Abstract
Background Celiac artery compression syndrome (CACS) is a rare but potentially life-threatening complication of spinal deformity correction. Although prior reports have suggested an association between spinal correction and vascular compression, the underlying anatomical mechanisms remain unclear. This study aimed to investigate the positional changes in the celiac artery and median arcuate ligament (MAL) during spinal corrective procedures using a cadaveric model.
Methods A human cadaver preserved using the Thiel method was used to simulate anterior extension correction via Smith-Petersen osteotomy (SPO) at the T12/L1 and L3/L4 levels and posterior shortening via pedicle subtraction osteotomy (PSO) at L1, each with a 30° correction angle. The T12/L1 and L3/L4 levels were located proximal and distal to the origin of the diaphragmatic crura, respectively. Pre- and postoperative computed tomography was conducted to measure the vertical and anteroposterior distances between the celiac artery and the MAL, with the anterior-inferior border of the 12th thoracic vertebra as a fixed reference point.
Results The vertical distances between the celiac artery and the MAL were 8.8 mm before correction, 2.6 mm after T12/L1 SPO, 9.3 mm after L3/L4 SPO, and 11.5 mm after L1 pedicle subtraction osteotomy. The corresponding horizontal distances were 6.6 mm, 11.3 mm, 8.2 mm, and 5.8 mm. Notably, SPO at T12/L1—proximal to the origin of the diaphragmatic crus—resulted in the greatest reduction in vertical distance.
Conclusion Anterior extension correction at the thoracolumbar junction significantly reduced the distance between the celiac artery and the MAL. These positional changes may contribute to the development of iatrogenic CACS. Surgeons should exercise caution when performing anterior correction near the diaphragmatic crus to minimize this vascular risk.
Clinical Relevance Anterior correction at the thoracolumbar junction, particularly at T12/L1, significantly shortens the distance between the MAL and the celiac artery, increasing the risk of vascular compression. Patients with a short MAL-celiac artery distance may be more susceptible to developing CACS. To prevent this potentially fatal complication, preoperative imaging and anatomically informed surgical planning are essential.
Level of Evidence 5.
Introduction
Celiac artery compression syndrome (CACS) is a condition caused by the extrinsic compression of the celiac artery by the median arcuate ligament (MAL) at the thoracolumbar junction.1,2 Since its initial description by Dunbar, the syndrome has been referred to by various names, including celiac trunk compression syndrome, celiac artery compression, and MAL syndrome.3 It is classically characterized by a triad of symptoms, namely postprandial abdominal pain, gastrointestinal dysfunction, and weight loss.4 If diagnosis and treatment are delayed, CACS can lead to severe complications, such as organ perforation, peritonitis, and intestinal necrosis.1
Recent advances in the surgical correction of adult spinal deformities have enabled the use of techniques such as lateral lumbar interbody fusion, vertebral body replacement, and osteotomy to achieve significant restoration of lumbar lordosis.5,6 However, these procedures may inadvertently cause celiac artery compression due to mechanical traction on vascular and abdominal structures.1 Despite its potential clinical implications, the anatomical mechanisms contributing to the development of CACS following spinal correction remain poorly understood.
This study aimed to investigate the anatomical changes in the positional relationship between the MAL and the celiac artery during spinal corrective procedures using a cadaveric model.
Methods
Cadaver Specimen
This study utilized a 78-year-old female cadaver donated for medical education, research, and experimental procedures, with consent obtained from both the donor and the bereaved family. Ethical approval for this cadaveric study was obtained from the Institutional Review Board of Juntendo University (approval number: 2014138). The specimen was preserved using the Thiel embalming method, which maintains tissue elasticity and pliability similar to that of living tissue.7 No obvious kyphotic or kyphoscoliotic deformity was identified by gross inspection or preoperative computed tomography (CT) evaluation of the specimen.
