The lordogenetic midline congestion syndrome

At the European Ultrasound Congress EUROSON in  Ljubljana, 22 nd  – 24 th  September 2017 I inaugurated my novel concept of the  lordogenetic midline congestion syndrome.

This is to underscore the pathogenetic continuum of all nine abdominal vascular compression syndromes. In my own practice I observe more than nine “officially known” compression syndromes. Not rarely, quite individual and unique syndromes can be found in some patients due to the compression of a certain mesenteric vein, compression of the colon or the stomach and others. With the exception of the lumbar artery compression, the femoral vein compression and the compression of the inferior vena cava the more common ones are described on the following pages of abdominal vascular compression syndromes.

The sequelae of the lumbar lordosis are not restricted to abdominal compression syndromes. A strong lumbar lordosis can cause subsequently a stronger cervical lordosis. Here the compression of the jugular veins can be found which may be compressesd by the lateral processes of the cervical vertebra.

Also a medium grade left sided convex scoliosis of the lumbar spine is quite often found. So the influx of congested blood from the left paravertebral veins is made easier. This may cause neurological as well as orthopedic symptoms.

 

My concept of the novel lordogenetic midline congestion syndrome is outlined below:

Abdominal vascular compression syndromes are regarded as rare diseases.

In fact, in the author‘s experience, they are very frequent but are missed due to misconceptions regarding their mechanisms.

A main characteristic of all vascular compression syndromes is the eye catching preponderance of females. For more than 90% of all cases occur in women or girls but quite rarely before puberty.

I present here a unifying concept for all kinds of vascular compression syndromes. It is based on the specific characteristics of the human spine. The bipedal human gait leads to a vertical orientation of the spine which is a unique feature not present in other bipedal animals. After the first year of life, the spine is set under a longitudinal gravitational pressure due to the upright position in standing and walking. The adaptation to gravity is an S-shaped configuration with a lordosis in the lumbar spine. Lordosis is more prominent in younger women and postpubertal girls than in any other population subset. The abdominal vascular compression syndromes may be regarded an extension of gynecology but prompt to dissolve the borders between medical specialties, because many of them are contacted by the suffering patient. Only who can look beyond the borders of one specialty will recognize  the true origin of the symptoms and can treat properly.

My thesis:

Lordosis is the decisive factor in all abdominal compression syndromes

The anterior lordotic bending of the aorta is closing the clamp of the aorto-mesenteric angle – causing

  1. Nutcracker syndrome
  2. Superior mesentric artery syndrome (aka Wilkie-or SMA syndrome) and

the diaphragmatic crura are thus pulled tight from above against the superior bow of lordosis – causing

3.Celiac trunk and celiac ganglion compression syndrome (AKA Arcuate ligament syndrome , Dunbar syndrome) and

4. Lumbar artery compression

The stretching of the right common iliac artery across the apex of the lordosis causes

5. May-Thurner-syndrome and

6. Compression of the inferior vena cava due to streching of this vein across the lordotic apex

The obstructed venous outflow from the left kidney is deviated via the so called midline organs causing a congestion of the pelvic organs as are

the uterus, left ovary, rectum, vagina, urinary bladder  this is called

7. Pelvic congestion syndrome

and with additional congestion of the spine ( via the tronc reno-rachidién and the hemiazygos vein towards the epidural plexus) which, together with the congestion of the pelvic midline organs, was named

  1. Midline congestion syndrome

Moreover, in slender women  the overextension of the hips in upright stance and supine posture  with stretched legs may cause

  1. Compression of the femoral veins

between the pecten ossis pubis and the inguinal ligament.

 

Important practical consequences

1.Abdominal vascular compression syndromes are not separate diseases but parts of a spectrum of one entity – the lordogenetic midline congestion syndrome and thus often occur together

2.The picturesque symptomatology* is not a psychologic dramatization by the patient but the consequence of venous congestion of many organs – from toe to brain

3.The diagnostic needs to rule in and out every single sub-syndrome

4.to establish a treatment plan that tackles the most relevant sub-syndromes orderly

5.The patient needs a doctor who is informed about the interplay of all sub-syndromes

The patient needs no psychiatrist but a surgeon to treat him successfully

 

*Picturesque symptomatology of the lordogenetic midline congestion syndrome (responsible sub-syndrome numbered as in the illustration)

 

1 –  Nutcracker syndrome:

Left flank pain, midabdominal pain, both aggravated by exercise and psychological stress – due to increased cardiac output, hematuria, proteinuria

2- Superior mesentric artery syndrome:

Vomiting, fullness after small meals, weight loss, severe postprandial pain, anxiety to ingest food, intolerance of solid food, sensation of bulging in the right upper abdomen

3- Celiac trunk and celiac ganglion compression syndrome:

Nausea, dizziness, vertigo, epigastric and thoracic pain, fainting, postural tachycardia, weight loss, flush, sweating, rapid blood pressure changes

4 – Lumbar artery compression:

Recurrent episodes 30 min – 2 hours of transient paraplegia and severe pain in the lower limbs after complete extension of the legs

5 – May-Thurner-syndrome:

Tension in the left leg, pain and swelling, thrombosis of the left leg and deep left pelvic veins – later similar symptoms in the right leg, genital and thigh varicoses

6 – Compression of the inferior vena cava:

Pelvic pain and leg swelling, other symptoms: see 7

7- Pelvic congestion syndrome:

Pelvic pain, rectal bleeding, menorrhagia, premenstrual pain syndrome, dyspareunia, constipation, dysuria, pollakisuria,

8- Midline congestion syndrome:

Headaches, migraine, morning congestion of the nasal mucosa – disappearing after 30 min in an upright position, back pain, sciatica, lumbago, throbbing pain in the back,

9- Compression of the femoral veins:

Pain in the legs, leg tension, restless legs, leg swelling, varicose veins in the legs and /or genitals, salient veins in the legs, genital pain, pain in the perineum and in the buttocks while sitting

A more detailed desription of vascular compression syndromes can be downloaded here.