Delayed Retroperitoneal Hemorrhage due to Lumbar Artery Pseudoaneurysm after Lumbar Posterolateral Fusion
A 55-year-old female patient with lower back pain and neurogenic intermittent claudication, who previously underwent L4-L5 PLF due to spinal stenosis, was presented to our hospital. She experienced small thalamic infarction 5 years ago, and since then, she started antiplatelet and antihypertensive medications. Lumbar spine magnetic resonance image revealed L3-L4 spinal stenosis due to adjacent segment degeneration. Hence, the patient underwent L3-L4 PLF. To prepare the bone fusion bed, the transverse process of L3 and L4 was decorticated with a drill. There was minimal bleeding during the surgery, and post-operative complaints only include mild back pain. However, on the 9th post-operative day, the patient complained of a sudden onset of severe abdominal pain and distension. Moreover, the patient was hemodynamically unstable (8.5 g/dL hemoglobin concentration; 90/60 mm Hg blood pressure; and 120/minute pulse rate). A late abdominal complication was suspected, and an emergency computed tomography (CT) scan of the abdomen with contrast enhancement was performed. This investigation revealed retroperitoneal hematoma in the right psoas muscle () and iatrogenic right L3 transverse process fracture (). The patient was resuscitated with blood transfusion, intravenous fluids for hypovolemic shock and an interventional radiologist was urgently consulted. Lumbar spinal angiography showed the delayed hematoma due to rupture of the 2nd lumbar artery pseudoaneurysm () and coil embolization was done at the ruptured lumbar artery (). After we confirmed the successful embolization through the final angiogram, the patient was sent to the ward. Since then, the patient's postoperative progress proceeded normally with recovery of the hemodynamic parameters. Two weeks after the embolization, follow-up abdominal CT showed the decreased retroperitoneal hematoma ().