Femoral nerve palsy secondary to traumatic iliacus muscle hematoma: course after nonoperative management

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.

Iliopsoas hematoma presenting with sudden knee extensor weakness: A case report

RATIONALE

Hematoma of the iliopsoas muscle is a rare condition. Prolonged pressure conditions due to hematoma of the femoral nerve can cause severe pain in the affected groin, hip, and thigh, and quadriceps weakness. We report a rare case of a spontaneous iliopsoas muscle hematoma that caused sudden femoral neuropathy.

PATIENT CONCERNS

A 71-year-old woman presented sudden left hip pain and knee extensor weakness. The pain was aggravated with left hip extension. She had a bilateral total hip replacement surgery due to avascular necrosis. She was diagnosed as mild stenosis of the cerebral artery and took aspirin to prevent cerebral artery atherosclerosis.

DIAGNOSIS

A hip computed tomography scan demonstrated a suspicious fluid collection at the left iliopsoas bursa. We considered the possibility of lower limb weakness due to neuralgic amyotrophy and performed electromyography and enhanced lumbosacral magnetic resonance imaging (MRI). Electromyography finding showed left femoral neuropathy of moderate severity around the inguinal area was diagnosed. On MRI, left iliopsoas bursitis or hematoma, and displacement of the left femoral nerve due to the iliopsoas bursitis/hematoma were observed.

INTERVENTION

Ultrasonography (US)-guided aspiration of the left iliopsoas hematoma was performed. We started steroid pulse therapy for 8 days.

OUTCOMES

After US-guided aspiration and steroid pulse therapy, the patient's knee extension motor grade improved from grade 1 to 2, and the pain was slightly reduced. At 3 weeks after the aspiration procedure, her hip flexion motor grade had improved from grade 3+ to 4 at follow-up.

LESSONS

Imaging studies are fundamental to diagnose of iliopsoas hematoma. Electromyography examination plays an important role in determining the prognosis of patients and lesion site. Despite the negligible change in sitting position, hematoma can develop. Physicians should consider hematoma that cause femoral neuropathy.

Subperiosteal Hematoma of the Iliac Bone: An Unusual Cause of Acute Hip Pain after a Fall

BACKGROUND Subperiosteal hematoma (SPH) of the iliac bone is an extremely uncommon clinical entity that occurs mostly in young patients with a history of a recent fall or sports-related injury. Patients usually complain of severe hip pain after a fall, mimicking femoral neck fracture. CASE REPORT An 18-year-old female was transported to our hospital complaining of pain in her left hip after falling on her buttocks while engaging in martial arts. Ultrasound of her left iliac region revealed a subperiosteal mass on the internal aspect of the iliac bone lifting the iliac muscle. SPH of the iliac bone was suspected, which was also evident on pelvis and hip magnetic resonance imaging. Repetitive ultrasound did not reveal hematoma expansion. She was discharged from the hospital the next day without femoral neuropathy. CONCLUSIONS Physicians should be aware of our report, which highlights a patient with the rare clinical condition of SPH of the iliac bone occurring immediately after a fall. The differential diagnosis of acute hip pain, which mimics femoral neck fracture, should be considered in young patients. Ultrasound of the iliac region may be useful in detection and further management of SPH of the iliac bone.

Safety and efficacy of a new procedure for treating traumatic iliopsoas hematoma: a retroperitoneoscopic approach

BACKGROUND

Surgical treatment is often recommended for traumatic iliopsoas hematoma. Open surgeries lead to severe surgical trauma, and minimally invasive surgeries cannot completely remove the hematoma. A new treatment protocol for traumatic iliopsoas hematoma by retroperitoneoscopic approach has been introduced. The goal of this study was to determine the safety and efficacy of retroperitoneoscopic approach used to remove iliopsoas hematoma.

METHODS

Between January 2009 and July 2012, 13 patients were diagnosed of traumatic iliopsoas hematoma. Retroperitoneoscopic surgeries were performed on all patients to remove the hematomas after admission. The size of hematoma, VASA score and neurologic status were dynamic evaluated before and after surgery. Soft tissue damage and complications caused by retroperitoneoscopic approach also were recorded and evaluated.

