Lumbosacral plexopathy from iliopsoas haematoma after combined general-epidural anaesthesia for abdominal aneurysmectomy

Abstract

Purpose: To report a case of iliopsoas haematoma after resection of an abdominal aortic aneurysm which resulted in a lumbosacral plexopathy. Clinical features: An 81-yr-old man presented with an abdominal aortic aneurysm for aneurysmectomy and tube grafting. An epidural catheter was placed at the Ll_ 2 spinal level and combined epidural-general anaesthesia was provided for surgery, The surgery was complex and a suprarenal clamp was necessary to obtain proximal control. A continuous infusion of demerol through the epidural catheter was prescribed for postoperative analgesia. On the first postoperative day, examination revealed a paretic, pulseless right leg and he was returned to the operating room for femoral-femoral bypass. By the following day, the motor and sensory impairment had progressed to complete paralysis with loss of all deep tendon reflexes and absent sensation below L~, despite palpable pulses in the leg. ACT of the abdomen demonstrated a right iliopsoas haematoma. There was no evidence of either disc herniation or an epidural haematoma. A diagnosis of lumbosacral plexopathy secondary to a iliopsoas haematoma was made. Conclusion: Iliopsoas haematoma is a rare cause of postoperative neurological deficit following aortic vascular surgery. The haematoma results in compression of the lumbosacral neural elements and typically presents as a femoral neuropathy. The diagnosis is clinical and can be readily validated with computed tomography.Objectif: Rapporter un hEmatome du psoas-iliaque compliquE d'une plexopathie Iombosacr& survenue apt& la resection d'un anEvrisme de I'aorte abcIominale. ]~l&nents cliniques : II s'agit d'un homme de 81 ans affligE d'un anEvdsme de I'aorte abdominale programmE pour une resection d'an~vrisme avec greffe. Une association anesthEsie ~pidurale-gEnErale a ErE administrEe avec I'installation d'un catheter Epidural ~ L~_ 2. La chirurgie &ait complexe et on a dfi utiliser un clamp suprar& nal pour le contr61e proximal. EanalgEsie postopEratoire Etait assurEe par une perfusion pEridurale continue de dEmErol. Le lendemain de rintervention, rexamen rEvElait une parEsie avec absence de pouls au membre infErieur clroit nEcessitant une rEintervention pour derivation fEmoro-fEmorale. Le jour suivant, I'atteinte motrice et sensorielle droite Evoluait vers la paralysie complete avec perte de tousles reflexes tendineux profonds et absence de sensation sous le niveau L, malgrE la presence de pouls palpables ~ la jambe. Une tomographie axiale de I'abdomen dEmontrait un hEmatome du psoas-iliaque droit. On n'a pu mettre en Evidence de hernie discale ou d'hEmatome Epidural, On portait le diagnostic de plexopathie IombosacrEe secondaire ~ un hEmatome du psoas-iliaque. Conclusion : I'hEmatome du psoas-iliaque constitue une cause rare de deficit neurologique aprEs une chirurgie vasculaire majeure. I'hEmatome provoque une compression des ElEments nerveux Iombosacr& et se pr&ente typiquement comme un neuropathie fEmorale. Ce diagnostic clinique peut &re validE rapidement par tomographie axiale.

Lower-extremity peripheral nerve blockade: Essentials of our current understanding

“…2,185 As opposed to spinal or epidural hematoma, in all cases, neuropathy from this etiology has resolved completely. 181,182,[218][219][220] Little data exist regarding the safety of peripheral nerve block in anticoagulated patients. The American Society of Re-gional Anesthesia and Pain Medicine has published guidelines regarding this issue.…”

The iliolumbar artery—Anatomic considerations and details on the common iliac artery trifurcation

“…The branches described as leaving the ILA are (a) the lumbar branch, leading into the psoas and quadratus lumborum muscles; (b) the spinal branch, passing between the sacrum and L5, to enter the vertebral canal; and (c) the iliac branch, passing to the iliacus muscle in the iliac fossa (Feneis and Dauber, 2000). Being also a feeder of the femoral nerve (Crosby et al, 1998), the ILA may be involved in neuropathic syndromes occurring after surgical procedures performed in the iliac fossa, at 4-6 cm above the inguinal ligament (Pastor Guzmán et al, 2007).…”

Traumatic Lumbar Plexopathy by Seat Belt Injury

“…In patients who develop a traumatic lumbosacral plexopathy, managements are still controversial and unresolved. 6) Both conservative and surgical management have been applied.…”

“…The other ten patients resulted in 50% total recovery after surgical treatment. 6) We stress the need to review the lumbar plexus pathway in patients with atypical motor weakness and sensory loss of lower extremity unaccompanied by demonstrable spinal lesions.…”