Anesthetic Management for Third Molar Surgery in a Patient with Concurrent Nutcracker, SMA, and Median Arcuate Ligament Syndromes

Background Concurrent nutcracker syndrome, superior mesenteric artery syndrome, and median arcuate ligament syndrome (the clinical expression of which is referred to celiac artery compression syndrome), is an extremely rare phenomenon. The purpose of this case report is to describe the anesthetic management of a patient who presented with this rare concurrence, for removal of third molar teeth under general anesthesia. The patient additionally had a history of problematic reactions to benzodiazepines, which further complicated his anesthetic management. Case Presentation A 16-year-old male presented for removal of his symptomatic third molar teeth. Comprehensive history and examination was performed, and medical clarification from his physician was obtained. The patient was treated in an outpatient setting with an anesthetic technique that avoided the use of nitrous oxide and any benzodiazepine, and which included oxygen, fentanyl, decadron, propofol, and local anesthesia. Postoperative antibiotics and pain medications were prescribed. Comprehensive post-operative instructions stressed the importance of postural requirements and adequate nutrition. The patient tolerated the procedure well, and experienced an uneventful recovery. Conclusion This case report illustrates the importance of comprehensive preoperative evaluation, including consultation with any treating physicians of record. It also serves to highlight the efficacy of total intravenous anesthesia, without the use of benzodiazepines or nitrous oxide. The importance of postoperative postural and nutritional requirements are critical with respect to the treatment of patients with any concurrence of the syndromes described in this report.