RESULTS

We performed retroperitoneoscopic surgery to remove traumatic iliopsoas hematoma successfully on 13 patients without complications. The mean procedure time was 52.5 ± 13.4 min, and mean blood loss was 30.7 ± 9.2 ml. Hematoma was completely removed confirmed by ultrasound after surgery. Pain in the affected lower abdominal and thigh immediately was relieved totally for ten patients and partly for three patients after surgery. Quadriceps strength was restored to grade 5 and pain completely disappeared 2 months postoperatively on all patients. Numbness along the femoral nerve distribution disappeared for 11 patients and improved for 2 patients until the last follow-up. None of 13 patients suffered from infection or a new hematoma during follow-up.

CONCLUSIONS

Retroperitoneoscopic approach is a safe and effective procedure alternative to conventional surgical approach for treating traumatic iliopsoas hematoma in terms of complete removal of hematoma, minimal invasiveness, absence of radiation, and rapid recovery.

Complete paralysis of the quadriceps secondary to post-traumatic iliopsoas hematoma: a systematic review

PURPOSE

Paralysis of the femoral nerve secondary to compression by a hematoma of the iliopsoas is rarely post-traumatic. The acute surgical removal of hematoma seems the treatment of choice. The main objective of this systematic review was to determine the optimal delay between the trauma and surgery, to obtain a total functional recovery.

METHODS

A search was performed via PubMed. The inclusion criteria were the studies in English language, reporting the results of the treatment of femoral nerve palsy secondary to compression by a post-traumatic hematoma of the iliopsoas. The primary evaluation criterion was the clinical recovery of femoral nerve function. The secondary criteria were the delay of recovery and the delay between the trauma and surgery.

RESULTS

Thirteen studies were identified, only case reports. Sixteen patients were included, mean age 16.6 ± 3.4 years, 11 men and 5 women. The injury was associated with the sports practice in 12/16 (75 %) cases. Neurological symptoms developed about 5 days after injury. Femoral palsy was complete in 8 patients and partial in 8 patients. The mean delay between the injury and the diagnosis was 7.3 (2-25) days in conservative group and 17.8 (4-45) days in surgical group. Seven patients were managed conservatively, 6 partial paralysis and 1 total paralysis, and 9 surgically, 7 total paralysis and 2 partial paralysis. The recovery was total in 13/14 patients (seven surgical treatment and six conservative management) and partial in one patient who was managed conservatively despite a total paralysis. The delay of total recovery varied from 1 month to 6 weeks in conservative group and 3 months to 2 years in surgical group.

CONCLUSION

This systematic review seems to indicate that whatever the delay, surgery is necessary in case of complete paralysis of the femoral nerve secondary to compression from a post-traumatic hematoma of the iliopsoas muscle.

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.

Subacute proximal leg weakness after a minor traffic accident in a patient treated with anticoagulants

One day after a minor accident, an 85-year-old man developed headache and proximal left leg weakness. He was on warfarin due to atrial fibrillation. On hospital admission, a right posterior parasagittal subdural haematoma that was visualised on CT was considered as cause of all symptoms. Although no surgical intervention was performed he stayed for 2 weeks in a neurosurgical ward. Clinical deterioration occurred within the first days as he was not able to stand on his left leg or rise up from the sitting position. Headache had ceased, but the patient reported low abdominal pain. This condition remained stable for over 2 months although haematoma size decreased significantly. He was then examined for the first time by a neurologist who documented typical clinical features of femoral nerve palsy. Pelvic CT established the diagnosis of traumatic iliacus- and iliopsoas-muscle haematoma under anticoagulants as cause of subacute femoral mononeuropathy.

Massive psoas haematoma causing lumbar plexus palsy: a case report

An 84-year-old man who was receiving oral anticoagulation therapy presented with complete lumbar plexus palsy caused by a massive psoas haematoma. Conservative treatment rather than drainage of the haematoma was undertaken, because of the risk of bleeding complications and mortality. At the one-year follow-up, the patient had no clinical signs of neurological recovery. The patient died 2 months later due to his concurrent medical problems. A high degree of suspicion is needed for the diagnosis because of the insidiously developing neurological deficit.

