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Lumbar Plexopathy Secondary to Spontaneous Large Retroperitoneal Hematoma
Accepted Manuscript Lumbar plexopathy secondary to spontaneous large retroperitoneal hematoma Simant Singh Thapa, MD, Nirmal J. Kaur, MD, Susan V. George, MD, FACP PII:
S0002-9343(16)30835-X
DOI:
10.1016/j.amjmed.2016.07.026
Reference:
AJM 13658
To appear in:
The American Journal of Medicine
Received Date: 6 July 2016 Revised Date:
29 July 2016
Accepted Date: 29 July 2016
Please cite this article as: Thapa SS, Kaur NJ, George SV, Lumbar plexopathy secondary to spontaneous large retroperitoneal hematoma, The American Journal of Medicine (2016), doi: 10.1016/ j.amjmed.2016.07.026. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE Article Type: Clinical communication to the editor
retroperitoneal hematoma. Running Head: Spontaneous retroperitoneal hematoma
SC
Authors:
RI PT
Title of the manuscript: Lumbar plexopathy secondary to spontaneous large
M AN U
1. Corresponding author: Simant Singh Thapa, MD, Department of Internal Medicine, Saint Vincent Hospital, Massachusetts.
2. Nirmal J Kaur, MD, Department of Internal Medicine, Saint Vincent Hospital, Massachusetts.
3. Susan V George, MD, FACP, Department of Internal Medicine, Saint Vincent
Funding: None.
TE D
Hospital, Massachusetts.
EP
Conflict of Interest: None.
AC C
Authorship: All authors had access to the data and played a role in writing this manuscript.
Requests for reprints should be addressed to corresponding author: Simant Singh Thapa, MD Department of Internal Medicine, Saint Vincent Hospital, 123 Summer Street, 01608, MA. E-mail address: [email protected]; [email protected]
ACCEPTED MANUSCRIPT
To the Editor:
RI PT
A 63 year old female with hypertension, hyperlipidemia, hypothyroidism, depression and eating disorder was sent in from from a nursing home for generalized weakness and a critically low sodium level of 113 mEq/l. Her hyponatremia resolved with
SC
medical management. She was on subcutaneous unfractionated heparin for venous thromoboembolism prophylaxis. On the day of planned discharge, the patient
M AN U
complained of a sudden onset of sharp left groin pain radiating towards the anteromedial aspect of the left thigh. It was associated with numbness, tingling sensation and muscle weakness towards anteromedial aspect of left thigh. There was a drop in patient hematocrit level from 33% at admission to 19.9%. The coagulation profile was within normal limits. A CT scan of the abdomen and pelvis
TE D
revealed an iliopsoas hematoma measuring 27cm x 8.6cm x 7.4cm in size (Figure A). She was managed conservatively with serial hemoglobin monitoring, blood transfusions and volume support. The follow up hemoglobin after 2 units of packed
EP
red blood blood cell transfusion remained stable for next 5 days. The patient’s groin
AC C
pain, tingling sensation and muscle weakness significantly improved over the course on next 4-5 days but her anteromedial hypoesthesia persisted upon discharge to a rehabilitation center. A repeat CT abdomen and pelvis in 6 weeks showed nearly resolved retroperitoneal hematoma without any drainable fluid collection (Figure B) and her symptoms had resolved and she was able to ambulate.
ACCEPTED MANUSCRIPT
Lumbar plexopathy due to spontaneous retroperitoneal hematoma has been
RI PT
infrequently described in the literature. It has been most commonly reported in patients with either various bleeding diatheses or undergoing therapeutic anticoagulation.1 It has also been reported after lumbar plexus block for postoperative analgesia in hip surgery
2
and following femoral vein dialysis.
3
In our
SC
patient the only possible risk factor was subcutaneous unfractionated heparin (UFH)
M AN U
used in prophylactic dose for deep vein thrombosis during her hospital stay. However, UFH in prophylactic doses has not been reported to be associated with spontaneous retroperitoneal hemorrhage.
