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Femoral neuropathy due to compression by retroperitoneal haemorrhage
Journal of the Neurological Sciences, 1979, 43: 479-482 © Elsevier/North-Holland Biomedical Press
479
Short Report
FEMORAL NEUROPATHY DUE TO COMPRESSION BY RETROPERITONEAL HAEMORRHAGE A Modern Evaluation
J. J. Z A R R A N Z 1 and P. SALISACHS ~,* 1 Seccion de Neurologia del Departamento de Medecina Interna, Ciudad Sanitaria de la Seguridad Social, Facultad de Medecina, Bilbao and ~ Servicio de Neurologia de la Residencia Sanitaria de la Seguridad Social, Badalona, Barcelona (Spain) (Received 9 July, 1979) (Accepted 12 July, 1979)
SUMMARY
We report a case of femoral neuropathy due to retroperitoneal haemorrhage occurring during the administration of heparin. The site of the hematoma is illustrated in the CT scan. It is emphasised that the modern assessment of peripheral neuropathies in the lower limbs associated with retroperitoneal haemorrhage by means of CT scan will promote our understanding of the natural history of this condition. INTRODUCTION
Retroperitoneal haemorrhage (RH) associated with anticoagulant therapy or blood dyscrasias may result in damage to the peripheral nervous system of the lower limbs. It is therefore important to recognise such peripheral nerve lesions because they may indicate the presence of RH. Conventional radiographic methods used to detect RH rely greatly on inferential signs and lack both sensitivity and specificity and may be inconclusive (Sagel 1977). However, RH can now be accurately diagnosed by using CT scan (Sagel 1977). Simeone et al. (1977) reported two cases of femoral neuropathy (FN) associated with RH diagnosed by CT scan. Emery and Ochoa (1978) published one case of lumbar plexus neuropathy associated with RH also diagnosed by CT scan. The purpose of this communication is: (1) to confirm the usefulness of the CT scan as a diagnostic tool of peripheral nerve lesions of the lower limbs associated with RH; and (2) to contribute to the understanding of the peripheral neuropathies caused by RH. * Present address: The National Hospital for Nervous Diseases, Queen Square, London WC1N 3BG, Great Britain.
480
Fig. 1. CT scan of the abdomen at the level of the iliac bones showing a mass (arrows). The iliac muscle hematoma (star) adjacent to the right iliac bone is compressing and distorting the psoas muscle (P).
CASE REPORT A 42-year-old married woman presented with venous thrombosis of her left leg during her 3rd post-partum period. Treatment with heparin was initiated and adequate control was established. Twelve days later she experienced pain in the right groin which radiated to the genitalia, the anterior aspect of the right thigh and abdomen. Weakness of extension of the right thigh was also experienced. On examination she was found to have an ill-defined small mass in her right groin. There was no haematoma in her thigh. The patient held her right thigh flexed. Extension of the thigh was possible but increased the severity of the pain. There was no pain in the abdominal wall nor in the lumbar region. There was moderate loss of strength in the ilio-psoas muscle (MRC grade 2); the right quadriceps muscle did not contract (grade 0); adductor, abductor and gluteal strength were considered normal within the limits of the patient's pain and there was no loss of strength in the muscles below the knee. The right knee jerk was absent and sensation to pin-prick was impaired over the anterior and lateral side of the right thigh. Heparin was discontinued. A C T scan of the lumbar region and pelvic region showed a smooth solid mass of increased density in the region of the right iliacus muscle at the level of the brim (Fig. 1) with density measurements consistent with those of haemorrhage. Twenty-four hours later the patient started to improve. So it was decided to treat her conservatively. Seventy hours later her right quadriceps was found to be within normal limits. One month later, the only abnormal finding was a diminished right quadriceps reflex. DISCUSSION D a m a g e to t h e n e r v e s o f the l o w e r l i m b s by h a e m o r r h a g e is m o r e f r e q u e n t t h a n s u s p e c t e d ( M a n t et al. 1977) a n d m a y be d u e to b l e e d i n g w i t h i n t h e n e r v e ( B i g e l o w a n d G r a v e s 1952) o r to c o m p r e s s i o n ( D e b o l t a n d J o r d a n 1966; Z a r r a n z et al. 1979), the
