Bilateral femoral nerve compression by iliacus hematomas complicating anticoagulant therapy

The epidemiology and management of iliopsoas hematoma with femoral nerve palsy: A descriptive systematic review of 174 cases

INTRODUCTION

Iliopsoas hematoma with femoral nerve palsy is a rare phenomenon with no consensus treatment algorithm. The objective of this study was to perform a systematic review of all reported cases of femoral nerve palsy secondary to iliopsoas hematoma to better elucidate it's optimal treatment.

MATERIALS AND METHODS

Queries of the PubMed, Embase, and Cochrane databases were performed for reports available in English of femoral nerve palsy secondary to iliopsoas, psoas, or iliacus hematoma. 1491 articles were identified. After removal of duplicated publications and review of abstract titles via a majority reviewer consensus, 217 articles remained for consideration. Dedicated review of the remaining articles (including their reference sections) yielded 122 articles representing 174 distinct cases. Clinical data including patient age, sex, medical history, use of pharmacologic anticoagulation, sensory and motor examination at presentation and follow-up, hematoma etiology and location, time to intervention, and type of intervention were collected. Descriptive statistics were generated for each variable.

RESULTS

Femoral nerve palsy secondary to iliopsoas hematoma occurred at a mean age of 44.5 years old. A majority of patients (60%) were male, and a majority of hematomas (54%) occurred due to pharmacologic anticoagulation. Most hematomas (57%) were treated conservatively, and almost half (49%) - regardless of treatment modality - resulted in persistent motor deficits at final follow-up. A minority of patients treated surgically (34%) had residual motor deficit at final follow-up, while 66% of those treated medically had resultant motor deficits, although no direct statistical comparison was able to be performed.

DISCUSSION AND CONCLUSIONS

The disparate available data on iliopsoas hematoma with femoral nerve palsy precludes the completion of a true metanalysis, and therefore any conclusions on an optimal treatment algorithm. Based on review of the literature, small to moderate hematomas are often treated conservatively, while larger hematomas with progressive neurological symptoms are usually managed with a percutaneous decompression or surgery.

LEVEL OF EVIDENCE

IV.

Compressive femoral neuropathy caused by anticoagulant therapy induced retroperitoneal hematoma: A case report

RATIONALE

Spontaneous retroperitoneal hematomas due to anticoagulant therapy rarely occur. Retroperitoneal hematomas can cause severe pain in the groin, quadriceps femoris muscle weakness, hemodynamic instability, and abdominal distension. They rarely cause compressive neuropathy of the femoral nerve transversing the iliacus muscle. Differential diagnosis is not easy because they have similar clinical features to retroperitoneal hematomas.

PATIENT CONCERNS

A 72-year-old female patient whose right arm was stuck in a bookshelf for 5 days developed right cephalic vein thrombosis. After 5 days of intravenous heparin therapy for venous thrombosis, she presented with sudden right groin pain, right leg paresis, hemodynamic instability, and abdominal distension.

DIAGNOSIS

Emergency abdominal and pelvic CT showed a large number of hematomas in the bilateral retroperitoneal space with active bleeding of the right lumbar artery. An electrodiagnostic study was performed 2 weeks later to check for neuromuscular damage in the right lower extremity, and right compressive femoral neuropathy was confirmed.

INTERVENTIONS

Heparin therapy was discontinued; emergency embolization of the lumbar artery was performed. After 2 weeks, the patient started receiving physical, occupational, and transcutaneous electrical stimulation therapies.

OUTCOMES

She became hemodynamically stable after arterial embolization; a significant decrease in hematoma and patency of the femoral nerve was confirmed on follow-up pelvic MRI. After 2 months of comprehensive rehabilitation, the muscle strength of the right leg significantly improved, and the pain disappeared.

LESSONS

Although rare, spontaneous retroperitoneal hematomas may occur in patients receiving anticoagulant medications. They may even occur in patients receiving emergency anticoagulant therapy. Compressive femoral neuropathy due to retroperitoneal hematomas should be considered if muscle weakness and groin pain are observed. Early diagnosis and appropriate treatment plan of compressive femoral neuropathy due to retroperitoneal hematoma are helpful for a good prognosis.

