Beyond compression—Autonomic, neurobiological, and psychophysiological dimensions of median arcuate ligament syndrome

Objective Median arcuate ligament syndrome (MALS) has traditionally been described as symptomatic extrinsic compression of the celiac artery and celiac plexus by the median arcuate ligament. However, discordance between radiographic compression and symptom severity challenges a strictly anatomical explanation. Significant celiac artery indentation is frequently observed in asymptomatic individuals, whereas some patients with minimal compression report severe postprandial pain and weight loss. Although surgical decompression improves symptoms in many cases, a subset of patients experiences persistent or recurrent pain despite technically adequate release. The aim of this study was to evaluate current evidence regarding the pathophysiology of MALS and assess whether available data support a purely structural model of celiac artery compression or a broader neurogenic–autonomic mechanism. Methods A narrative review of published literature was conducted focusing on imaging–symptom correlation, surgical outcomes, psychiatric comorbidities, and mechanisms of visceral pain and autonomic dysfunction relevant to MALS. Results Available studies demonstrate variable correlation between degree of vascular compression and clinical presentation. Psychiatric comorbidities, including anxiety, depressive disorders, and somatization, are commonly reported and have been associated with less favorable postoperative outcomes. Emerging evidence from neurogastroenterology suggests that visceral pain may arise from sympathetic dysregulation, peripheral sensitization of the celiac plexus, and central pain amplification independent of fixed vascular obstruction. Conclusions Current evidence supports the possibility of heterogeneous mechanisms in MALS, including both structural compression and neurogenic–autonomic dysfunction. Recognition of this potential heterogeneity may improve patient selection and inform multidisciplinary treatment strategies.