481 latter being by far the more common (Chiu, 1976; Young and Norris 1976; Emery and Ochoa, 1978). The frequency of damage caused to the femoral nerve or lumbar plexus during haemorrhagic conditions is not known and needs to be assessed more accurately to improve treatment. As it is known that in compressive neuropathies damage is determined by a combination of factors the most important of which are the severity and duration of the injury, the problem of surgical decompression arises. An analysis of the literature is inconclusive since some cases improve whereas others do not and still others get worse (Chiu 1976; Young and Norris 1976; Emery and Ochoa 1978). Parkes and Kidner (1970) studied a patient (Case II) with sciatic nerve involvement and reviewed the reports of peripheral nerve and root lesions due to haematoma formation during anticoagulant therapy. Rajashekhar and Herbison (1974) reported two cases of lumbosacral plexopathy caused by RH. In a detailed study Emery and Ochoa (1978) discussed two anatomically distinct syndromes in the lower limbs associated with RH, namely: (a) involvement of the lumbar plexus caused by bleeding within the psoas muscle caused by larger blood loss (which may result in hypovolemia) and often requiring blood transfusion; and (b) F N which is produced by bleeding within the iliacus muscle above the inguinal ligament or within the iliopsoas below. The extent of the haemorrhage seems to be less than in the former syndrome so hypovolemia is less common. Treatment in the former condition may be surgical decompression whereas in the latter it could be conservative with discontinuation of the heparin. Our case and the two cases with F N reported by Simeone et al. (1977) and those of plexus neuropathy of Emery and Ochoa (1978) and of Zarranz et al. (1979) agree with the above-mentioned groups (Emery and Ochoa 1978), whereas the post-mortem case of F N of Debolt and Jordan (1966) and the two cases of lumbosacral plexopathy of Rajashekhar and Herbison (1974) do not seem to fit these groups. The cases reported by Simeone et al. (1977), Emery and Ochoa (1978), and the present case permit the conclusion that R H resulting in peripheral nerve involvement of the lower limbs can be diagnosed accurately by CT scan. This non-invasive technique will permit: (a) the study of more cases with greater accuracy and thus promote our understanding of the natural history of this condition; and (2) correlate clinical, CT scan and treatment data in order to see whether the existence of groups (Emery and Ochoa 1978) is warranted.
REFERENCES Bigelow, N. H. and R. W. Graves (1952) Peripheral nerve lesions in haemorrhagic diseases, Arch. NeuroL Psychiat. (Chic.), 68 : 819-830. Chiu, W. S. (1976) The syndrome of retroperitoneal heamorrhage and lumbar plexus neuropathies during anticoagulent therapy, South. med. J., 69: 595-599. Debolt, W. L. and J. C. Jordan (1966) Femoral neuropathy from heparin hematoma, Bull. Los Angeles neurol. Soc., 31 : 45-50. Emery, S. and J. Ochoa (1978)Lumbar plexus neuropathy resulting from retroperitoneal haemorrhage, Muscle Nerve, 1 : 330-334. Mant, M. J., B. D. O'Brien, K. L. Thong, G. W. Hammond, R. V. Birtwhistleand M. G. Grace (1977) Haemorrhagic complications of heparin therapy, Lancet, 1 : 1133-1135.
482 Parkes, J. D. and P. H. Kidner (1970) Peripheral nerve and root lesions developing as a result of hematoma formation during anticoagulant treatment, Postgrad. reed. J., 46: 146-148, Rajashekhar, T. P. and G. J. Herbison (1974) Lumbosacral plexopathy caused by retroperitoneal haemorrhage, Arch. phys. Med. Rehab., 55: 91-93. Sagel, S. S. (1977) Detection of retroperitoneal haemorrhage, Amer. J. Roentgenol., 129: 403-407. Simeone, J. F., F. Robinson, S. L. G. Rothman and C. C. Jaffe (1977) Computerized tomographic demonstration of a retroperitoneal hematoma causing femoral neuropathy, J. Neurosurg., 47: 946-948. Zarranz, J. J., R. Simon and P. Salisachs (1979) Acute anticoagulant-induced lumbar plexus neuropathy - - A post-mortem study, In preparation.
