Anatomy of the intraosseous arterial microvasculature of the adult lumbar vertebral body and its role in fracture healing: a literature review and historical perspective.

Background and Objective: Although awareness of vertebral body osteonecrosis following fractures has increased, it remains underdiagnosed and represents one of the most challenging and unpredictable complications after spinal trauma. The arterial supply of the vertebral body may play an important role in fracture healing; however, this remains unproven and is not currently incorporated into treatment algorithms. This study aims to conduct a narrative review of the intraosseous arterial microvasculature of the adult lumbar vertebral body and its role in fracture healing, including a historical perspective. Methods: A literature review of the PubMed/MEDLINE databases was conducted using two separate searches: one focusing on the anatomy of the intraosseous arterial microvasculature of the adult lumbar vertebral body, and the other on the role of arterial injury in vertebral body fracture healing. Key Content and Findings: Seventeen articles were included in the first topic and forty-seven in the second. All studies included in this review are presented in ascending chronological order of publication to provide a clear overview of the progression of knowledge over time. The evolution of intraosseous arterial anatomical descriptions and their evaluation methods is presented, along with the currently accepted and established arterial morphology, including arteriole groups and vascular segments. The role of ischemic arterial vascular injury in vertebral body fracture healing and its contribution to post-traumatic vertebral osteonecrosis are discussed from a historical perspective and according to levels of evidence, culminating in an overview of state-of-the-art evidence. Conclusions: Despite the limited number of available anatomical studies, the most widely accepted description includes one group of arteries penetrating the anterolateral surfaces of the vertebral body and another entering through the posterior surface, with anterior arterial dominance being widely recognized. The anterior third is more susceptible to ischemia due to limited collateral capacity, particularly in the anterosuperior and anteroinferior regions, as well as in the central area. Despite the low level of evidence, the most accepted etiological theory for post-traumatic vertebral osteonecrosis is ischemic and vascular in origin, suggesting a vicious cycle of fracture-ischemia-necrosis. Understanding the intraosseous arterial anatomy of vertebral bodies is important for elucidating the pathophysiology of fracture healing and post-traumatic vertebral osteonecrosis.