From the nutcracker-phenomenon of the left renal vein to the midline congestion syndrome as a cause of migraine, headache, back and abdominal pain and functional disorders of pelvic organs

Med Hypotheses. 2007;68(6):1318-27. doi: 10.1016/j.mehy.2006.10.040. Epub 2006 Dec 11.


This paper presents the hypothesis, that pain and functional disturbances of organs which lie on the midline of the body might be caused by a venous congestion of these organs. Cause of their congestion is the participation of these organs (vertebral column, skull, brain, spinal medullary, uterus, prostate, left ovary/testis, urinary bladder rectum, vagina, urethra) in the collateral circulation of the left renal vein. In many patients with complaints of the above mentioned organs the left renal vein is compressed inside the fork formed by the superior mesenteric artery and the aorta. This so called nutcracker phenomenon is incompletely understood today. It can lead to a marked reduction of left renal perfusion and forces the left renal blood to bypass the venous compression site via abundant collaterals. These collaterals are often not sufficient. Their walls become stretched and distorted - varices with inflamed walls are formed. These dilated veins are painful, interfere with the normal organ's function and demand more space than usual. This way pain in the midline organs and functional derangement of the midline organs can occur. The term "midline congestion syndrome" seems appropriate to reflect the comprehensive nature of this frequent disorder. The rationale for this hypothesis is based on the novel PixelFlux-technique ( of renal tissue perfusion measurement. With this method a relevant decline of left renal cortical perfusion was measured in 16 affected patients before therapy (left/right ratio: 0.79). After a treatment with acetylsalicylic acid in doses from 15 to 200mg/d within 14-200 days a complete relief of so far long lasting therapy-resistant midline organ symptoms was achieved. Simultaneously the left/right renal perfusion ratio increased significantly to 1.24 (p=0.021). This improvement of left renal perfusion can be explained by a better drainage of collateral veins, diminution of their wall distension, thereby decline of their intramural inflammation, reduction of their mass effects (especially by the replaced spinal fluid inside the spinal canal and the skull), and altogether a reduction of pain and functional derangement in the affected midline organs. The proposed theory might influence the current understanding of such frequent and difficult to treat diseases as chronic back pain, headaches, frequent cystitis, enuresis, abdominal pain, flank pain and might spur new theories of arterial hypertension, placental insufficiency, prostate diseases and myelopathies.

MeSH terms

  • Abdominal Pain / etiology*
  • Adolescent
  • Aspirin / therapeutic use
  • Back Pain / drug therapy
  • Back Pain / etiology*
  • Child
  • Child, Preschool
  • Constriction, Pathologic / diagnostic imaging
  • Constriction, Pathologic / drug therapy
  • Constriction, Pathologic / pathology
  • Dose-Response Relationship, Drug
  • Female
  • Follow-Up Studies
  • Headache / drug therapy
  • Headache / etiology*
  • Humans
  • Male
  • Migraine Disorders / drug therapy
  • Migraine Disorders / etiology*
  • Migraine Disorders / therapy
  • Models, Biological*
  • Pelvic Pain / drug therapy
  • Pelvic Pain / etiology*
  • Renal Circulation / drug effects
  • Renal Veins / diagnostic imaging
  • Renal Veins / drug effects
  • Renal Veins / pathology*
  • Time Factors
  • Treatment Outcome
  • Ultrasonography, Doppler, Color


  • Aspirin