Surgical Procedures
All intra-abdominal organs were removed in the supine position, while the aorta, major arterial branches, and diaphragmatic crura were preserved. Skin staplers were placed at the origins of the celiac artery and the MAL to serve as anatomical markers (Figure 1). Anterior extension correction via Smith-Petersen osteotomy (SPO) was simulated at 2 vertebral levels, with a 30° correction angle: T12/L1 (proximal to the origin of the diaphragmatic crus) and L3/L4 (distal to the diaphragmatic crus origin). These levels were selected to represent correction sites proximal and distal to the diaphragmatic crura, respectively, in order to evaluate the influence of correction level on MAL displacement. The osteotomy was performed with the cadaver in the right lateral decubitus position. A wooden cage was inserted into the intervertebral disc space to simulate anterior distraction. The cadaver was then repositioned prone. A midline incision was made, exposing the spinous processes and laminae of 3 vertebrae above and below the osteotomy site. Pedicle screws were inserted, and rods were affixed. After resecting the ligamentum flavum and excising the facet joints, the osteotomy site was closed to simulate extension correction.
Median arcuate ligament and celiac artery origin viewed from the ventral side. Intra-abdominal organs were removed in the supine position, preserving the aorta, major arterial branches, and diaphragmatic crura. Skin staplers were placed to mark the origin of the celiac artery and the median arcuate ligament.
A 30° pedicle subtraction osteotomy (PSO) was performed at L1 with the cadaver in the prone position. Pedicle screws were placed into 3 vertebrae above and below the osteotomy site. The transverse processes and anterolateral portion of the vertebral body were exposed, and the spinous process, lamina, and bilateral T12/L1 facet joints were resected. The posterior vertebral body was carefully removed while preserving the dura. A stepwise resection of the anterior cortex was then performed. A rod was inserted, and compression was applied to close the osteotomy site and achieve spinal shortening.
Imaging and Measurement
CT scans were obtained before and after each corrective procedure. On sagittal CT images, the anterior-inferior border of the 12th thoracic vertebra was used as the reference point. A horizontal line through this point was defined as the X-axis and the vertical as the Y-axis. The positions of the celiac artery and MAL were designated as (Xa, Ya) and (Xb, Yb), respectively. The anteroposterior and craniocaudal distances between the 2 markers were calculated as Xa − Xb and Ya − Yb (Figure 2).
Positional relationship between the median arcuate ligament and the celiac artery, using the anterior-inferior border of the 12th thoracic vertebra as a reference. The horizontal line passing through the anterior-inferior border of T12 was defined as the X-axis and the perpendicular line as the Y-axis. The position of the celiac artery was denoted as (Xa, Ya), and that of the median arcuate ligament as (Xb, Yb).
Results
The relative positional changes between the celiac artery and the MAL before and after each corrective procedure are summarized in Figure 3. The vertical distances between the celiac artery and the MAL were 8.8 mm before correction, 2.6 mm after T12/L1 SPO, 9.3 mm after L3/L4 SPO, and 11.5 mm after L1 PSO. The corresponding horizontal distances were 6.6 mm, 11.3 mm, 8.2 mm, and 5.8 mm (Figure 4). Photographic and CT images confirmed that the anterior extension correction at a level proximal to the origin of the celiac artery led to a notable reduction in the vertical distance between the MAL and the celiac artery (Figure 5).
The positional relationship between the median arcuate ligament and the celiac artery. (A) prior to correction, (B) following T12/L1 SPO, (C) following L3/L4 SPO, and (D) following L1 pedicle subtraction osteotomy, evaluated using the anterior-inferior border of T12 as a reference point. SPO, Smith-Petersen osteotomy.
Distance between the median arcuate ligament and the celiac artery before and after each corrective procedure. (A) Vertical distance. (B) Horizontal distance. PSO, pedicle subtraction osteotomy; SPO, Smith-Petersen osteotomy.
Median arcuate ligament and celiac artery before and after correction. (A) Positional changes of the median arcuate ligament and celiac artery before and after correction. Left panel: precorrection positions. Right panel: post-T12/L1 SPO. The distance between the median arcuate ligament (□) and the celiac artery (*) decreased after correction. (B) Coronal computed tomography images showing the median arcuate ligament and celiac artery before and after correction. Left panel: precorrection image. Right panel: post-T12/L1 SPO image. The distance between the median arcuate ligament and celiac artery decreased following correction. SPO, Smith-Petersen osteotomy.