Femoral nerve palsy secondary to traumatic iliacus haematoma--a young athlete's injury

Femoral neuropathy secondary to iliacus haematoma in the absence of a bleeding diathesis is rare. Of the few documented cases in the literature, most have occurred in adolescents participating in sport. We report a case of femoral nerve palsy complicating an iliacus haematoma occurring in a young person with minimal trauma that resolved with non-operative management. Although rare, iliacus haematoma should be included in the differential diagnosis of groin pain as the number of children and young adults participating in sport increases.

Non-operative management of femoral neuropathy secondary to a traumatic iliacus haematoma in an adolescent

Iliacus haematoma is a relatively rare condition, which may cause a local compressive neuropathy. It is usually diagnosed in adults with haemophilia or those on anticoagulation treatment and may occur after trauma. We present the case of a healthy 15-year-old boy with a femoral neuropathy due to an iliacus haematoma which resolved following conservative treatment.

Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?

BACKGROUND

Retroperitoneal haematoma is a rare clinical entity with variable aetiology, which is increasing in incidence mainly due to complications related to interventional procedures. There is no general consensus as to the best management plan for patients with retroperitoneal haematoma.

METHODS

A literature review was undertaken using MEDLINE, all relevant papers on retroperitoneal haemorrhage or haematoma were used.

RESULTS

The diagnosis is often delayed as symptoms are nonspecific. Retroperitoneal haematoma should be suspected in patients with significant groin, flank, abdominal, back pain or haemodynamic instability following an interventional procedure. Spontaneous haemorrhage usually occurs in patients who are anticoagulated. Multi-slice CT and arteriography are important for diagnosis. Most haemodynamically stable patients can be managed with fluid resuscitation, correction of coagulopathy and blood transfusion. Endovascular treatment involving selective intra-arterial embolisation or the deployment of stent-grafts over the punctured vessel is attaining an increasingly important role. Open repair of retroperitoneal bleeding vessels should be reserved for cases when there is failure of conservative or endovascular measures to control the bleeding. Open repair is also required if endovascular facilities or expertise is unavailable and in cases where the patient is unstable. If treated inappropriately, the mortality of patients with retroperitoneal haematoma remains high.

CONCLUSION

There is a lack of level I evidence for the best management plans for retroperitoneal haematoma, and evidence is based on small cohort series or isolated case reports. Conservative management should only be reserved for patients who are stable. Interventional radiology with intra-arterial embolisation or stent-grafting is the treatment of choice. Open surgery is now rarely required.

Femoral nerve palsy due to iliacus hematoma occurred after primary total hip arthroplasty

The perforation of the medial acetabular wall during total hip arthroplasty due to drilling is not uncommon. But, it has rarely been associated with serious adverse events. Here, we present a case report describing an iliacus hematoma with subsequent femoral nerve palsy after primary total hip arthroplasty in a 67-year-old woman who underwent primary total hip arthroplasty due to painful hip osteoarthritis. The diagnosis was made by pelvic magnetic resonance imaging. Conservative treatment was employed and the symptoms were resolved within 3 months. It should be borne in mind that femoral nerve palsy may occur after total hip arthroplasty. It may be due to a treatable cause, such as iliacus hematoma. So, pelvic MRI is recommended in such a condition, rather than just observation.

Femoral nerve palsy following iliacus hematoma

We report a rare case of femoral nerve palsy secondary to hematoma compression of the iliacus. The patient presented with pain 2 days after performing a double kick in karate. The femoral nerve symptoms (numbness and weakness) did not begin until 3 to 4 days after the initial trauma. Magnetic resonance imaging (MRI) confirmed that there was a hematoma compressing the iliacus (and femoral nerve). This hematoma was subperiosteal, within the iliac fossa. This case is rare because the femoral nerve palsy resolved without surgical intervention, the mechanism of injury, the imaging used to diagnose the iliacus hematoma, and the hematoma was subperiosteal and not within the actual iliacus muscle. A review of the literature regarding femoral nerve palsy secondary to traumatic iliacus hematoma is presented. If the diagnosis of femoral nerve palsy secondary to iliacus hematoma is suspected after history and physical examination, MRI is the imaging study of choice. If MRI does not depict a discreet hematoma mass, nonoperative management should be considered. Electromyography has not been shown to offer information that was not provided by history, physical examination, and other imaging. Surgery should be considered if there is progression of the femoral nerve symptoms, or if MRI depicts a discreet collection of blood impinging on the femoral nerve.

