Disclosures: Liridon Zendeli, MD: No financial relationships or conflicts of interest

Case Diagnosis: May-Thurner syndrome (MTS) is an anatomic variant which is present in over 20% of the population. MTS is most commonly due to compression of the left common iliac vein between the right common iliac artery and lumbar vertebrae. Prolonged compression results in endothelial hyperplasia with fibrotic adhesions leading to risk for development of iliofemoral deep vein thrombosis (DVT). MTS typically presents with left lower extremity (LLE) symptoms, however right lower extremity (RLE) involvement can be rarely seen.

Case Description or Program Description: Our patient is a 61-year-old female referred to the pain clinic for acute low back pain. Associated symptoms include RLE pain, paresthesia, claudication, peripheral edema, and temperature changes. She attempted physical therapy but reported intolerance due to exacerbation of her symptoms. On examination, inspection revealed tortuous varicosities along the anteromedial RLE. Provocative testing suggested presence of sacroiliac dysfunction. Recent magnetic resonance imaging (MRI) of her lumbar spine was unremarkable, but MRI of her pelvis incidentally revealed mild compression of the left common iliac vein by the right common iliac artery.

Setting: Outpatient interventional spine and pain management clinic.

Assessment/Results: Our patient presented with mixed findings of sacroiliac arthropathy and atypical right-sided MTS. Initial intolerance to physical activity provides diagnostic value to consider other non-musculoskeletal etiologies.

Discussion (relevance): Both clinical and radiologic findings are necessary to diagnose MTS, and computed tomography (CT) venography is the gold standard. Ultrasonography is used to evaluate for proximal DVT but cannot visualize the inferior vena cava and iliac veins. Treatment involves therapeutic anticoagulation combined with interventions including mechanical thrombectomy, catheter-directed thrombolysis, stenting, and angioplasty.

Conclusions: The precise epidemiology of MTS is unknown, but important to consider in the differential diagnosis for etiology of pain with or without DVT in either LLE or RLE. This case study serves to highlight the pathophysiology, diagnostic evaluation, and management of MTS.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/may-thurner-syndrome-a-case-report-of-atypical-presentation-of-right-lower-extremity-pain-in-the-outpatient-pain-clinic-setting/