Complete Femoral Nerve Palsy Following Traumatic Iliacus Hematoma: A Case Report and Literature Review

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.

Spontaneous iliacus haematoma with femoral nerve palsy: an appeal to involve surgical teams early

We report the case of a 68-year-old man who was placed on heparin as bridge therapy and subsequently developed an iliacus haematoma with associated femoral nerve palsy. His team involved the orthopaedic surgery team in delayed fashion after his symptom onset. Due to his active medical conditions, he did not undergo surgical decompression of his haematoma until late into his hospital course. Unfortunately, this patient did not regain meaningful function from his femoral nerve deficit. We believe this case highlights the high index of suspicion necessary for making this diagnosis as well as the repercussions of an untimely decompression for this acute, compressive neuropathy. Although we are surgeons and this is a surgical case, we hope to publish this case in a medical journal to raise awareness that surgical decompression does have a role in this diagnosis and should ultimately be pursued early in its course for optimal patient benefit.

Iliacus hematoma syndrome: A systematic review of recent literature and case report

BACKGROUND

Femoral nerve palsy caused by iliacus hematoma is an infrequent diagnosis often missed because of its insidious presentation. However, due to potentially devastating outcomes, prompt recognition and management are essential.

OBJECTIVES

The aim with this study was to better characterize clinical presentation, diagnosis, treatment, and prognosis of iliacus hematoma.

METHODS

We performed a systematic review of recent literature regarding femoral neuropathy secondary to an iliacus hematoma. A structured literature review of multiple databases ((PubMed, Web of Science, EMBASE, and Cochrane library) referenced articles from 2000 to 2019.

RESULTS

A total of 25 patients from 25 published studies were identified. The average age of the patients was forty years (range, 12 to 85 years). There were 16 male patients and 9 female patients. The single most important predisposing cause of iliacus hematoma was trauma (14/25), with a pooled percentage of 56%. All patients with spontaneous hematoma were taking antiplatelet medications. Thirteen patients (52%) were treated conservatively with analgesia. Surgical decompression was performed in 10 patients (40%). At the final follow-up, complete resolution of symptoms was achieved in 12 patients (48%).

CONCLUSIONS

Although rare, iliacus hematoma syndrome carries significant morbidity. Spontaneous iliacus muscle hematoma should be considered in the differential diagnosis of leg pain in a patient who is on anticoagulation therapy. In patients with an iliacus hematoma and neurology deficit, conservative treatment can be considered initially if there is no progression in the symptoms evident at the time of presentation. However, prompt surgical decompression has been highly recommended in patients with progressive neurological deficits.