Conservative management of psoas haematoma following complex lumbar surgery
A 50-year-old female without any history of bleeding disorders presented to us with a 2 year old history of severe discogenic low back pain with left-sided lower limb radiculopathy in lumbar 4, 5 and S1 nerve root. Additional symptoms included difficulty in walking up to 15-20 m due to neurological claudication. A complete spinal assessment revealed restricted spinal movements and decreased sensation over left L3. Patient was on analgesics (Tramadol, Paracetamol), antihypertensives (Lisinopril) and inhalers for asthma. There was no history of ingestion of anticoagulant medications. The preoperative blood parameters including hematology, biochemistry and clotting profiles were within normal limits. Initial radiographs of lumbar spine revealed degenerative scoliosis with convexity to right from L1 to S1 with a sideway slip at L4/5 and rotation from the L3/4 level upward in the vertebrae [Figure and ]. Magnetic resonance imaging (MRI) scans preoperatively revealed severe stenosis at L4/5 and L5/S1 [Figure and ]. After failed conservative measures for 6 months, the patient was offered surgery. He underwent dynamic stabilization using Inlign™ multiaxial pedicle screws [Disc Motion Technologies (DMT), Yarm UK] at L3 and L4 levels and a posterior lumbar interbody fusion using 11 mm cages (SABER CFRP I/F cage system, DePuy spine, Warsaw, In, USA) using a less invasive approach at L4/5 and L5/S1 levels []. There were no intraoperative complications. She received two doses of perioperative antibiotic prophylaxis (Cefuroxime) and pneumatic calf compression device as mechanical thromboprophylaxis. In the immediate postoperative period, the radicular pain symptoms settled completely and no further neurological deficiency was observed. She was mobile independently without any aids on the second postoperative day and discharged with oral analgesics.\nSubsequently, on the fourth postoperative day, she was readmitted to the hospital with symptoms of left-sided radicular pain, similar to the preoperative symptoms. On clinical examination, she was apyrexial, tender over the left iliac fossa and percussion of the left flank produced left radicular symptoms again. A detailed neurological examination was performed which revealed decreased sensation over L4 and 5 dermatomes and motor power of Medical Research Council (MRC) grade 4 on left L4 and L5 myotomes. She was started on analgesic medications such as Tramadol, Paracetamol, Diclofenac, and oral morphine. In addition, Amitryptyline and Gabapentine were started to ease the radicular pain. Blood investigations such as full blood count, urea and electrolyte, C-reactive protein (CRP), coagulation profile, blood culture and erythrocyte sedimentation rate (ESR) were done. Initial postoperative radiographs of lumbar spine did not show any obvious abnormalities. A computed tomography (CT) scan of the abdomen was performed to rule out any retroperitoneal hematoma, deep infection, or screw malplacement. CT scan revealed a collection with gas behind the left psoas muscle at the level of L4/5 vertebral body. MRI [] of the lumbar spine revealed a large collection measuring 7.6 × 4.3 × 3.3 cm adjacent to the L4–S1 vertebral bodies. In addition, there was 3 × 3.5 cm collection containing gas, which was noted posteriorly at the L4 level, displacing the thecal sac anteriorly. This collection was communicating with the extradural hematoma through the left L4 exit foramen []. In addition to this, a decision was made for further image-guided drainage of the collection for the next day. However, as the patient reported substantial improvement in her symptoms within 12 h of starting conservative measures, it was decided to wait for further improvement. Surprisingly, within 2 days of starting the conservative therapy, her symptoms settled completely and she started mobilizing independently. She was discharged within 4 days of second admission. At discharge, her CRP was 6 mg/L and WBC 13 10 cells/L). Blood cultures did not grow any organisms. At 6 months followup, she was symptom free, without any residual neurological deficit, walking up to 2 miles, and had resumed her profession as a cook.