Femoral neuropathy in a patient with rheumatoid arthritis

Femoral mononeuropathy (FMN) as an extraarticular finding of rheumatoid arthritis (RA) is a phenomenon which has not been reported previously. We report a 53-year-old female patient with RA, presenting FMN findings during the course of the disease. On examination, right quadriceps and iliopsoas muscles showed grade 3 weakness on the Medical Research Council (MRC) scale. Sensory examination revealed sensory loss in the right medial leg and thigh. Patellar tendon reflex was absent in the right side. A diagnosis of a partial right femoral neuropathy was confirmed using nerve conduction study and electromyography. The probable mechanism of FMN was thought to be vasculitis.

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.

Femoral nerve entrapment: A new insight

Compression of the femoral nerve in the iliac fossa has been reported as a consequence of several pathologies, but never as a result of muscular compression. Aberrant slips of iliacus, however, have occasionally been reported to cover or split the femoral nerve. This study aimed to assess such variations as potential factors in femoral nerve compression. A large and homogeneous sample of 121 embalmed cadavers (242 specimens) was studied. Statistical comparisons were made using the chi-squared test. Muscular slips from iliacus and psoas, piercing or covering the femoral nerve, were found in 19 specimens (7.9%). No significant differences by sex or side were found. The more frequent variation was piercing of the femoral nerve by a muscular slip (17 specimens, 7.0%). The nerve then entered the thigh as one or more branches. The less frequent variation found was a muscular slip or sheet covering the femoral nerve as it lay on iliacus (2 specimens, 0.8%). Each disposition may be a potential risk for nerve entrapment.

Femoral Neuropathy following Retroperitoneal Hemorrhage: Case Series and Review of the Literature

Femoral neuropathy due to retroperitoneal hematoma has been infrequently described in the literature. While occasionally due to trauma, it has been most commonly reported in association with various bleeding diatheses and therapeutic anticoagulation. As the indications for the use of anticoagulants and antiplatelet agents increase, associated hemorrhagic complications will likely also increase. The management of retroperitoneal hematoma with consequent femoral nerve palsy remains controversial. We present a series of four cases of femoral nerve palsy due to retroperitoneal hematoma managed by surgical decompression. Hematoma evacuation at the time of the development of femoral neuropathy results in immediate benefit, with greater likelihood of a return to pre-event neurological status. Delays in operative treatment, despite the presence of a neurological deficit, may lead to significant and prolonged neurological dysfunction. Surgical decompression should be highly considered in all patients who develop femoral neuropathy from a retroperitoneal hematoma.

Femoral neuropathy in a dog with iliopsoas muscle injury

OBJECTIVE

To report femoral nerve dysfunction caused by focal iliopsoas muscle injury and treated by performing tenectomy of the muscle insertion.

STUDY DESIGN

Case report.

ANIMALS

A 4-year-old, castrated male, English Mastiff.

RESULTS

Iliopsoas muscle injury caused femoral nerve deficits and severe pain. Focal injury was not detected by ultrasonography or computed tomography but was visible on magnetic resonance (MRI) images. Tenectomy of the insertion of the iliopsoas muscle relieved signs of pain.

CONCLUSIONS

Femoral nerve dysfunction may occur with iliopsoas muscle injury.

CLINICAL RELEVANCE

Iliopsoas muscle injury should be considered in patients with hip pain and MRI is a useful test for diagnosis. Tenectomy may be indicated for relief of chronic iliopsoas muscle pain.

Femoral nerve palsy secondary to traumatic pseudoaneurysm and iliacus hematoma

The authors report a case of traumatic femoral nerve palsy caused by a pseudoaneurysm of the iliolumbar artery and a iliacus muscle hematoma. This case report details not only the classic history and physical findings seen in patients such as this one, but also illustrates an unusual source of the hematoma and a discussion of its treatment. A 20-year-old man was assaulted and presented to the authors's institution with a 1-week history of severe pain in the left anterior thigh and groin, weakness in the left quadriceps muscle, and numbness in the anterior thigh and medial distal leg. Imaging studies demonstrated a large, 9.4 x 6.4 x 5.2-cm iliacus hematoma as well as a pseudoaneurysm originating from the left iliolumbar artery. The patient underwent angiographic embolization of the pseudoaneurysm followed by surgical evacuation of the hematoma. The embolization was performed before surgery to prevent any possible rebleeding from the pseudoaneurysm during evacuation of the hematoma. Femoral nerve palsy caused by traumatic iliacus hematoma is an infrequent diagnosis often missed because of its insidious presentation. In this case, embolization of the iliolumbar artery pseudoaneurysm followed by surgical evacuation of the hematoma resulted in a nearly full recovery of the femoral nerve as of the last follow-up examination.

