Case report 769
Conservative treatment of femoral neuropathy following retroperitoneal hemorrhage: a case report and review of literature ¨ zgu¨r Tosund, Aliye Tosuna, Elem ˙Inalb, Is¸ık Keles¸b, Murat Tulmac¸c, O Gu¨lu¨mser Aydınb and Sevim Orkunb Anticoagulant drugs are used to reduce the incidence of thromboembolic events in patients at risk. However, minor and major bleeding complications may occur during anticoagulation therapy. Femoral neuropathy secondary to retroperitoneal hematoma is a well known complication of anticoagulant drugs. However, treatment of these patients is still controversial, both conservative and surgical treatments have been advocated. Herein, we report a male patient receiving warfarin for 7 years who developed femoral neuropathy due to retroperitoneal hematoma and was successfully treated with conservative methods. We suggest that conservative treatment and appropriate rehabilitation program should be given to the patients who do not demonstrate any signs of a continued bleeding and any progressive neurological deficits. Blood Coagul
Introduction Anticoagulant drugs are used to reduce the incidence of thromboembolic events in patients at risk. However, minor and major bleeding complications may occur during anticoagulation therapy [1]. Retroperitoneal hematomas, abdominal wall hematomas, spinal epidural hematomas, subconjunctival hematomas, lower extremity hematomas, liver hematomas, renal hematomas, bowel hematomas, intracerebral hematomas, retropharyngeal hematomas, intraneural hematomas (median nerve), mesenteric hematomas, and hemarthroses have been reported in anticoagulated patients. Femoral neuropathy secondary to retroperitoneal hematoma is a well known complication of anticoagulant drugs. However, treatment of these patients is still controversial, both conservative and surgical treatments have been advocated. Herein, we report a male patient receiving warfarin for 7 years who developed femoral neuropathy due to spontaneous iliacus muscle hematoma.
Case-report A 21-year-old man with the complaints of severe groin pain, which was radiating toward his left knee and numbness of the left thigh and leg, was admitted to the emergency room wherein he was examined by our Physical Medicine and Rehabilitation Clinics. The patient stated that his pain started 8 days previously and gradually increased. An intramuscular injection at the right gluteal region was given for pain relief in another medical center. However, he described that intensity of 0957-5235 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fibrinolysis 25:769–772 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Blood Coagulation and Fibrinolysis 2014, 25:769–772 Keywords: anticoagulants, conservative treatment, femoral neuropathy, retroperitoneal hematoma a Clinics of Physical Medicine and Rehabilitation, Ankara Atatu¨rk Education and Research Hospital, bDepartment of Physical Medicine and Rehabilitation, c Department of Cardiology, Kırıkkale University Faculty of Medicine and dClinics of Radiodiagnostics, Ankara Atatu¨rk Education and Research Hospital, Ankara, Turkey
Correspondence to Associate Professor, Dr Aliye Tosun, MD, Clinics of Physical Medicine and Rehabilitation, Ankara Atatu¨rk Education and Research Hospital, Ankara 06600, Turkey Tel: +90 532 787 42 96; e-mail: [email protected] Received 27 November 2013 Revised 10 January 2014 Accepted 18 January 2014
his pain was increased, and a localized swelling at the injection site developed afterwards. The patient had been receiving the anticoagulant warfarin for 7 years after previous aortic and mitral valve replacements. On physical examination, left inguinal region was tender, and an about 3 3 cm mass was palpable in the right gluteal region. Left hip and left knee were positioned in flexion. Range of motion was also very painful and limited in both joints. On neurological examination, left quadriceps muscle strength was 2/5, left knee jerk reflex was absent, and hypoesthesia was found in the left anteromedial thigh and medial leg. Left hip flexion strength could not be evaluated because of severe hip pain. On laboratory examination, hemoglobin was 11.8 g/dl, hematocrit 34.8%, platelet count 126 000/mm3, white blood cell count 7700/mm3, and international normalized ratio (INR) was 5.47. Blood chemistry was unremarkable. Abdominopelvic ultrasonography (USG) revealed a 5.5 6.5 cm smooth contoured lesion compatible with hematoma in lower quadrant adjacent laterally to the femoral artery and vein. Abdominopelvic computerized tomography scan revealed a hypodense hematoma at a dimension of 13 6.5 8 cm lying down the course of the left iliac muscle. Left psoas muscle was displaced anteriorly and medially at the pelvic region due to the hematoma (Figs. 1 and 2). Warfarin treatment was discontinued, one unit of fresh frozen plasma and 1 mg vitamin K intravenously were given after consultation with Cardiology. Cardiovascular Surgery consultation was planned, but the patient wanted to be referred to the DOI:10.1097/MBC.0000000000000110
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
770 Blood Coagulation and Fibrinolysis 2014, Vol 25 No 7
Fig. 1
exercises of left hip and knee were started. The pain gradually decreased, and range of motion and muscle strength of left hip and knee were found to be gradually increased during the course of rehabilitation. Left hip flexion strength was 5/5, and right knee extension strength was 4 – /5 at the fourth week of the treatment. Afterward, a home-based quadriceps strengthening program was maintained. On follow-up, it was seen that neurological examination was fully recovered, and the patient was ambulating independently without an assistive device at the end of 3 months.