479
Short Report
FEMORAL NEUROPATHY DUE TO COMPRESSION BY RETROPERITONEAL HAEMORRHAGE A Modern Evaluation
J. J. Z A R R A N Z 1 and P. SALISACHS ~,* 1 Seccion de Neurologia del Departamento de Medecina Interna, Ciudad Sanitaria de la Seguridad Social, Facultad de Medecina, Bilbao and ~ Servicio de Neurologia de la Residencia Sanitaria de la Seguridad Social, Badalona, Barcelona (Spain) (Received 9 July, 1979) (Accepted 12 July, 1979)
SUMMARY
We report a case of femoral neuropathy due to retroperitoneal haemorrhage occurring during the administration of heparin. The site of the hematoma is illustrated in the CT scan. It is emphasised that the modern assessment of peripheral neuropathies in the lower limbs associated with retroperitoneal haemorrhage by means of CT scan will promote our understanding of the natural history of this condition. INTRODUCTION
Retroperitoneal haemorrhage (RH) associated with anticoagulant therapy or blood dyscrasias may result in damage to the peripheral nervous system of the lower limbs. It is therefore important to recognise such peripheral nerve lesions because they may indicate the presence of RH. Conventional radiographic methods used to detect RH rely greatly on inferential signs and lack both sensitivity and specificity and may be inconclusive (Sagel 1977). However, RH can now be accurately diagnosed by using CT scan (Sagel 1977). Simeone et al. (1977) reported two cases of femoral neuropathy (FN) associated with RH diagnosed by CT scan. Emery and Ochoa (1978) published one case of lumbar plexus neuropathy associated with RH also diagnosed by CT scan. The purpose of this communication is: (1) to confirm the usefulness of the CT scan as a diagnostic tool of peripheral nerve lesions of the lower limbs associated with RH; and (2) to contribute to the understanding of the peripheral neuropathies caused by RH. * Present address: The National Hospital for Nervous Diseases, Queen Square, London WC1N 3BG, Great Britain.
480
Fig. 1. CT scan of the abdomen at the level of the iliac bones showing a mass (arrows). The iliac muscle hematoma (star) adjacent to the right iliac bone is compressing and distorting the psoas muscle (P).
CASE REPORT A 42-year-old married woman presented with venous thrombosis of her left leg during her 3rd post-partum period. Treatment with heparin was initiated and adequate control was established. Twelve days later she experienced pain in the right groin which radiated to the genitalia, the anterior aspect of the right thigh and abdomen. Weakness of extension of the right thigh was also experienced. On examination she was found to have an ill-defined small mass in her right groin. There was no haematoma in her thigh. The patient held her right thigh flexed. Extension of the thigh was possible but increased the severity of the pain. There was no pain in the abdominal wall nor in the lumbar region. There was moderate loss of strength in the ilio-psoas muscle (MRC grade 2); the right quadriceps muscle did not contract (grade 0); adductor, abductor and gluteal strength were considered normal within the limits of the patient's pain and there was no loss of strength in the muscles below the knee. The right knee jerk was absent and sensation to pin-prick was impaired over the anterior and lateral side of the right thigh. Heparin was discontinued. A C T scan of the lumbar region and pelvic region showed a smooth solid mass of increased density in the region of the right iliacus muscle at the level of the brim (Fig. 1) with density measurements consistent with those of haemorrhage. Twenty-four hours later the patient started to improve. So it was decided to treat her conservatively. Seventy hours later her right quadriceps was found to be within normal limits. One month later, the only abnormal finding was a diminished right quadriceps reflex. DISCUSSION D a m a g e to t h e n e r v e s o f the l o w e r l i m b s by h a e m o r r h a g e is m o r e f r e q u e n t t h a n s u s p e c t e d ( M a n t et al. 1977) a n d m a y be d u e to b l e e d i n g w i t h i n t h e n e r v e ( B i g e l o w a n d G r a v e s 1952) o r to c o m p r e s s i o n ( D e b o l t a n d J o r d a n 1966; Z a r r a n z et al. 1979), the
481 latter being by far the more common (Chiu, 1976; Young and Norris 1976; Emery and Ochoa, 1978). The frequency of damage caused to the femoral nerve or lumbar plexus during haemorrhagic conditions is not known and needs to be assessed more accurately to improve treatment. As it is known that in compressive neuropathies damage is determined by a combination of factors the most important of which are the severity and duration of the injury, the problem of surgical decompression arises. An analysis of the literature is inconclusive since some cases improve whereas others do not and still others get worse (Chiu 1976; Young and Norris 1976; Emery and Ochoa 1978). Parkes and Kidner (1970) studied a patient (Case II) with sciatic nerve involvement and reviewed the reports of peripheral nerve and root lesions due to haematoma formation during anticoagulant therapy. Rajashekhar and Herbison (1974) reported two cases of lumbosacral plexopathy caused by RH. In a detailed study Emery and Ochoa (1978) discussed two anatomically distinct syndromes in the lower limbs associated with RH, namely: (a) involvement of the lumbar plexus caused by bleeding within the psoas muscle caused by larger blood loss (which may result in hypovolemia) and often requiring blood transfusion; and (b) F N which is produced by bleeding within the iliacus muscle above the inguinal ligament or within the iliopsoas below. The extent of the haemorrhage seems to be less than in the former syndrome so hypovolemia is less common. Treatment in the former condition may be surgical decompression whereas in the latter it could be conservative with discontinuation of the heparin. Our case and the two cases with F N reported by Simeone et al. (1977) and those of plexus neuropathy of Emery and Ochoa (1978) and of Zarranz et al. (1979) agree with the above-mentioned groups (Emery and Ochoa 1978), whereas the post-mortem case of F N of Debolt and Jordan (1966) and the two cases of lumbosacral plexopathy of Rajashekhar and Herbison (1974) do not seem to fit these groups. The cases reported by Simeone et al. (1977), Emery and Ochoa (1978), and the present case permit the conclusion that R H resulting in peripheral nerve involvement of the lower limbs can be diagnosed accurately by CT scan. This non-invasive technique will permit: (a) the study of more cases with greater accuracy and thus promote our understanding of the natural history of this condition; and (2) correlate clinical, CT scan and treatment data in order to see whether the existence of groups (Emery and Ochoa 1978) is warranted.
REFERENCES Bigelow, N. H. and R. W. Graves (1952) Peripheral nerve lesions in haemorrhagic diseases, Arch. NeuroL Psychiat. (Chic.), 68 : 819-830. Chiu, W. S. (1976) The syndrome of retroperitoneal heamorrhage and lumbar plexus neuropathies during anticoagulent therapy, South. med. J., 69: 595-599. Debolt, W. L. and J. C. Jordan (1966) Femoral neuropathy from heparin hematoma, Bull. Los Angeles neurol. Soc., 31 : 45-50. Emery, S. and J. Ochoa (1978)Lumbar plexus neuropathy resulting from retroperitoneal haemorrhage, Muscle Nerve, 1 : 330-334. Mant, M. J., B. D. O'Brien, K. L. Thong, G. W. Hammond, R. V. Birtwhistleand M. G. Grace (1977) Haemorrhagic complications of heparin therapy, Lancet, 1 : 1133-1135.
482 Parkes, J. D. and P. H. Kidner (1970) Peripheral nerve and root lesions developing as a result of hematoma formation during anticoagulant treatment, Postgrad. reed. J., 46: 146-148, Rajashekhar, T. P. and G. J. Herbison (1974) Lumbosacral plexopathy caused by retroperitoneal haemorrhage, Arch. phys. Med. Rehab., 55: 91-93. Sagel, S. S. (1977) Detection of retroperitoneal haemorrhage, Amer. J. Roentgenol., 129: 403-407. Simeone, J. F., F. Robinson, S. L. G. Rothman and C. C. Jaffe (1977) Computerized tomographic demonstration of a retroperitoneal hematoma causing femoral neuropathy, J. Neurosurg., 47: 946-948. Zarranz, J. J., R. Simon and P. Salisachs (1979) Acute anticoagulant-induced lumbar plexus neuropathy - - A post-mortem study, In preparation.