Acute celiac artery compression syndrome (ACACS) after surgery for spinal deformity is a rare but severe complication with potentially fatal consequences1-6). We report a case in which median arcuate ligament (MAL) resection was performed before spinal surgery for preoperative celiac artery (CA) compression.
A 71-year-old female patient with a history of Parkinson's disease visited our hospital with a chief complaint of trunk imbalance and leg pain. Preoperative standing radiographs showed scoliosis with substantial coronal imbalance and thoracolumbar kyphosis (Fig. 1). We planned a two-stage anterior-posterior combined surgery. Contrast-enhanced abdominal computerized tomography (CT) was performed to evaluate the abdominal anatomy and found stenosis of the CA (Fig. 2).
Figure 1.
Preoperative radiographs.
a. Preoperative whole spine standing radiographs showing scoliosis with substantial coronal imbalance (18.2 cm).
b. Lateral radiograph showing kyphotic deformity with a thoracolumbar kyphosis of 27°.
Figure 2.
Preoperative contrast-enhanced abdominal computerized tomography images.
A. Contrast-enhanced abdominal CT image of the abdomen, showing stenosis of the celiac artery (a. 3D image, b. sagittal image).
B. Sagittal image of another patient with adult spinal deformity, but without celiac artery stenosis.
Arrow, celiac artery; dotted arrow, superior mesenteric artery.
In the gastrointestinal field, the chronic compression of the CA by the MAL is known as MAL compression syndrome, but the syndrome is rare7). Similar to the mechanism of MAL compression syndrome, excessive kyphosis correction also causes acute compression of the CA, leading to multiple organ failure in ACACS1-3,5,6). Moreover, because of the preoperative stenosis of the CA, we were concerned that this patient was at considerably more risk of developing ACACS1,3). We considered it would be better to perform MAL resection before spine surgery to avoid ACACS. Therefore, we sought a gastrointestinal surgeon at another hospital with experience in MAL resection and requested MAL resection. After laparotomy, the MAL was dissected to release compression of the CA (Fig. 3).
Figure 3.
Intraoperative photograph of median arcuate ligament resection.
The celiac artery was compressed by a median arcuate ligament. After the median arcuate ligament was resected, the compression of the celiac artery was relieved.
Two months after MAL resection, oblique lumbar interbody fusion at L3-L4 and L4-L5 and posterior fixation from L1 to the ilium were performed. Because excessive correction of kyphosis of the thoracolumbar spine is also considered to cause ACACS1), we took care not to overcorrect the kyphosis. Neither abdominal pain nor elevation of transaminase and amylase, which are signs of ACACS8,9), was seen after surgery. Two days after the initial surgery, a final corrective fusion from T4 to ilium was performed. Postoperatively there were no important complications. The patient's preoperative deformity and preoperative pain had been resolved (Fig. 4).
Figure 4.
Radiographs after final correction and fusion surgery.
a. Postoperative radiograph showing improvement of coronal imbalance (2.8 cm).
b. We were careful not to overcorrect the thoracolumbar kyphosis (11°).
We had taken the following three measures to avoid ACACS. First, we confirmed the anatomy of the CA using contrast-enhanced CT before surgery because the incidence of CA stenosis in the general population was seen in 4.46%10). Second, the MAL resulting in CA stenosis was resected before spinal surgery. Third, final fixation was conducted after initial lumbar correction confirmed the absence of ACACS. After the initial surgery, if ACACS signs were present, we could weaken the kyphosis correction during our final fixation.
Of the reported cases of ACACS, some have had severe outcomes, including death1,2,4), while for two cases in which MAL resection was performed within a few days after spinal surgery, there were good postoperative outcomes3,6). Thus, early MAL resection after the onset of ACACS is an effective treatment. However, MAL resection is not a frequently performed surgery in the gastrointestinal field7). Furthermore, the occurrence of ACACS due to corrective surgery is not well known, except to spine surgeons. Therefore, even if spine surgeons discovered ACACS postoperatively and requested an urgent MAL resection, the procedure may not be performed immediately, leading to missed life-saving opportunities. Therefore, we chose to perform a preoperative MAL resection before spine surgery.
To our knowledge, this is the first report of a patient with CA stenosis at risk of causing ACACS who underwent MAL resection before spinal surgery and had a favorable outcome. Although further analysis is needed to determine which patients may develop ACACS, preoperative MAL resection may be an option to avoid ACACS in patients with CA stenosis, who are at high risk of developing the syndrome.
Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.
Sources of Funding: None.
Author Contributions: Toshiaki Kotani wrote and prepared the manuscript, and all the authors contributed to the study design. All authors have read, reviewed, and approved the manuscript.
Ethical Approval: Ethical approval was not necessary for clinical correspondence.
Informed Consent: The patient and her family consented to submitting the case data for publication.
Acknowledgement
The authors thank Ms. Yuri Ichikawa and Ms. Nana Kondo for assisting with the data collection.
References
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