Discussion
Hematoma in the left iliacus muscle (thin arrow), left psoas muscle was displaced to anteriorly and medially due to hematoma (thick arrow).
cardiovascular unit of another hospital wherein he had been on follow-up for 7 years. Surgical treatment was not performed, and close monitoring of bleeding was recommended there. The patient was readmitted to our Physical Medicine and Rehabilitation Outpatient Clinics. He was walking with double crutches with touchdown weight bearing on the left. Electroneuromyographic evaluation revealed left femoral neuropathy. The patient was closely monitored with frequent neurologic checks to assess progression of symptoms or indication of a continued bleeding. The neurologic examination did not demonstrate any progression of motor weakness or change in sensory deficit. A rehabilitation program consisting of electrical stimulation of the left quadriceps muscle and active and active-resistive range of motion Fig. 2
Extension of left iliacus hematoma in lower axial CT sections. (arrow). CT, computed tomography.
Patients with mechanical heart valves require life-long warfarin therapy to prevent thromboembolic complications. The incidence of thromboembolic events increases with subtherapeutic INR less than 2.0, and hemorrhagic complications increase with INR more than 4.8. The incidence of major embolization in prosthetic heart valve patients is roughly 4% per patient year in the absence of antithrombotic therapy, 2% with antiplatelet therapy, and 1% with warfarin therapy. Overall, major bleeding is 2.7% per year in anticoagulated patients with heart valves [2]. Retroperitoneal hemorrhage is a serious and well described complication in patients who develop increased coagulation and may result in femoral neuropathy [3]. The femoral nerve is a branch of the lumbar plexus arising from the posterior divisions of the ventral rami of the second, third, and fourth lumbar roots. It emerges from the lateral border of the psoas muscle, descends between the psoas and iliacus groove beneath the iliac fascia, exits the pelvis below the inguinal ligament, and divides into its terminal branches. In the thigh, the anterior division of the femoral nerve gives off anterior cutaneous and muscular branches. The anterior cutaneous branches comprise the intermediate and medial cutaneous nerves. Its motor branches supply the iliacus, pectineus, sartorius, and quadriceps femoris muscles. Its terminal cutaneous branches innervate the anterior, anteromedial region of the thigh via the anterior femorol-cutaneous nerve, and medial side of the leg via the saphenous nerve [4–6]. Femoral neuropathy is characterized by weakness of the quadriceps femoris, decrease or loss of the knee jerk, and sensory loss over the anteromedial aspect of the thigh and medial aspect of lower leg. Weakness in hip flexion due to iliacus muscle denervation may also be observed [6]. Femoral neuropathy develops usually secondary to compression or trauma. The nerve may be damaged in the retroperitoneal space, especially in psoas–iliacus groove due to a retroperitoneal hematoma. Therapeutic anticoagulation may lead to retroperitoneal hematomas. The incidence of retroperitoneal hemorrhage has been reported at 1.3–6.6% of patients undergoing therapeutic anticoagulation [5,7]. Hematomas are more frequently
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conservative treatment of femoral neuropathy Tosun et al. 771
seen in the iliacus muscle than in the psoas and often present insidiously and are not heralded by an obvious lesion or ecchymosis [8]. Therefore, the diagnosis is often delayed, although iliopsoas hematoma is a known complication of anticoagulant therapy [9]. The clinical presentation of a retroperitoneal hemorrhage is initially a sudden onset of severe pain in the affected groin and hip, which radiates toward the anterior thigh and the flank. Characteristically, the patient lies with the hip in a flexed and externally rotated position due to the iliacus muscle spasm. Passive extension of the hip exacerbates pain. Other associated findings may include a fall in the hematocrit, increased INR, tachycardia, hypotension, abdominal pain, and a palpable mass, depending on the severity of the hemorrhage. Femoral nerve dysfunction usually appears later, but in rapidly expansive compressive lesions, such as in anticoagulant-related hematoma, the femoral nerve deficits may develop acutely [5,7,10]. Differential