Late superior mesenteric artery syndrome in paraplegia: case report and review

Study design: A case report of superior mesenteric artery syndrome (SMA syndrome) occurring in a paraplegic patient 3 months after injury. Objectives: To report an unusual case and review the literature of SMA syndrome in spinal cord injured patients, focusing on paraplegic subjects and on tardive presentations. Setting: A Physical Medicine and Rehabilitation Center in Garches (France). Method: Current medical literature includes reports of only 14 spinal cord injured patients with SMA syndrome. This syndrome has been often described in anorexia nervosa, burns or other causes of cachexia, following correction of spinal deformities or after application of body casts. Results: In spinal cord injured patients SMA usually occurs in tetraplegic patients during the first weeks after injury. Only four cases of SMA syndrome in paraplegic patients have been described. Late forms are less common than acute ones: only three cases among 14. SMA syndrome consists of a vascular compression of the third part of the duodenum between the ventrally oriented SMA and the aorta. The normal aorto-mesenteric angle ranges between 38degrees and 65 and can be as low as 6degrees in patients with SMA syndrome. The diagnosis is usually based on upper gastro-intestinal contrast X-ray study, which shows abrupt vertical compression of the third part of the duodenum. CT scan with angiography is useful in some difficult cases. Conservative management includes early correction of dehydration and electrolyte imbalance, insertion of a nasojejunal tube beyond the obstruction and renutrition. Duodenojejunostomy may be necessary in case of failure of conservative treatment. Conclusion: SMA syndrome is an unusual gastro-intestinal complication that may occur in paraplegic patients, even late after injury.