ASA Abstract Reviews

Median Arcuate Ligament Syndrome: Psychological Factors Affecting Postoperative Pain Management

Alina Lazar, MD, Aisha Sozzer, MD, Devang Patel, MD, MBA, Tina Drossos, PhD, Magdalena Anitescu, MD, PhD
Anesthesia and Critical Care, The University of Chicago Medicine, Chicago, IL, USA,
(Summarized and Submitted by Alina Lazar MD, Aisha Sozzer MD)

Median arcuate ligament (MAL) syndrome is caused by external compression of the celiac artery and celiac plexus by the median arcuate ligament. This condition often generates chronic, difficult-to-control pain that is thought to be ischemic and neuropathic in nature. Other symptoms include nausea, vomiting, decreased appetite, and weight loss. At our institution, before laparoscopic release of the MAL, patients with the syndrome undergo extensive preoperative assessment and optimization, including thorough evaluations by a psychologist and a pain specialist. The objective of our study was to assess the impact of anxiety and pain catastrophizing on the perioperative pain management of patients with MAL syndrome. The primary outcome variable was postoperative opioid requirement measured in morphine equivalents per day.

We retrospectively reviewed the charts of 39 pediatric patients from February 2014 to August 2016. Data on anxiety, depression, and pain coping skills were extracted from our institution’s database. Pain catastrophizing was assessed using the pediatric pain inventory on a 3-point scale (0-2), with higher scores representing more catastrophization. Postoperatively, patients received either medical management with parental or oral analgesic, or epidural analgesia and medical management. Of the patients evaluated, 23 patients opted for an epidural and 15 patients for medical management. Groups were similar in demographics, preoperative pain scores, duration of pain, and preoperative use of opioids. The postoperative opioid requirement was higher in patients with anxiety in both the medical management and epidural groups, although the correlation was not statistically significant. There was, however, a statistically significant difference in the epidural group between high-, and low-catastrophisers, with higher opioid requirements in patients with higher levels of pain catrastrophizing, despite epidurals providing adequate coverage in both groups. The difference was not statistically significant in patients with medical management.

Our results suggest that pain catastrophizing plays a major role in the postoperative pain of pediatric patients after laparoscopic release of the MAL.  Although the correlation between catastrophizing and opioid requirement was strong in patients primarily managed with epidural analgesia, it was less evident in patients whose pain was managed medically. This finding suggests that a multimodal, balanced analgesic technique may mitigate the effect of catastrophizing on opioid requirement. Overall, patients who are identified as high-catastrophizers may benefit from epidural anesthesia, as it is associated with decreased opioid requirements. Psychologic interventions targeting high-catastrophizers could improve post-operative pain management in pediatric patients.