diagnosis includes appendicitis, diverticulitis, peritonitis, inguinal hernia, lumbar disc herniation, or kidney disorders. Acute suppurative arthritis or hemarthrosis of the hip may present with similar symptoms, but is unlikely to cause femoral nerve dysfunction [9,11]. To explain the clinical syndrome consisting of sudden onset of severe pain in the groin accompanied by marked flexion deformity at the hip, followed by a mass in the iliac fossa and femoral nerve palsy, which occurs as a complication of hemophilia; Goodfellow et al. [12] injected water into the psoas and iliacus muscles in a fresh cadaver and observed that very large quantities of water could be injected into the distensible sheath of the psoas muscle at low pressures. Therefore, primary distension of the psoas sheath would be unlikely to give rise to nerve compression. However, iliac fascia was thick, and injected fluid resulted with the occurence of a tense globular swelling, which compresses the femoral nerve. In addition, ischemia from compression of vascular supply of the femoral nerve may also have a role in the development of femoral neuropathy due to iliac hematoma. Blood supply to the femoral nerve in the iliopsoas gutter is not as rich as adjacent areas, and therefore the femoral nerve in the iliopsoas gutter is particularly susceptible to ischemia [4,11]. However, why the iliacus muscle is proposed to spontaneous intramuscular hemorrhage in patients receiving anticoagulation therapy remains unexplained [4]. The diagnosis of retroperitoneal hematoma is not difficult to determine. Plain radiography of abdomen and pelvis provides nonspecific information as an enlarged psoas shadow. USG, computed tomography (CT), and MRI can be used in visualizing the disease. Although USG is the most simple and noninvasive method, and may be helpful in retroperitoneal and pelvic masses; it provides only limited information about the exact extent of the disease and involvement of adjacent structures, especially when
the iliacus muscle is concerned. Also, it is affected from body habitus, underlying bowel gas, and operator skill. CT is an accurate, noninvasive method and provides useful information, as it can demonstrate the size and location of the mass. The retroperitoneal hematoma appears as an abnormal soft tissue density, which compresses adjacent normal structures. MRI delivers better contrast resolution and is very sensitive for the detection of retroperitoneal processes and helpful to rule out nerve root compression. However, besides being a more expensive method, it may be also contraindicated in many patients on anticoagulants, such as patients with cardiac valve replacements [4,7,11,13]. The treatment of retroperitoneal hematoma with associated femoral neuropathy remains controversial. In the presence of inherited disorders, such as hemophilia, it has generally been accepted that factor replacement and a conservative nonoperative approach can be taken with good functional results [12,14]. Initial immobilization is followed by gradual ambulation. Several case reports have suggested clinical improvement after conservative therapies [4,5,8,15]. In patients receiving anticoagulation therapy who develop femoral nerve dysfunction due to iliacus hematoma, management is the most controversial. To prevent irreversible nerve damage, anticoagulant therapy should be discontinued, and Vit K and/or fresh frosen plasma may be administered. Some authors advocate surgical decompression or percutaneous drainage of the femoral nerve after witholding anticoagulant drugs and reversing coagulopathy [3,7,11,16]. Instead of open surgical procedures, a less invasive percutaneous drainage of the iliopsoas hematoma can also effectively provide decompression of the femoral nerve and allow functional recovery [10]. With the availability of high-resolution USG, aspiration of hematoma under US guidance should always be attempted before any operative intervention. An adequate decompression by this relatively noninvasive procedure may well be expected in cases of unclotted hematoma. The present case reveals that conservative treatment may provide complete recovery in femoral neuropathy due to iliacus muscle hematoma in anticoagulated patients. Conservative treatment and appropriate rehabilitation program should be given to the patients who do not demonstrate any signs of a continued bleeding and any progressive neurological deficits.
