Bilateral iliopsoas hematoma: Case report and literature review

Abstract

Background:Clinically significant spontaneous bilateral iliopsoas hematoma is a rare complication of anticoagulation therapy. Definitive treatment of spontaneous iliopsoas hematomas is not well-established and varies between observation and surgical intervention. The intramuscular hematoma causes severe pain, muscle dysfunction, and occasionally nerve palsy with the femoral nerve most commonly affected. Most patients are neurologically normal but when a significant neurological deficit is associated with iliopsoas hematoma, optimal treatment recommendations vary. We report a case of spontaneous bilateral iliopsoas hematomas causing significant bilateral femoral nerve dysfunction.Case Description:The authors present the case of a 63-year-old female who developed bilateral femoral nerve palsy due to anticoagulation bleeding complication. Magnetic resonance imaging demonstrated large bilateral intramuscular psoas hematomas causing femoral nerve compression. Surgical evacuation and decompression of the femoral nerves was performed with rapid neurological improvement.Conclusion:Management recommendations depend on the volume and cause of the hematoma, timing of diagnosis, and the degree of neurological impairment. A conservative approach with bed rest and correction of bleeding abnormalities to allow the hematoma to spontaneously resorb has been utilized for patients with small hematomas and little to no neurological symptoms. In contrast, more aggressive recommendations have been made for patients with large hematomas, severe motor function deficits, or hemodynamic instability.

Spontaneous Iliopsoas Hematoma following Microvascular Free Tissue Transfer

“…SIH is most commonly seen in patients with type A or type B hemophilia but has also been noted in anticoagulated patients and even in patients with no bleeding diathesis [1, 2, 7]. Patients undergoing head and neck free flap reconstruction are often anticoagulated postoperatively.…”

Iliopsoas haematoma in a rugby player

“…[5,8] The flexed position imposes the least tension on the iliopsoas muscle whereby the muscle is relaxed, with pain and limitation on passive hip extension as the muscle is stretched. [9] Owing to the strong fibrous tissue layers of the muscle, large volumes of intramuscular bleeding are entrapped causing severe pain as a result of pressure build-up. Inhibition of muscular function with femoral nerve involvement could present a serious and potentially severe neurological dysfunction.…”

“…[8] Depending on the rate of active bleeding and the degree of impairment, treatment of an iliopsoas haematoma remains conservative comprising a period of total inactivity, adequate analgesia and gentle physiotherapy to allow the haematoma to spontaneously resorb. [2,3,9] In cases where an iliopsoas haematoma diagnosis is suspected, an MRI scan is the imaging modality of choice due to its high sensitivity and specificity in the detection of small haematomas. [8,9] In patients presenting with femoral neuropathy as a consequence of retroperitoneal bleeding, an MRI scan will assist in ruling out nerve root compression or spinal problems.…”

“…[2,3,9] In cases where an iliopsoas haematoma diagnosis is suspected, an MRI scan is the imaging modality of choice due to its high sensitivity and specificity in the detection of small haematomas. [8,9] In patients presenting with femoral neuropathy as a consequence of retroperitoneal bleeding, an MRI scan will assist in ruling out nerve root compression or spinal problems. In view of its usefulness in studying deep soft tissue, ultrasonography, although being operator-dependent and influenced by surrounding organs, may also provide valuable information in detecting these lesions.…”

Femoral Nerve Pulsy due to Iliopsoas Muscle Hematoma: A Mini Literature Review

“…CT-guided needle aspiration of hematoma has also been reported [10], but the hematoma is hard and organized in many cases, for which needle aspiration is not indicated. Open Journal of Orthopedics mained in one case, which received conservative treatment [6]. The times to resolution of mild hypesthesia and recovery of lower limb muscle strength to MMT 4 or higher were 3.6 and 2.3 months in cases treated with conservative and surgical treatment, respectively.…”