Bilateral iliopsoas hematoma: Case report and literature review
A 63-year-old female presented to the emergency room with acute chest pain, discomfort, and breathing difficulties. A computed tomography (CT) angiogram of the chest revealed a sub-segmental pulmonary embolism in the right lower lung lobe. The patient was subsequently admitted and started on intravenous heparin. She also received a single dose of clopidogrel (Plavix®) at the time of admission. The next day, she was started on warfarin (Coumadin®) 7.5 mg at bedtime with heparin bridging. Partial thromboplastin time was monitored but poorly controlled, showing variations from 29 to 180 seconds over the next several days. Five days later, the patient's International Normalized Ratio reached a therapeutic range at 2.0 and heparin was discontinued. That same day, she began complaining of abdominal and flank pain.\nOn day 7 of hospitalization, the patient developed moderate weakness in the proximal lower extremities. A CT scan of the abdomen was performed and demonstrated large, bilateral iliopsoas muscle hematomas. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated acute hematoma formation in the iliopsoas bilaterally [Figure -]. Neurosurgery was consulted on day 8. On physical examination, the patient was in no apparent distress and stable hemodynamically. She had normal tone, but moderate bilateral proximal lower extremity weakness with 3/5 strength in bilateral iliopsoas and 2/5 strength in quadriceps. Extension of the hip elicited pain in the back and groin. The patient also exhibited hyperalgesia and numbness over the L2-L4 dermatomes, bilaterally.\nConservative management using vitamin K and fresh frozen plasma for Coumadin® reversal was recommended, with the intention of monitoring and following the patient's clinical examination. Over the next 2 days, the patient reported symptomatic improvement of her abdominal pain and thigh numbness, but persistent weakness. On day 11 of hospitalization, it was noted that the patient's strength had deteriorated further with iliopsoas and quadriceps strength of 1/5, bilaterally. Based on this neurological deterioration, she was taken for surgical decompression of the hematomas through bilateral flank incisions. The external oblique muscle and external oblique fascia were transected. The incision was carried down to the internal oblique muscle and preperitoneal space. A longitudinal incision was made over the psoas major muscles and hematoma material of 240 and 220 ml was drained from the right and left compartments, respectively. The femoral nerves were identified and separated from clot material. Despite bipolar stimulation of 1-4 μV to the femoral nerve, no significant electromyography response was elicited.\nBy the third postoperative day, the patient demonstrated marked improvement in strength and near complete resolution of her thigh numbness; both iliopsoas muscles had 4/5 power. The left quadriceps showed 4/5 strength while her right quadriceps remained 0/5. She was then discharged to a rehabilitation facility. Iliopsoas strength remained 4/5 bilaterally at 6-week follow-up. Her left quadriceps improved to 5/5 and her right quadriceps improved to 1/5. At 3- and 6-month follow-up visits, the patient was noted to have full strength in her lower extremities, but experienced continued mild dysesthesias in anterolateral thighs bilaterally.