Acknowledgements Conflicts of interest
All authors declare that there are no conflicts of interest.
References 1 2
Charney R, Leddomado E, Rose DN, Fuster V. Anticoagulation clinics and the monitoring of anticoagulant therapy. Int J Cardiol 1988; 18:197–206. Ananthasubramaniam K, Beattie JN, Rosman HS, Jayam V, Borzak S. How safely and for how long can warfarin therapy be withheld in prosthetic valve patients hospitalized with a major hemorrhage? Chest 2001; 119:478–484.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
772 Blood Coagulation and Fibrinolysis 2014, Vol 25 No 7
3
4
5
6 7
8
9
Topgu¨l K, Uzun O, Anadol AZ, Go¨k A. Surgical management of enoxiparin and/or warfarin-induced massive retroperitoneal bleeding: report of a case and review of the literature. South Med J 2005; 98:104–106. Reinstein L, Alevizatos AC, Twardzik FG, DeMarco SJ 3rd. Femoral nerve dysfunction after retroperitoneal hemorrhage: pathophysiology revealed by computed tomography. Arch Phys Med Rehabil 1984; 65:37–40. Seijo-Martinez M, Castro del Rio M, Fontoira E, Fontoira M. Acute femoral neuropathy secondary to an iliacus muscle hematoma. J Neurol Sci 2003; 209:119–122. Pirouzmand F, Midha R. Subacute femoral compressive neuropathy from iliacus compartment hematoma. Can J Neurol 2001; 28:155–158. Parmer SS, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral neuropathy following retroperitoneal hemorrhage: case series and review of the literature. Ann Vasc Surg 2006; 20:536–540. Fealy S, Paletta GA. Femoral nerve palsy secondary to traumatic iliacus muscle hematoma: course after nonoperative management. J Trauma 1999; 47:1150–1152. Niakan E, Carbone JE, Adams M, Schroeder FM. Anticoagulants, iliopsoas hematoma and femoral nerve compression. Am Fam Physician 1991; 44:2100–2102.
10
11
12
13
14 15 16
Merrick HW, Zeiss J, Woldenberg LS. Percutaneous decompression for femoral neuropathy secondary to heparin-induced retroperitoneal hematoma. Am Surg 1991; 57:706–711. Jamjoom ZA, al-Bakry A, al-Momen A, Malabary T, Tahan AR, Yacub B. Bilateral femoral nerve compression by iliacus hematomas complicating anticoagulant therapy. Surg Today 1993; 23:535–540. Goodfellow J, Fearn CBd’A. Matthews JM. Iliacus haematoma. A common complication of haemophilia. J Bone J Surg (Br) 1967; 49B:748– 756. Nakao A, Sakagami K, Mitsuoka S, Uda M, Tanaka N. Retroperitoneal hematoma associated with femoral neuropathy: a complication under antiplatelets therapy. Acta Med Okayama 2001; 55:363–366. Silverstein A. Neuropathy in hemophilia. JAMA 1964; 190:554– 555. Weiss JM, Tolo V. Femoral nerve palsy following iliacus hematoma. Orthopedics 2008; 31:178. Sreenivas VI, Pelliccia O Jr, Job G, Ragaza EP, Robinson F. Femoral neuropathy secondary to anticoagulant therapy. Int Surg 1980; 65:279– 281.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conservative treatment of femoral neuropathy following retroperitoneal hemorrhage: a case report and review of literature ¨ zgu¨r Tosund, Aliye Tosuna, Elem ˙Inalb, Is¸ık Keles¸b, Murat Tulmac¸c, O Gu¨lu¨mser Aydınb and Sevim Orkunb Anticoagulant drugs are used to reduce the incidence of thromboembolic events in patients at risk. However, minor and major bleeding complications may occur during anticoagulation therapy. Femoral neuropathy secondary to retroperitoneal hematoma is a well known complication of anticoagulant drugs. However, treatment of these patients is still controversial, both conservative and surgical treatments have been advocated. Herein, we report a male patient receiving warfarin for 7 years who developed femoral neuropathy due to retroperitoneal hematoma and was successfully treated with conservative methods. We suggest that conservative treatment and appropriate rehabilitation program should be given to the patients who do not demonstrate any signs of a continued bleeding and any progressive neurological deficits. Blood Coagul
Introduction Anticoagulant drugs are used to reduce the incidence of thromboembolic events in patients at risk. However, minor and major bleeding complications may occur during anticoagulation therapy [1]. Retroperitoneal hematomas, abdominal wall hematomas, spinal epidural hematomas, subconjunctival hematomas, lower extremity hematomas, liver hematomas, renal hematomas, bowel hematomas, intracerebral hematomas, retropharyngeal hematomas, intraneural hematomas (median nerve), mesenteric hematomas, and hemarthroses have been reported in anticoagulated patients. Femoral neuropathy secondary to retroperitoneal hematoma is a well known complication of anticoagulant drugs. However, treatment of these patients is still controversial, both conservative and surgical treatments have been advocated. Herein, we report a male patient receiving warfarin for 7 years who developed femoral neuropathy due to spontaneous iliacus muscle hematoma.
Case-report A 21-year-old man with the complaints of severe groin pain, which was radiating toward his left knee and numbness of the left thigh and leg, was admitted to the emergency room wherein he was examined by our Physical Medicine and Rehabilitation Clinics. The patient stated that his pain started 8 days previously and gradually increased. An intramuscular injection at the right gluteal region was given for pain relief in another medical center. However, he described that intensity of 0957-5235 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fibrinolysis 25:769–772 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Blood Coagulation and Fibrinolysis 2014, 25:769–772 Keywords: anticoagulants, conservative treatment, femoral neuropathy, retroperitoneal hematoma a Clinics of Physical Medicine and Rehabilitation, Ankara Atatu¨rk Education and Research Hospital, bDepartment of Physical Medicine and Rehabilitation, c Department of Cardiology, Kırıkkale University Faculty of Medicine and dClinics of Radiodiagnostics, Ankara Atatu¨rk Education and Research Hospital, Ankara, Turkey
Correspondence to Associate Professor, Dr Aliye Tosun, MD, Clinics of Physical Medicine and Rehabilitation, Ankara Atatu¨rk Education and Research Hospital, Ankara 06600, Turkey Tel: +90 532 787 42 96; e-mail: [email protected] Received 27 November 2013 Revised 10 January 2014 Accepted 18 January 2014
his pain was increased, and a localized swelling at the injection site developed afterwards. The patient had been receiving the anticoagulant warfarin for 7 years after previous aortic and mitral valve replacements. On physical examination, left inguinal region was tender, and an about 3 3 cm mass was palpable in the right gluteal region. Left hip and left knee were positioned in flexion. Range of motion was also very painful and limited in both joints. On neurological examination, left quadriceps muscle strength was 2/5, left knee jerk reflex was absent, and hypoesthesia was found in the left anteromedial thigh and medial leg. Left hip flexion strength could not be evaluated because of severe hip pain. On laboratory examination, hemoglobin was 11.8 g/dl, hematocrit 34.8%, platelet count 126 000/mm3, white blood cell count 7700/mm3, and international normalized ratio (INR) was 5.47. Blood chemistry was unremarkable. Abdominopelvic ultrasonography (USG) revealed a 5.5 6.5 cm smooth contoured lesion compatible with hematoma in lower quadrant adjacent laterally to the femoral artery and vein. Abdominopelvic computerized tomography scan revealed a hypodense hematoma at a dimension of 13 6.5 8 cm lying down the course of the left iliac muscle. Left psoas muscle was displaced anteriorly and medially at the pelvic region due to the hematoma (Figs. 1 and 2). Warfarin treatment was discontinued, one unit of fresh frozen plasma and 1 mg vitamin K intravenously were given after consultation with Cardiology. Cardiovascular Surgery consultation was planned, but the patient wanted to be referred to the DOI:10.1097/MBC.0000000000000110
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
770 Blood Coagulation and Fibrinolysis 2014, Vol 25 No 7
Fig. 1
exercises of left hip and knee were started. The pain gradually decreased, and range of motion and muscle strength of left hip and knee were found to be gradually increased during the course of rehabilitation. Left hip flexion strength was 5/5, and right knee extension strength was 4 – /5 at the fourth week of the treatment. Afterward, a home-based quadriceps strengthening program was maintained. On follow-up, it was seen that neurological examination was fully recovered, and the patient was ambulating independently without an assistive device at the end of 3 months.
Discussion
Hematoma in the left iliacus muscle (thin arrow), left psoas muscle was displaced to anteriorly and medially due to hematoma (thick arrow).
cardiovascular unit of another hospital wherein he had been on follow-up for 7 years. Surgical treatment was not performed, and close monitoring of bleeding was recommended there. The patient was readmitted to our Physical Medicine and Rehabilitation Outpatient Clinics. He was walking with double crutches with touchdown weight bearing on the left. Electroneuromyographic evaluation revealed left femoral neuropathy. The patient was closely monitored with frequent neurologic checks to assess progression of symptoms or indication of a continued bleeding. The neurologic examination did not demonstrate any progression of motor weakness or change in sensory deficit. A rehabilitation program consisting of electrical stimulation of the left quadriceps muscle and active and active-resistive range of motion Fig. 2
Extension of left iliacus hematoma in lower axial CT sections. (arrow). CT, computed tomography.
Patients with mechanical heart valves require life-long warfarin therapy to prevent thromboembolic complications. The incidence of thromboembolic events increases with subtherapeutic INR less than 2.0, and hemorrhagic complications increase with INR more than 4.8. The incidence of major embolization in prosthetic heart valve patients is roughly 4% per patient year in the absence of antithrombotic therapy, 2% with antiplatelet therapy, and 1% with warfarin therapy. Overall, major bleeding is 2.7% per year in anticoagulated patients with heart valves [2]. Retroperitoneal hemorrhage is a serious and well described complication in patients who develop increased coagulation and may result in femoral neuropathy [3]. The femoral nerve is a branch of the lumbar plexus arising from the posterior divisions of the ventral rami of the second, third, and fourth lumbar roots. It emerges from the lateral border of the psoas muscle, descends between the psoas and iliacus groove beneath the iliac fascia, exits the pelvis below the inguinal ligament, and divides into its terminal branches. In the thigh, the anterior division of the femoral nerve gives off anterior cutaneous and muscular branches. The anterior cutaneous branches comprise the intermediate and medial cutaneous nerves. Its motor branches supply the iliacus, pectineus, sartorius, and quadriceps femoris muscles. Its terminal cutaneous branches innervate the anterior, anteromedial region of the thigh via the anterior femorol-cutaneous nerve, and medial side of the leg via the saphenous nerve [4–6]. Femoral neuropathy is characterized by weakness of the quadriceps femoris, decrease or loss of the knee jerk, and sensory loss over the anteromedial aspect of the thigh and medial aspect of lower leg. Weakness in hip flexion due to iliacus muscle denervation may also be observed [6]. Femoral neuropathy develops usually secondary to compression or trauma. The nerve may be damaged in the retroperitoneal space, especially in psoas–iliacus groove due to a retroperitoneal hematoma. Therapeutic anticoagulation may lead to retroperitoneal hematomas. The incidence of retroperitoneal hemorrhage has been reported at 1.3–6.6% of patients undergoing therapeutic anticoagulation [5,7]. Hematomas are more frequently
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conservative treatment of femoral neuropathy Tosun et al. 771
seen in the iliacus muscle than in the psoas and often present insidiously and are not heralded by an obvious lesion or ecchymosis [8]. Therefore, the diagnosis is often delayed, although iliopsoas hematoma is a known complication of anticoagulant therapy [9]. The clinical presentation of a retroperitoneal hemorrhage is initially a sudden onset of severe pain in the affected groin and hip, which radiates toward the anterior thigh and the flank. Characteristically, the patient lies with the hip in a flexed and externally rotated position due to the iliacus muscle spasm. Passive extension of the hip exacerbates pain. Other associated findings may include a fall in the hematocrit, increased INR, tachycardia, hypotension, abdominal pain, and a palpable mass, depending on the severity of the hemorrhage. Femoral nerve dysfunction usually appears later, but in rapidly expansive compressive lesions, such as in anticoagulant-related hematoma, the femoral nerve deficits may develop acutely [5,7,10]. Differential diagnosis includes appendicitis, diverticulitis, peritonitis, inguinal hernia, lumbar disc herniation, or kidney disorders. Acute suppurative arthritis or hemarthrosis of the hip may present with similar symptoms, but is unlikely to cause femoral nerve dysfunction [9,11]. To explain the clinical syndrome consisting of sudden onset of severe pain in the groin accompanied by marked flexion deformity at the hip, followed by a mass in the iliac fossa and femoral nerve palsy, which occurs as a complication of hemophilia; Goodfellow et al. [12] injected water into the psoas and iliacus muscles in a fresh cadaver and observed that very large quantities of water could be injected into the distensible sheath of the psoas muscle at low pressures. Therefore, primary distension of the psoas sheath would be unlikely to give rise to nerve compression. However, iliac fascia was thick, and injected fluid resulted with the occurence of a tense globular swelling, which compresses the femoral nerve. In addition, ischemia from compression of vascular supply of the femoral nerve may also have a role in the development of femoral neuropathy due to iliac hematoma. Blood supply to the femoral nerve in the iliopsoas gutter is not as rich as adjacent areas, and therefore the femoral nerve in the iliopsoas gutter is particularly susceptible to ischemia [4,11]. However, why the iliacus muscle is proposed to spontaneous intramuscular hemorrhage in patients receiving anticoagulation therapy remains unexplained [4]. The diagnosis of retroperitoneal hematoma is not difficult to determine. Plain radiography of abdomen and pelvis provides nonspecific information as an enlarged psoas shadow. USG, computed tomography (CT), and MRI can be used in visualizing the disease. Although USG is the most simple and noninvasive method, and may be helpful in retroperitoneal and pelvic masses; it provides only limited information about the exact extent of the disease and involvement of adjacent structures, especially when
the iliacus muscle is concerned. Also, it is affected from body habitus, underlying bowel gas, and operator skill. CT is an accurate, noninvasive method and provides useful information, as it can demonstrate the size and location of the mass. The retroperitoneal hematoma appears as an abnormal soft tissue density, which compresses adjacent normal structures. MRI delivers better contrast resolution and is very sensitive for the detection of retroperitoneal processes and helpful to rule out nerve root compression. However, besides being a more expensive method, it may be also contraindicated in many patients on anticoagulants, such as patients with cardiac valve replacements [4,7,11,13]. The treatment of retroperitoneal hematoma with associated femoral neuropathy remains controversial. In the presence of inherited disorders, such as hemophilia, it has generally been accepted that factor replacement and a conservative nonoperative approach can be taken with good functional results [12,14]. Initial immobilization is followed by gradual ambulation. Several case reports have suggested clinical improvement after conservative therapies [4,5,8,15]. In patients receiving anticoagulation therapy who develop femoral nerve dysfunction due to iliacus hematoma, management is the most controversial. To prevent irreversible nerve damage, anticoagulant therapy should be discontinued, and Vit K and/or fresh frosen plasma may be administered. Some authors advocate surgical decompression or percutaneous drainage of the femoral nerve after witholding anticoagulant drugs and reversing coagulopathy [3,7,11,16]. Instead of open surgical procedures, a less invasive percutaneous drainage of the iliopsoas hematoma can also effectively provide decompression of the femoral nerve and allow functional recovery [10]. With the availability of high-resolution USG, aspiration of hematoma under US guidance should always be attempted before any operative intervention. An adequate decompression by this relatively noninvasive procedure may well be expected in cases of unclotted hematoma. The present case reveals that conservative treatment may provide complete recovery in femoral neuropathy due to iliacus muscle hematoma in anticoagulated patients. Conservative treatment and appropriate rehabilitation program should be given to the patients who do not demonstrate any signs of a continued bleeding and any progressive neurological deficits.
Acknowledgements Conflicts of interest
All authors declare that there are no conflicts of interest.
References 1 2
Charney R, Leddomado E, Rose DN, Fuster V. Anticoagulation clinics and the monitoring of anticoagulant therapy. Int J Cardiol 1988; 18:197–206. Ananthasubramaniam K, Beattie JN, Rosman HS, Jayam V, Borzak S. How safely and for how long can warfarin therapy be withheld in prosthetic valve patients hospitalized with a major hemorrhage? Chest 2001; 119:478–484.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
772 Blood Coagulation and Fibrinolysis 2014, Vol 25 No 7
3
4
5
6 7
8
9
Topgu¨l K, Uzun O, Anadol AZ, Go¨k A. Surgical management of enoxiparin and/or warfarin-induced massive retroperitoneal bleeding: report of a case and review of the literature. South Med J 2005; 98:104–106. Reinstein L, Alevizatos AC, Twardzik FG, DeMarco SJ 3rd. Femoral nerve dysfunction after retroperitoneal hemorrhage: pathophysiology revealed by computed tomography. Arch Phys Med Rehabil 1984; 65:37–40. Seijo-Martinez M, Castro del Rio M, Fontoira E, Fontoira M. Acute femoral neuropathy secondary to an iliacus muscle hematoma. J Neurol Sci 2003; 209:119–122. Pirouzmand F, Midha R. Subacute femoral compressive neuropathy from iliacus compartment hematoma. Can J Neurol 2001; 28:155–158. Parmer SS, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral neuropathy following retroperitoneal hemorrhage: case series and review of the literature. Ann Vasc Surg 2006; 20:536–540. Fealy S, Paletta GA. Femoral nerve palsy secondary to traumatic iliacus muscle hematoma: course after nonoperative management. J Trauma 1999; 47:1150–1152. Niakan E, Carbone JE, Adams M, Schroeder FM. Anticoagulants, iliopsoas hematoma and femoral nerve compression. Am Fam Physician 1991; 44:2100–2102.
10
11
12
13
14 15 16
Merrick HW, Zeiss J, Woldenberg LS. Percutaneous decompression for femoral neuropathy secondary to heparin-induced retroperitoneal hematoma. Am Surg 1991; 57:706–711. Jamjoom ZA, al-Bakry A, al-Momen A, Malabary T, Tahan AR, Yacub B. Bilateral femoral nerve compression by iliacus hematomas complicating anticoagulant therapy. Surg Today 1993; 23:535–540. Goodfellow J, Fearn CBd’A. Matthews JM. Iliacus haematoma. A common complication of haemophilia. J Bone J Surg (Br) 1967; 49B:748– 756. Nakao A, Sakagami K, Mitsuoka S, Uda M, Tanaka N. Retroperitoneal hematoma associated with femoral neuropathy: a complication under antiplatelets therapy. Acta Med Okayama 2001; 55:363–366. Silverstein A. Neuropathy in hemophilia. JAMA 1964; 190:554– 555. Weiss JM, Tolo V. Femoral nerve palsy following iliacus hematoma. Orthopedics 2008; 31:178. Sreenivas VI, Pelliccia O Jr, Job G, Ragaza EP, Robinson F. Femoral neuropathy secondary to anticoagulant therapy. Int Surg 1980; 65:279– 281.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