CT scan of the abdomen and pelvis remains the most commonly utilized test for the
TE D
diagnosis as it is readily accessible, fast and has a high degree of sensitivity.4 Treatment of a retroperitoneal hematoma primarily consists of addressing the acute manifestations such as hypovolemia and shock. Management is usually
EP
conservative, consisting of bed rest, correction of underlying bleeding abnormalities if any and blood transfusion as needed. Rarely, surgical evacuation may be needed
AC C
in severe acute cases with hemodynamic instability or in chronic, unresolved lumbar plexopathy with significant motor deficits.
3,4
Ultrasound-guided
percutaneous aspiration has been reported to be safe and beneficial in patients who are poor surgical candidates.
5,6
A high clinical suspicion for retroperitoneal hematoma should be kept in all hospitalized patients on subcutaneous or intravenous heparin who complain of new onset back or thigh pain with accompanying focal neurological symptoms.
ACCEPTED MANUSCRIPT
1.
RI PT
References: Parmer SSp, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral
neuropathy following retroperitoneal hemorrhage: case series and review of the
Klein SM, D'Ercole F, Greengrass RA, Warner DS. Enoxaparin associated with
M AN U
2.
SC
literature. Ann Vasc Surg. 2006 Jul;20(4):536-40. Epub 2006 May 31.
psoas hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology
3.
TE D
1997; 87:1576.
Kaymak B, Ozçakar L, Cetin A, et al. Bilateral lumbosacral plexopathy after
Choa GP, Lim CS. Iliopsoas hematoma: An uncommon differential diagnosis
AC C
4.
EP
femoral vein dialysis: synopsis of a case. Joint Bone Spine 2004; 71:347.
for groin pain. Hong Kong J Emerg Med. 2011;18:173–6.
5.
Holscher RS, Leyten FS, Oudenhoven LF, Puylaert JB. Percutaneous
decompression of an iliopsoas hematoma. Abdom Imaging. 1997;22:114–6.
ACCEPTED MANUSCRIPT
6.
Merrick HW, Zeiss J, Woldenberg LS. Percutaneous decompression for
femoral neuropathy secondary to heparin-induced retroperitoneal hematoma: Case
RI PT
report and review of the literature. Am Surg. 1991;57:706–11.
Figure legends:
SC
Figure A, shows large retroperitoneal hematoma marked by an arrow.
M AN U
Figure B, imaging in 6 weeks shows near complete resolution of retroperitoneal
AC C
EP
TE D
hematoma.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0002-9343(16)30835-X
DOI:
10.1016/j.amjmed.2016.07.026
Reference:
AJM 13658
To appear in:
The American Journal of Medicine
Received Date: 6 July 2016 Revised Date:
29 July 2016
Accepted Date: 29 July 2016
Please cite this article as: Thapa SS, Kaur NJ, George SV, Lumbar plexopathy secondary to spontaneous large retroperitoneal hematoma, The American Journal of Medicine (2016), doi: 10.1016/ j.amjmed.2016.07.026. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
TITLE PAGE Article Type: Clinical communication to the editor
retroperitoneal hematoma. Running Head: Spontaneous retroperitoneal hematoma
SC
Authors:
RI PT
Title of the manuscript: Lumbar plexopathy secondary to spontaneous large
M AN U
1. Corresponding author: Simant Singh Thapa, MD, Department of Internal Medicine, Saint Vincent Hospital, Massachusetts.
2. Nirmal J Kaur, MD, Department of Internal Medicine, Saint Vincent Hospital, Massachusetts.
3. Susan V George, MD, FACP, Department of Internal Medicine, Saint Vincent
Funding: None.
TE D
Hospital, Massachusetts.
EP
Conflict of Interest: None.
AC C
Authorship: All authors had access to the data and played a role in writing this manuscript.