Discussion
This cadaveric study anatomically evaluated the spatial relationship between the celiac artery and the MAL during spinal deformity correction. Our findings showed that PSO had minimal impact on the sagittal alignment between these structures. In contrast, anterior extension correction at the T12/L1 level—proximal to the origin of the diaphragmatic crus—resulted in a marked reduction in the vertical distance between the MAL and the celiac artery. Conversely, anterior correction at the L3/L4 level—distal to the diaphragmatic crus origin—caused minimal positional change. These findings suggest that the MAL, which bridges the right and left diaphragmatic crura, is pulled inferiorly due to traction on the crura—anchored to the anterior lumbar spine—during anterior correction. While the celiac artery itself slightly descended, the MAL shifted more significantly downward, and the artery moved anteriorly, leading to mechanical compression of the vessel by the MAL (Figure 6).
(A) Anatomical relationships of vessels and ligaments around the diaphragmatic crura before and after correction. Left panel: precorrection anatomy. Right panel: postcorrection anatomy. Correction pulled the median arcuate ligament inferiorly, reducing the distance to the celiac artery. (B) Sagittal view showing the relationship between the median arcuate ligament and celiac artery before and after T12/L1 SPO. The vertical distance between the median arcuate ligament and celiac artery was significantly reduced postcorrection. The celiac artery shifted slightly downward, while the median arcuate ligament moved further downward and anteriorly, suggesting potential arterial compression. SPO, Smith-Petersen osteotomy.
The celiac artery supplies blood to the liver, spleen, stomach, gallbladder, and pancreas. While the pancreas benefits from collateral perfusion, the spleen, stomach, and gallbladder rely predominantly on celiac arterial flow. Although hepatic perfusion is also supported by the portal vein, it can still be compromised in severe cases of celiac artery compression.1 The MAL is composed of muscle fibers bridging the diaphragmatic crura and lies anterior to the aortic hiatus.8 Downward displacement of the MAL can lead to ischemic necrosis of celiac-dependent organs.1,8
A more commonly reported vascular complication of spinal surgery is superior mesenteric artery (SMA) syndrome, which results from duodenal compression and presents with postprandial pain, nausea, vomiting, and weight loss.9–12 SMA syndrome typically has a favorable prognosis and often resolves with conservative treatments, such as fasting, nasogastric decompression, nutritional support, and correction of fluid and electrolyte imbalances.10 In contrast, CACS poses a more serious risk, potentially leading to irreversible organ ischemia and peritonitis if diagnosis and treatment are delayed.1
Although anatomical changes to the SMA following spinal correction are well documented, reports on postoperative CACS remain rare. To date, only 7 cases of CACS following spinal deformity correction have been reported (Table).1,4,13–16Daniels et al described a case involving ischemic necrosis of the stomach, gallbladder, and spleen after Scheuermann kyphosis correction, which required prolonged intensive care and Roux-en-Y reconstruction.1 von Glinski et al reported hepatic ischemia, acute cholecystitis with perforation, and splenic infarction; surgical exploration revealed a 2 cm overlap of the MAL at the celiac artery origin, and surgical release improved perfusion.14 Notani et al presented a case of CACS after multilevel extreme lateral interbody fusion (L1–L5) and posterior fusion (T10–ilium) for kyphotic deformity, which was successfully managed with MAL release.13 In contrast, Kotani et al reported a fatal case involving multilevel extreme lateral interbody fusion and anterior column realignment, in which the patient succumbed to multiple organ failure and sepsis.15
Clinical characteristics of patients with celiac artery compression syndrome following spinal deformity correction surgery.