Ultrasound-Guided Thrombin Injection for Iliopsoas Pseudoaneurysm

Bilateral iliopsoas hematoma is an uncommon phenomenon, which has been described in individuals receiving anticoagulation therapy. The hematoma is caused by bleeding of arteries to the muscle. In rare cases, pseudoaneurysms can also be formed. We present a case of an adolescent, with partial factor XI deficiency, who experienced a mild fall. Imaging studies revealed large bilateral iliopsoas hematomas and bilateral iliopsoas pseudoaneurysms. One pseudoaneurysm was demonstrated by angiography and was embolized with micro coils. The second, more persistent one, was sealed via ultrasound-guided thrombin injection, with excellent morphological and clinical results.

Iliopsoas Haematoma: An Uncommon Differential Diagnosis for Groin Pain

Bleeding complications should be considered in the differential diagnosis of any patient on warfarin therapy. A 66-year-old man presenting with right groin pain due to a spontaneous iliopsoas hematoma is reported. Computed tomography of the abdomen and pelvis at the emergency department confirmed the diagnosis. Fresh frozen plasma was given to correct the clotting derangement. The patient was managed conservatively. He was subsequently discharged well without complication. Iliopsoas haematoma or spontaneous retroperitoneal haemorrhage is an uncommon complication that needs to be considered in the differential diagnosis of a patient on warfarin therapy with abdominal, flank or groin pain.

Delayed iliacus compartment syndrome following femoral artery puncture: case report and literature review

Iliacus compartment syndrome is a rare retroperitoneal compartment neuropathy caused by bleeding within the iliacus muscle leading to hematoma formation and compression upon the femoral nerve, causing both sensory and motor deficits. A 75-year-old Caucasian man presented with severe right hip pain associated with motor and sensory deficit in the right lower extremity, 2 weeks post elective balloon aortic valvuloplasty for critical aortic stenosis. A non-contrast computed tomography scan revealed low-attenuation areas in keeping with an iliacus hematoma. An iliacus fasciotomy and hematoma evacuation was performed with retroperitoneal approach. The patient reported marked reduction in his groin pain with clinical improvement of the right hip flexion though the sensory deficit was unchanged. On Day 3, postoperatively the patient died from respiratory and multi-organ failure. Iliac hematomas are rare and can be caused by traumatic and non-traumatic injury, and can be exacerbated by complications of anticoagulant therapy. Delaying surgical evacuation of the hematoma can lead to prolonged or permanent disability. However, there are other reports describing good recovery with non-operative management. Non-surgical intervention is recommended if radiological studies do not explicitly confirm the presence of a discreet hematoma compressing the femoral nerve, unless progression of symptoms increases.

Intraneural Hematoma: A Proposed Anatomic Classification with Potential Treatment Implications

Intraneural hematoma is a rare entity with fewer than 20 cases reported in the literature. There is no consensus on surgical treatment due to its rarity. We present a novel classification for intraneural hematomas based on a review of the literature and illustrated by 4 cases that were treated in our 3 centers. This classification system localizes the hematoma to the different connective tissue layers that compose the nerve: the paraneurium, epineurium, and perineurium. We believe that this classification has consequences for surgical treatment and can form the foundation for future research into the natural history of these types of lesions.

Bilateral psoas haematomata complicating renal transplantation

Background. The challenge in managing patients undergoing renal transplantation is how to achieve optimum levels of anticoagulation to avoid both clotting and postoperative bleeding. We report a rare case of severe postoperative retroperitoneal bleeding including psoas haematomata complicating renal transplantation. Case Report. SM, a 55-year-old female, had a past history of aortic valve replacement, cerebrovascular event, and thoracic aortic aneurysm and was on long-term warfarin that was switched to enoxaparin 60 mg daily a week prior to her living donor transplantation. Postoperatively, she was started on a heparin infusion, but this was complicated by a large retroperitoneal bleed requiring surgical evacuation on the first postoperative day. Four weeks later, she developed features compatible with acute femoral neuropathy and a CT scan revealed bilateral psoas haematomata. Following conservative management, she made steady progress and was discharged home via a community hospital 94 days after transplantation. At her last visit 18 months after transplantation, she had returned to full fitness with excellent transplant function. Conclusion. Patients in established renal failure who require significant anticoagulation are at increased risk of bleeding that may involve prolonged hospitalisation and more protracted recovery and patients should be carefully counselled about this.

Femoral Nerve Palsy due to Anticoagulant Induced Retroperitoneal Hematoma

A forty-one-year-old man who, sought evaluation for a sudden hip flexion contracture and groin pain with a history of mechanical mitral valve replacement, had been misdiagnosed and treated as having lumbar discopathy for two days. This patient finally was diagnosed with compressive femoral neuropathy due to warfarin-induced retroperitoneal hematoma and successfully managed nonoperatively. This case is reported in order to draw attention to this rare presentation.

Bilateral iliopsoas hematoma: Case report and literature review

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.

Subperiosteal hematoma of the iliac bone: imaging features of acute and chronic stages with emphasis on pathophysiology

PURPOSE

The goal of this work is to describe the radiological appearance and clinical presentation of subperiosteal iliac hematoma and present a review of the literature.

MATERIALS AND METHODS

We retrospectively reviewed the radiological and clinical files of 19 patients (age range: 12-75; mean: 47) who presented with acute or chronic subperiosteal iliac hematomas. Imaging findings and relevant clinical information were recorded. A thorough literature search was performed to find additional cases of this rare condition.

RESULTS

Three young patients presented with acute subperiosteal iliac hematoma following a fall. Clinical presentation was characterized by pain and gait disturbance presumed to result from crural nerve compression. Unilateral or bilateral lenticular hematomas deep in the iliacus muscle were demonstrated by CT for all patients while MRI was also available for two of them. In 16 asymptomatic patients, chronic ossified subperiosteal iliac hematomas were incidentally detected by CT. Progressive ossification of acute hematoma was demonstrated at follow-up in two patients.

CONCLUSIONS

Subperiosteal iliac hematoma is rare but has typical imaging findings that may present acutely in adolescents or chronically in asymptomatic adults.

Femoral nerve palsy as a complication of anterior iliac crest bone harvest: Report of two cases and review of the literature

There are many documented neurological complications of anterior iliac crest bone harvest. Until now, these have included injuries to the iliohypogastric, subcostal and lateral femoral cutaneous nerves. Femoral nerve palsy as a direct surgical complication of anterior iliac crest bone harvest has never been cited in any surgical literature, although it has been reported in deep pelvic and abdominal surgeries in which improper retraction and/or prolonged hyperextension of the hip may have caused a nerve compression syndrome. In addition, surgical patients on antithrombolytic therapy have experienced hemorrhage within the iliacus and iliopsoas muscles, resulting in hematoma and secondary femoral nerve compression. The classic motor and sensory deficits reported in femoral nerve palsies are reduced or absent patellar reflex, weak hip flexion, quadriceps muscle weakness, and anesthesia of the anterior thigh and medial aspect of the leg. Two cases of femoral nerve palsy with different etiologies are presented.

Bilateral iliopsoas intramuscular bleeding following anticoagulant therapy with heparin: a case report

Iliopsoas haematoma is an uncommon complication that may arise during anticoagulant therapy, especially with heparin and warfarin. Besides determining patient distress secondary to femoral nerve compression, this event may progress to life-threatening complications and require expensive treatments. We describe the case of a 70-year-old healthy man complaining of severe bilateral groin, lumbar and thigh pain, and paralytic ileus after therapy with heparin. The angio-computed tomography scan observed bilateral iliopsoas haematomas. In view of the clinical and radiological scenarios, we ordered a diagnostic and therapeutic angiography of the bleeding vessels by trans-catheter arterial embolization of the fourth right lumbar artery trunk. The treatment proved to be beneficial from a clinical, radiological and laboratory point of view. To the best of our knowledge, this is the first reported case of bilateral iliopsoas haematoma occurring in a male treated with therapeutic levels of heparin alone.

Femoral nerve palsy after mandibular reconstruction with microvascular iliac flap: a complication under anticoagulation therapy

Pharmacological prophylaxis and intervention are used extensively in head and neck reconstructions with microvascular flaps. There is no universally accepted protocol, but the microvascular surgery literature recommends intraoperative anticoagulation with heparin. Here is reported a case of iliacus haematoma with subsequent femoral nerve palsy after the harvest of a microvascular iliac flap for mandibular reconstruction in a patient who had been treated with heparin. The association between femoral nerve palsy and anticoagulant therapy has been well described. It remains unclear as to why the iliacus muscle is particularly vulnerable to intramuscular haemorrhage. Femoral nerve neuropathy is also an uncommon but recognized complication after abdominopelvic surgery. Iliacus haematoma secondary to microvascular surgery has not been previously reported. This case illustrates the need to be aware of this type of complication and its clinical manifestations for patients under anticoagulant therapy in the perioperative period during microvascular reconstructions.

Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin

Several commonly prescribed antibiotics are known to interact with warfarin, increasing its anticoagulant effect by different mechanisms. Retroperitoneal bleeding with consequent haematoma is recognised as a complication of over-anticoagulation. Consequences, which are potentially fatal, include hypovolaemic shock and compression of retroperitoneal structures such as the ureter and inferior vena cava.

Bilateral iliopsoas hematomas complicating anticoagulant therapy

An 85-year-old woman receiving anticoagulant therapy for transient ischemic attack suddenly developed bilateral femoral nerve palsy and severe pain in the bilateral groin and thighs. Her platelet count, prothrombin time and activated partial thromboplastin time were within the therapeutic range. Hematomas in the bilateral iliopsoas muscles were clearly detectable on CT scan. The right hematoma was larger than the left one and caused more severe femoral neuropathy, but improved gradually without surgical decompression. This case is reported here because bilateralism is exceptional, and iliopsoas hematoma should be suspected when a patient receiving anticoagulant therapy presents with pain in the groin or thigh.

Sonography of peripheral nerves: technique, anatomy, and pathology

Sonography provides a unique method for evaluating peripheral nerves because of its high spatial resolution, its ability to follow structures over long distances in a limb, and its dynamic nature that allows movement of patient and transducer. When combined with the wide availability and relatively low cost, sonography is an excellent modality for peripheral nerve assessment. The authors review the techniques used in assessment of peripheral nerves, the relevant anatomy, and common pathologic processes.

Lower extremity hematoma as a complication of warfarinization in patients with artificial heart valves

Four cases of lower extremity hematoma in patients undergoing anticoagulant therapy after heart valve replacement are herein reported, with special emphasis on the comparative diagnostic value of ultrasonography and computerized tomography. Although conservative management is sufficient for patients with no neurological impairment, needle aspiration after autolysis of the hematoma, which can be confirmed by CT study, is also recommended.

Surgical correction of proximal femoral nerve entrapment

BACKGROUND

Femoral nerve palsy is usually a result of trauma. Isolated femoral nerve palsy without external trauma is restricted to occasional case reports in various circumstances.

CASE DESCRIPTION

Three cases of nontraumatic femoral nerve palsy are reported who presented with pain and weakness. Symptoms were relieved by transection of the iliopectineal arch. This is believed to be a newly described syndrome. An additional case of femoral nerve entrapment following vaginal hysterectomy is described. This case presented only as a pain syndrome.

CONCLUSIONS

There is a syndrome of femoral nerve entrapment at the iliopectineal arch that can be easily relieved by sectioning of this arch, analogous to carpal tunnel syndrome. Several cases of femoral nerve palsy previously reported may be examples of this syndrome.

Iliopsoas haematoma in an adolescent Taekwondo player

A 16-year-old male Taekwondo player was admitted with a 1-day history of right groin pain and a palpable mass in the right lower abdominal quadrant following a Taekwondo training session. No history of direct trauma was given, but the pain followed a high inward-to-outward kick. The patient was not on any medication, and tumour and infection were excluded. A high-resolution real-time ultrasound scan identified a well-defined, hyperechoic, heterogeneous mass in the substance of the right iliopsoas muscle, compatible with a collection of partially clotted blood, confirming the clinical diagnosis of iliopsoas haematoma. After conservative treatment the patient resumed training and is now fully asymptomatic.