Requests for reprints should be addressed to corresponding author: Simant Singh Thapa, MD Department of Internal Medicine, Saint Vincent Hospital, 123 Summer Street, 01608, MA. E-mail address: [email protected]; [email protected]
ACCEPTED MANUSCRIPT
To the Editor:
RI PT
A 63 year old female with hypertension, hyperlipidemia, hypothyroidism, depression and eating disorder was sent in from from a nursing home for generalized weakness and a critically low sodium level of 113 mEq/l. Her hyponatremia resolved with
SC
medical management. She was on subcutaneous unfractionated heparin for venous thromoboembolism prophylaxis. On the day of planned discharge, the patient
M AN U
complained of a sudden onset of sharp left groin pain radiating towards the anteromedial aspect of the left thigh. It was associated with numbness, tingling sensation and muscle weakness towards anteromedial aspect of left thigh. There was a drop in patient hematocrit level from 33% at admission to 19.9%. The coagulation profile was within normal limits. A CT scan of the abdomen and pelvis
TE D
revealed an iliopsoas hematoma measuring 27cm x 8.6cm x 7.4cm in size (Figure A). She was managed conservatively with serial hemoglobin monitoring, blood transfusions and volume support. The follow up hemoglobin after 2 units of packed
EP
red blood blood cell transfusion remained stable for next 5 days. The patient’s groin
AC C
pain, tingling sensation and muscle weakness significantly improved over the course on next 4-5 days but her anteromedial hypoesthesia persisted upon discharge to a rehabilitation center. A repeat CT abdomen and pelvis in 6 weeks showed nearly resolved retroperitoneal hematoma without any drainable fluid collection (Figure B) and her symptoms had resolved and she was able to ambulate.
ACCEPTED MANUSCRIPT
Lumbar plexopathy due to spontaneous retroperitoneal hematoma has been
RI PT
infrequently described in the literature. It has been most commonly reported in patients with either various bleeding diatheses or undergoing therapeutic anticoagulation.1 It has also been reported after lumbar plexus block for postoperative analgesia in hip surgery
2
and following femoral vein dialysis.
3
In our
SC
patient the only possible risk factor was subcutaneous unfractionated heparin (UFH)
M AN U
used in prophylactic dose for deep vein thrombosis during her hospital stay. However, UFH in prophylactic doses has not been reported to be associated with spontaneous retroperitoneal hemorrhage.
CT scan of the abdomen and pelvis remains the most commonly utilized test for the
TE D
diagnosis as it is readily accessible, fast and has a high degree of sensitivity.4 Treatment of a retroperitoneal hematoma primarily consists of addressing the acute manifestations such as hypovolemia and shock. Management is usually
EP
conservative, consisting of bed rest, correction of underlying bleeding abnormalities if any and blood transfusion as needed. Rarely, surgical evacuation may be needed
AC C
in severe acute cases with hemodynamic instability or in chronic, unresolved lumbar plexopathy with significant motor deficits.
3,4
Ultrasound-guided
percutaneous aspiration has been reported to be safe and beneficial in patients who are poor surgical candidates.
5,6
A high clinical suspicion for retroperitoneal hematoma should be kept in all hospitalized patients on subcutaneous or intravenous heparin who complain of new onset back or thigh pain with accompanying focal neurological symptoms.
ACCEPTED MANUSCRIPT
1.
RI PT
References: Parmer SSp, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral
neuropathy following retroperitoneal hemorrhage: case series and review of the
Klein SM, D'Ercole F, Greengrass RA, Warner DS. Enoxaparin associated with
M AN U
2.
SC
literature. Ann Vasc Surg. 2006 Jul;20(4):536-40. Epub 2006 May 31.
psoas hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology
3.
TE D
1997; 87:1576.
Kaymak B, Ozçakar L, Cetin A, et al. Bilateral lumbosacral plexopathy after
Choa GP, Lim CS. Iliopsoas hematoma: An uncommon differential diagnosis
AC C
4.
EP
femoral vein dialysis: synopsis of a case. Joint Bone Spine 2004; 71:347.
for groin pain. Hong Kong J Emerg Med. 2011;18:173–6.
5.
Holscher RS, Leyten FS, Oudenhoven LF, Puylaert JB. Percutaneous
decompression of an iliopsoas hematoma. Abdom Imaging. 1997;22:114–6.
ACCEPTED MANUSCRIPT
6.
Merrick HW, Zeiss J, Woldenberg LS. Percutaneous decompression for
femoral neuropathy secondary to heparin-induced retroperitoneal hematoma: Case
RI PT
report and review of the literature. Am Surg. 1991;57:706–11.
Figure legends:
SC
Figure A, shows large retroperitoneal hematoma marked by an arrow.
M AN U
Figure B, imaging in 6 weeks shows near complete resolution of retroperitoneal
AC C
EP
TE D
hematoma.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT