Nutcracker syndrome: A rare cause of chronic pelvic pain and left back pain

Abstract

The Nutcracker Syndrome is a rare and often unrecognized cause of chronic pelvic pain and left back pain. These symptoms are due to the left renal vein compression between the aorta and the superior mesenteric artery (anterior nutcracker) or between the aorta and the spine (posterior nutcracker). The variety of clinical manifestations make the diagnosis difficult and commonly delayed. Therefore, imaging plays a key role in correcting the diagnosis by confirming the left renal vein stenosis and ruling out any differential diagnosis. Treatment options are discussed by a multidisciplinary team involving urologists, nephrologists and vascular surgeons for each patient. We report the case of 2 patients presenting chronic pelvic and lower back pain in whom clinical investigation and CT imaging findings were consistent with a nutcracker syndrome.

Spontaneous rupture of the ovarian vein in association with nutcracker syndrome: a case report

“…NCS diagnosis is confirmed mainly by image evaluation, but no unified diagnostic standard exists [ 1 , 2 , 11 ]. CT and Doppler ultrasonography are the imaging methods most commonly used for diagnosis; the diagnostic criteria are the distance between the SMA and abdominal aorta and the beak sign in axial images, and the angle between SMA and abdominal aorta in sagittal images [ 1 , 4 , 11 , 12 ]. Another method of diagnosis is to measure the blood pressure gap between the IVC and LRV, but this method is invasive and uncommon [ 1 , 2 , 4 , 12 ].…”

“…CT and Doppler ultrasonography are the imaging methods most commonly used for diagnosis; the diagnostic criteria are the distance between the SMA and abdominal aorta and the beak sign in axial images, and the angle between SMA and abdominal aorta in sagittal images [ 1 , 4 , 11 , 12 ]. Another method of diagnosis is to measure the blood pressure gap between the IVC and LRV, but this method is invasive and uncommon [ 1 , 2 , 4 , 12 ]. In this case, we diagnosed NCS because the CT images showed clear LRV stenosis and because venography confirmed regurgitation from the LRV to LOV.…”

“…For young patients, conservative treatment with monitoring for changes is the first choice, and for mild symptoms, follow-up monitoring for weight gain is the first choice. Although no clear criteria have been established, surgical and endovascular treatment can be used for severe symptoms [ 1 , 2 , 4 , 13 ]. In this case, endovascular embolization therapy was performed to treat the emergency caused by rupture.…”

Robotic assisted kidney auto‐transplantation as a safe alternative for treatment of nutcracker syndrome and loin pain haematuria syndrome: A case series report

“…1,3 NCS results from compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery (SMA), or between the aorta and the spine, resulting in LRV compression and development of collateral veins. 4,5 The main symptoms are flank (loin) or abdominal pain, haematuria, and pelvic congestion. The severity of symptoms guides the clinical management.…”

“…Other indications for performing a RAT are rare conditions such as loin pain haematuria syndrome (LPHS), and the nutcracker syndrome (NCS), especially when other treatments have failed 1,3 . NCS results from compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery (SMA), or between the aorta and the spine, resulting in LRV compression and development of collateral veins 4,5 . The main symptoms are flank (loin) or abdominal pain, haematuria, and pelvic congestion.…”