Spinal venous hypertension secondary to Nutcracker Syndrome—a previously unreported cause of congestive myelopathy

Objective We report a case of myelopathy associated with nutcracker syndrome. Clinical and imaging findings indicate that nutcracker syndrome caused left renal vein stenosis, resulting in spinal venous hypertension. Case presentation : A 15-year-old girl presented with abnormal sensations in both lower limbs, followed by progressive motor impairment and bowel and bladder dysfunction. Magnetic resonance imaging (MRI) revealed an abnormal signal in the spinal cord at the T12–L1 level. Although she was initially diagnosed with acute transverse myelitis (ATM) and treated with intravenous steroids, cerebrospinal fluid (CSF) analysis showed no signs of inflammation. Further evaluation with Doppler ultrasound and left renal arteriovenous angiography suggested that nutcracker syndrome led to compression of the left renal vein, with malformed branches draining into the spinal venous system. This resulted in spinal venous hypertension and subsequent spinal cord injury. Initial treatment with corticosteroids and immunoglobulins was discontinued due to disease progression. After identifying a left renal vein vascular malformation at an external hospital, balloon dilation of the left renal vein was performed, yielding mild symptomatic relief. Subsequent interventional embolization of the malformed vessels temporarily improved symptoms, though her condition later deteriorated. Ultimately, she underwent laparoscopic robot-assisted external stent placement in the left renal vein at our institution. During the three-month postoperative follow-up, sensory function gradually improved and the clinical condition stabilized. Conclusions To our knowledge, this is the first reported case of spinal venous hypertension syndrome secondary to nutcracker syndrome, presenting as myelopathy. We emphasize that in cases of acute myelitis or spinal cord disease of unknown etiology, screening for extramedullary vascular abnormalities—such as left renal artery or vein compression or malformations—is essential.