Intrapelvic and thigh-level femoral nerve lesions: management and outcomes in 119 surgically treated cases

OBJECT

The authors present a retrospective analysis of 119 surgically treated femoral nerve lesions at intrapelvic and thigh levels seen at the Louisiana State University Health Sciences Center.

METHODS

Femoral nerve lesions treated between 1967 and 2000, (89 traumatic injuries and 30 tumors and cystic lesions) were evaluated for injury mechanisms, resulting lesions, surgical management, and postoperative functional outcomes by using retrospective chart reviews. The most common injury mechanism was iatrogenic (52 cases), which occurred after hernia and hip operations (10 each), followed by arterial bypass and gynecological procedures (eight each), angiography (seven), abdominal surgery (five), appendectomy (two), a laparoscopy, and a lumbar sympathectomy. Other injury mechanisms included hip or pelvic fractures (19), gunshot wounds (10), and lacerations (eight). The 30 femoral nerve tumors and cystic lesions consisted of neurofibromas (16), schwannomas (nine), ganglionic cysts (two), neurogenic sarcomas (two), and a leiomyosarcoma. Forty-four patients underwent neurolysis. Some had recordable nerve action potentials (NAPs) across their lesions in continuity, despite severe distal loss. Others with recordable NAPs had mild loss, but also experienced a pain problem, which was helped in some by neurolysis. In 36 patients, in whom repairs were performed using long sural grafts for mostly proximal pelvic-level injuries, recovery of useful function occurred. Eight of nine thigh-level suture repairs led to improvement to good functional levels. Most of the tumors and cystic lesions were resected, with preservation of preoperative function.

CONCLUSIONS

The majority of femoral nerve injuries resulted in lesions in continuity, and intraoperative NAP recordings were essential in evaluating axonal regeneration across these lesions. Despite severe and frequently proximal injury levels requiring repairs with long grafts, femoral nerve lesion repairs resulted in good functional recovery.

Complete paralysis of the quadriceps muscle caused by traumatic iliacus hematoma: a case report

A15-year-old girl who developed traumatic iliacus hematoma and complete paralysis of the quadriceps muscle is reported. The current case and literature review revealed that incomplete quadriceps paralysis associated with traumatic iliacus hematoma is likely to progress to complete paralysis in days or weeks as a result of increased intracompartmental pressure. However, surgical decompression of the femoral nerve could produce good results even in patients who have complete quadriceps paralysis preoperatively.

Iliopsoas hematoma with femoral neuropathy presenting a diagnostic dilemma after spinal decompression

STUDY DESIGN

Case report of an iliopsoas hematoma with femoral neuropathy appearing 8 weeks after a posterior spinal decompression procedure.

OBJECTIVES

To describe a potential complication and differential diagnosis for nerve root symptoms following spinal decompression.

SUMMARY OF BACKGROUND DATA

Iliopsoas hematoma is usually a complication of anticoagulation, hemophilia, or trauma. It has not been described previously as a complication of posterior spinal decompression. Femoral neuropathy results from compression within the iliopsoas compartment.

METHODS

A 53-year-old woman reported pain in the right side of her groin and an increasing fixed flexion deformity of the right hip 8 weeks after a posterior, midline, spinal decompression. A femoral neuropathy later developed. Magnetic resonance imaging and computed tomography were performed.

RESULTS

Imaging studies demonstrated a diffusely enlarged iliopsoas. Exploration revealed a large hematoma, which was evacuated. The compartment was fully decompressed with resolution of the nerve root symptoms within 48 hours.

CONCLUSIONS

Iliopsoas pathology is a rare cause of nerve root symptoms and presented diagnostic difficulties after an apparently successful spinal decompression.