<p>Psoas Hematoma and Late Femoral Nerve Palsy After Extreme Lateral Interbody Fusion and Posterior Spinal Fusion with Instrumentation: A Case Report</p>

Abstract

Introduction: Psoas hematoma is an uncommon complication following spinal surgeries. It has been reported in both extreme lateral interbody fusion (XLIF) and posterior spinal fusion with instrumentation. Minimally invasive techniques are gaining popularity in recent years due to the appealing advantages of reduced operative time, blood loss, hospital stay, and faster recovery. Case Presentation: We are presenting a case of a 77-year-old male with chronic low back pain, diagnosed to have multilevel degenerative disc disease with central and foraminal disc protrusion at L2-L3, L3-L4, L4-L5 with secondary spinal stenosis, underwent XLIF at L3-L4, L4-L5 and then 2nd stage with posterior L3-L5 fusion with pedicle screws. On the fourth day post-operatively, the patient had flank pain and dropping hemoglobin with femoral nerve palsy symptoms, a CT scan revealed a large psoas hematoma. Conservative management was decided on; a follow-up CT scan and examination showed complete resolution of the hematoma and femoral nerve recovery. Discussion: The approach to iliopsoas hematoma post spinal surgeries remains controversial. Iliopsoas hematoma should be suspected in any patients post spinal surgeries even with delayed presentations. The decision to proceed with either surgical intervention or conservative management depends on multiple factors, including patient hemodynamic status, progression of collection and femoral nerve palsy. Conclusion: The exact cause of iliopsoas hematoma post different spinal surgery approaches remains vague. In our opinion, other causes including pre-and post-operative anticoagulants should be investigated. Rushing to drain iliopsoas hematomas in case of femoral nerve palsy might not be the ideal option. Instead, monitoring patient responses to resuscitation and taking a watch and wait approach for femoral nerve palsy might be the proper approach.

Psoas Hematoma After Posterior Lumbar Interbody fusion: A Case Report and Literature Review

“…After reviewing the literature, the main mechanism of vascular injury caused by posterior thoracolumbar surgery are almost all sustained by impingement or avulsion of the artery leading to a delayed hemothorax. 9 - 12 …”

“…After reviewing the literature, the main mechanism of vascular injury caused by posterior thoracolumbar surgery are almost all sustained by impingement or avulsion of the artery leading to a delayed hemothorax. [9][10][11][12] The main reason for our case is during the operation of the patient's left side screw implantation, the second conical dilation channel slipped and entered the lateral side of the vertebral body along the transverse process. The abdominal aorta is located on the left side and may be injured during the operation.…”

Iatrogenic femoral nerve injuries: analysis of medico-legal issues through a scoping review approach

“…Several possible mechanisms of damage are described: excessive stretching, direct compression or compression by haematoma of the psoas, displacement of an endplate fragment, and postoperative herniation [ [51] , [52] , [53] , [54] , [55] ].…”

Using an Extreme Lateral Interbody Fusion (XLIF) in Revising Failed Transforaminal Lumbar Interbody Fusion (TLIF) With Exchange of Cage

“…However, it is not without any complication. Some of the reported include iliopsoas weakness, anterior thigh numbness, quadriceps weakness, radiculopathy, and iliopsoas hematoma [ 10 , 11 ].…”