MEDIAN ARCUATE LIGAMENT SYNDROME CAUSED BY TRAUMA

Objectives: Median arcuate ligament syndrome (MALS) results in the in symptoms such as epigastric pain, air hunger, nausea, difficulty eating due to postprandial pain and weight loss. This condition is secondary to compression of the celiac artery and celiac nerve ganglia by the median arcuate ligament as it attaches from the spine to the diaphragm. Given that the symptoms can be nondescript, MALS can be a challenging diagnosis to make. Herein we present the first series of patient who developed MALS following abdominal or spinal trauma.

Methods: Retrospective chart review of MALS patients with history of trauma.

Results: Four patients, each suffered a traumatic injury to their spine or abdomen, then developed symptomatic MALS and required surgical intervention. Two patients suffered back injury following a fall, 1 had a motor vehicle accident and 1 patient developed symptoms following iatrogenic injury to the spleen requiring splenectomy for a different surgical procedure. No patients had epigastric or postprandial pain prior to their injury. After injury each patient reported feelings of debilitating pain, nausea or discomfort, particularly after eating. Patient age ranged from 17 to 37 years old, and 75% were female. During the course of their work-up for chronic abdominal pain, mesenteric duplex ultrasound was performed and identified elevated peak systolic velocities in the celiac artery consistent with a diameter reduction of 60-99%. One patient underwent mesenteric angiogram where it was noted to have pronounced hooking of the celiac artery along with 90% compression of the celiac artery with inspiration which resolved with expiration. Each patient underwent a diagnostic celiac plexus nerve block that relieved their symptoms and allowed for increased oral intake. The diagnostic block gave relief for between 4 and 72 hours. Each patient underwent surgical decompression with resection of the median arcuate ligament and extensive neurolysis that resulted in complete resolution of postprandial pain and nausea.

Conclusion: Median arcuate ligament syndrome is a difficult diagnosis to make and requires a high index of clinical suspicion. If left undiagnosed and untreated, MALS can result in severe disability and poor quality of life due to chronic pain and malnutrition. To our knowledge, this is a first series to identify a correlation between abdominal and spinal trauma with MALS.