A case report of May-Thurner syndrome induced by anterior lumbar disc herniation: Novel treatment with radiofrequency thermocoagulation

Abstract

Rationale: Lumbar degeneration-related May-Thurner syndrome (dMTS) is characterized by venous compression induced by degenerated lower lumbar structures. Treatment strategies for May-Thurner syndrome (MTS) include clearing the thrombus and correcting venous compression. Despite having different etiological factors from other MTS types, treatments for dMTS are similar, including endovascular angioplasty and continuous anticoagulation therapies. Thus, a particular treatment was designed herein to focus on compressive lumbar structures instead of intravenous management.

Patient concerns: A 59-year-old female patient with dMTS, which was induced by inferior vena cava (IVC) stenosis compressed by L4-5 anterior disc herniation.

Diagnosis: The patient was diagnosed with IVC stenosis and L4-5 lumbar disc herniation based on abdominal computed tomography, ultrasound, and lumbar magnetic resonance imaging findings.

Interventions: Radiofrequency thermocoagulation (RF) was applied to the patient to decrease the compression caused by anterior disc herniation.

Outcomes: After surgery, the patient's swelling started to improve within 5 hours and completely diminished after 48 hours. Postsurgical abdominal ultrasound showed that her IVC patency increased by 20%. On follow-up, her leg symptoms did not recur at 12 months after surgery.

Lessons: We provided a novel idea in the treatment of dMTS, in which we shifted the treatment focus from endovascular patency restoration to extravascular decompression. Our case proved that RF was effective in treating dMTS, which is a complementary treatment modality to angioplasty.

Figure 1

Preoperative MRI shows the lumbar disc degeneration, and the white arrows point out the up-migrating anterior LDH on the segment of L4-5 and the disc fragments enlarged the front margin of L4-5 disc (A). Transverse MRI plain shows irregular front margins at the level of L4-5 intervertebral disc and inferior vena cava (pointed by blue arrow) under the compressive effect of anterior LDH (white arrow) and the overlying right iliac common artery (red arrow) (B). LDH = lumbar disc herniation, MRI = magnetic resonance imaging.

Figure 2

Preoperative CT shows the anterior LDH on the segment of L4-5, which causes the stenosis of inferior vena cava (A). The right iliac common artery is outlined by red, the LDH is outlined in white, and the compressed inferior vena cava is outlined in blue. Preoperative abdomen Doppler ultrasound shows the over 50% patency loss on the left inferior vena cava (B). CT = computed tomography, LDH = lumbar disc herniation.

Figure 3

C-arm fluoroscopy monitored lumbar disc radiofrequency thermocoagulation. The puncture needles were inserted bilaterally and symmetrically until the needles reached the edge of the Kambin triangle (A). The puncture needles were further inserted through the annulus fibrosus into the disc towards the midline on the anteroposterior view (B).

Figure 4

Postoperative abdomen Doppler shows that as the stenosis of inferior vena cava was relieved, the venous patency increased to 70%.