Collectively, these cases highlight that extensive anterior correction near the diaphragmatic crus—including multilevel lateral lumbar interbody fusion, vertebral column resection, and aggressive SPO—can exert significant tension on the crura, displacing the MAL and increasing the risk of iatrogenic CACS.1,4,13–15 Although rare, spinal surgeons should remain vigilant for this potentially fatal complication. Excessive anterior extension correction at the thoracolumbar junction should be avoided, especially in patients with predisposing anatomical risk factors. If unexplained sepsis, acute abdominal symptoms, or elevated liver enzyme levels occur postoperatively, CACS should be strongly suspected. When diagnosed, prompt treatment, such as MAL release or revision of the correction, should be considered.1,14
The anatomical findings of this cadaveric study align with prior clinical imaging reports. Kagami et al reported that a high body mass index, J-type celiac artery morphology (defined as upward angulation >90° after a short descending segment), and shorter MAL-celiac artery distance were associated with celiac artery stenosis.17Ohyama et al similarly demonstrated that preoperative MAL overlap with the celiac artery origin increased the risk of developing MAL syndrome and concluded that patients without this overlap are less likely to develop CACS following spinal correction.18
Our cadaveric model confirmed that anterior extension correction at T12/L1 resulted in the significant caudal displacement of the MAL relative to the celiac artery, substantially reducing the interstitial distance. These findings support the biomechanical hypothesis that anterior correction exerts traction on the diaphragmatic crura, thereby displacing the MAL. This provides anatomical validation of previously observed clinical outcomes and a mechanical explanation for vascular compression during spinal deformity correction. Taken together, these findings suggest that anterior correction at or near the MAL attachment—especially in patients with a short MAL-celiac artery distance or J-type morphology—may increase the risk of iatrogenic CACS. Therefore, careful preoperative evaluation of ligament and arterial anatomy is essential, and surgical planning should consider the potential biomechanical consequences of MAL displacement.
To minimize the risk of postoperative CACS, preoperative contrast-enhanced CT angiography should be considered in patients undergoing substantial sagittal correction. This may be particularly important when anterior correction is planned near the thoracolumbar junction, where the diaphragmatic crura originate.17,18 Preoperative evaluation should include the presence of MAL overlap, J-type celiac artery morphology, the MAL-celiac artery distance, preexisting celiac artery stenosis, and atherosclerotic changes of the abdominal aorta and visceral arteries.2,15–18 Iijima et al demonstrated that celiac and SMA stenosis are not uncommon in patients undergoing lumbar and thoracolumbar spinal surgery.2 Furthermore, elderly patients frequently exhibit atherosclerotic changes, which may reduce vascular compliance and limit the ability to maintain adequate blood flow when additional external compression occurs.2 Therefore, preexisting arterial stenosis or severe atherosclerosis may increase susceptibility to ischemic complications after spinal correction.2,15 In patients with renal dysfunction or contrast allergy, noncontrast CT may still provide useful information regarding the anatomical relationship between the MAL and celiac artery, although its ability to assess arterial stenosis is limited. In such cases, careful assessment of preexisting vascular disease and clinical risk factors is important, and consultation with vascular surgeons may be considered when high-risk anatomical features or significant vascular disease are suspected.
Limitations
This study had some limitations. The analysis was based on a single cadaveric specimen, and all corrective procedures were performed sequentially on the same model. In addition, the specimen did not exhibit kyphotic or kyphoscoliotic deformity. Therefore, the influence of preexisting spinal deformity on the relationship between the MAL and the celiac artery could not be evaluated. Although the cadaver was preserved using the Thiel method, which provides tissue flexibility similar to that of living patients, it may not fully replicate the in vivo mechanical dynamics of the diaphragmatic crura. Consequently, the extent of MAL displacement might have been underestimated. Nonetheless, this is the first study to clearly demonstrate dynamic anatomical changes in the relationship between the MAL and the celiac artery during corrective spinal procedures using a cadaveric model.
Conclusion
This cadaveric study demonstrated that anterior extension correction at the thoracolumbar junction significantly reduced the distance between the celiac artery and the MAL. Excessive correction at this level may predispose patients to iatrogenic CACS by exerting traction on the diaphragmatic crura and altering the position of the MAL. Careful preoperative assessment and conservative correction strategies are essential to prevent this potentially life-threatening complication. Future studies involving a larger number of cadaveric specimens and in vivo imaging assessments are warranted to validate these findings and to further elucidate the biomechanical mechanisms underlying celiac artery compression during spinal deformity correction.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Institutional Review Board The approval code is No. 2014138 of Juntendo University. The test subject consented in advance to the use of her body for medical education and research and cadaver experiments.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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