogram with digital subtraction angiography technique. Common lumbar spinal artery trunks are also quite common, especially in the lower lumbar spine. This image demonstrates a common trunk (green arrow) for the right L5 lumbar spinal artery (yellow arrow) as well as the left L5 lumbar spinal artery (blue arrow). The artery descending inferiorly is the middle sacral artery (purple artery).
Figure 9: Conventional angiogram with utilization of digital subtraction angiography technique. This angiogram is at the level of the right L1 lumbar artery which demonstrates the Artery of Adamkiewicz, the largest anterior segmental medullary artery (blue arrows). This artery ascends on the mid-sagittal anterior surface of the spinal cord, usually less than 2.5 vertebral body lengths. This image demonstrates the classic hairpin turn at its anastomosis with the anterior spinal artery (green arrow). The radiculomedullary artery (yellow arrow) often demonstrates a small segment of narrowing at the point where the artery pierces the dura of the spinal canal (purple arrow).
Typically, the intrinsic cord venous drainage consists of paired radial draining veins, which drain into the anastomoses on the cord surface. Central veins in the anterior median fissure provide for venous return from the anterior horns and surrounding white matter and form the anterior median vein. The anterior median vein continues caudally along the filum terminale to the end of the thecal sac. The median veins drain to the “trans-dural” medullary (radicular) veins, which leave the intradural space at the root sleeve.
Peripheral and dorsolateral cord drainage is via the radial venous plexus, which extends to the coronal venous plexus on the cord surface, and then drains to the epidural venous plexus (of Batson), plexiform venous channels located at the anterior and posterior midline and antero- and posterolaterally along the line of attachments of the dorsal and ventral rootlets, a
continuous system from the sacrum to the skull base.
Connections with the azygos and hemiazygos venous systems include the vertebral and deep cervical veins (cervical); the intercostal-segmental veins (thoracic); segmental veins connected by the ascending lumbar vein (lumbar). Additionally, the basivertebral veins (intravertebral body), anterior plexus (vertebral body) and posterior plexus (posterior elements) components connect with the superior and inferior vena cava, azygos and hemiazygos systems, and the intracranial dural sinuses.
Intradural veins
Intrinsic cord venous system
Figure 10: CT angiogram of the neck at the T1 vertebral body with contrast. This image demonstrates the venous plexus that surrounds the spinal canal. Along the posterior aspect of the vertebral body, there is demonstration of the Batson’s venous plexus (blue arrow). From the Batson’s venous plexus centrally, there are additional veins that extend laterally called the anterior epidural venous plexus (green) and travel within and around the corresponding nerve sheaths (yellow arrow) called emissary veins. The vessels that travel through the vertebral body from the Batson’s venous plexus correspond to the basivertebral veins (purple).
Figure 11: Sagittal CT Angiogram of the neck with contrast. The venous plexus surrounding the spinal canal can be visualized occasionally on a CT Angiogram. The Batson’s venous plexus is located along the posterior aspect of the vertebral body (blue arrow). Additionally, there are veins that extend from the Batson’s venous plexus laterally to the level of the neuroforamina which are medullary veins (yellow arrow). There is also an extensive venous network which surround the spinous processes which are referred to as the paraspinal venous network (green).
Figure 12: Coronal CT angiogram of the neck with contrast. The venous plexus occasionally can be visualized on a CT angiogram. On this coronal image, the venous network is within and surrounding the corresponding nerve sheaths (blue arrow) which are called emissary veins.
Figure 13: Axial MRI image of the lumbar spine at the L1 vertebral body level with contrast. With contrast administration, along the anterior aspect of the spinal canal, the Batson’s venous plexus is highlighted (blue arrow). There are additional veins that are extending through the central aspect of the vertebral body corresponding to the basivertebral vein (yellow arrow).
Figure 14: Sagittal MRI image of the lumbar spine with contrast. This image demonstrates the Batson’s venous plexus along the anterior spinal canal (blue arrow). Additionally, there are small veins running through the vertebral body from the Batson’s venous plexus called the basivertebral veins (yellow arrow).
Contributors: Katie Traylor DO, Daniel Murph MD
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