It is necessary to assess the branching level of the artery of Adamkiewicz (AKA) before repair of the thoracoabdominal or descending thoracic aorta. Spinal damage (paraplegia/paraparesis) is a severe complication that can arise during such surgery, as a result of ischemia, and the risk of such damage is therefore a limitation of this procedure. Irreversible spinal complications can drastically decrease a patients quality of life. Recent studies have demonstrated the feasibility and advantages of the assessment of the AKA with both magnetic resonance (MR) angiography and computed tomographic (CT) angiography. In this article, the authors review the challenges surrounding the current imaging and clinical work-up of the AKA and provide a framework for understanding the potential role of MR and CT in a pre-operative setting for the prevention of the spinal complications.