Location
Philadelphia, PA
Start Date
3-5-2023 1:00 PM
End Date
3-5-2023 4:00 PM
Description
Setting: Outpatient pain management office
Case Diagnosis: A 52-year-old man presents with spontaneous retroperitoneal hematoma and secondary femoral neuropathy.
Introduction: While traumatic retroperitoneal injury is common, spontaneous retroperitoneal hematoma (SRH) is relatively rare with a documented rate of 0.6-6.6%. Spontaneous retroperitoneal hematoma typically presents with pain of the abdomen, hip, or leg. Rarely, symptoms associated with lumbosacral plexus compression are present. Leg numbness and weakness are present in less than 10% of cases. Today, treatment remains largely conservative with a low percentage of patients requiring angioembolization.
Case Description: A 52-year-old male with significant past medical history of mechanical aortic valve requiring lifelong Coumadin presented to the orthopedics office following a visit to the emergency department (ED) for low back pain. He had low back pain radiating to the right anterior thigh associated with weakness for a duration of 1 week. He was wheelchair bound due to pain. There was no history of trauma. Two weeks later, his pain continued, but he required a wheelchair only for assistance. Treatment included cyclobenzaprine, steroids, and physical therapy. An electromyography (EMG) of lower extremities and magnetic resonance imaging (MRI) of lumbar spine and pelvis were ordered. He was diagnosed with L4 radiculopathy in the right lower extremity by the orthopedist and referred to pain management for epidural steroid foraminal injections.
Results: In addition to multilevel spondylosis, lumbar spine MRI showed 7.2cm x 4.7cm x 4.0cm hyperintense lesion in the right iliacus consistent with unclear etiology. Pelvic MRI showed a 6.0cm x 3.1cm x 3.7cm collection in the right iliacus most consistent with hematoma.
After 5 months since onset of symptoms, the patient presented to the pain management office. On exam, he had 4/5 strength in the right quadriceps, reduced sensation along the right medial thigh, calf, and ankle, and absent right patellar reflex. He was diagnosed with femoral neuropathy secondary to retroperitoneal hematoma. He was scheduled for follow-up in 4 weeks to see if his symptoms have improved.
Discussion: Studies have shown that the incidence of spontaneous retroperitoneal hematoma is rare, occurring 0.6-6.6% of the time with <10% of the cases having symptoms of leg pain and weakness. Many cases are only found in case reports. This patient presented with low back pain, leg pain, and secondary femoral neuropathy. From this case, we can learn to keep a broad differential for low back pain particularly when imaging can point to multiple explanations for back pain. The history of present illness over time showed improvement in pain and weakness concordant with hematoma reabsorption. This diagnosis changed management from potential epidural steroid foraminal injection to conservative management.
Embargo Period
6-7-2023
Included in
Spontaneous Retroperitoneal Hematoma in a Patient on Lifelong Anticoagulation with Secondary Femoral Neuropathy: A Case Report
Philadelphia, PA
Setting: Outpatient pain management office
Case Diagnosis: A 52-year-old man presents with spontaneous retroperitoneal hematoma and secondary femoral neuropathy.
Introduction: While traumatic retroperitoneal injury is common, spontaneous retroperitoneal hematoma (SRH) is relatively rare with a documented rate of 0.6-6.6%. Spontaneous retroperitoneal hematoma typically presents with pain of the abdomen, hip, or leg. Rarely, symptoms associated with lumbosacral plexus compression are present. Leg numbness and weakness are present in less than 10% of cases. Today, treatment remains largely conservative with a low percentage of patients requiring angioembolization.
Case Description: A 52-year-old male with significant past medical history of mechanical aortic valve requiring lifelong Coumadin presented to the orthopedics office following a visit to the emergency department (ED) for low back pain. He had low back pain radiating to the right anterior thigh associated with weakness for a duration of 1 week. He was wheelchair bound due to pain. There was no history of trauma. Two weeks later, his pain continued, but he required a wheelchair only for assistance. Treatment included cyclobenzaprine, steroids, and physical therapy. An electromyography (EMG) of lower extremities and magnetic resonance imaging (MRI) of lumbar spine and pelvis were ordered. He was diagnosed with L4 radiculopathy in the right lower extremity by the orthopedist and referred to pain management for epidural steroid foraminal injections.
Results: In addition to multilevel spondylosis, lumbar spine MRI showed 7.2cm x 4.7cm x 4.0cm hyperintense lesion in the right iliacus consistent with unclear etiology. Pelvic MRI showed a 6.0cm x 3.1cm x 3.7cm collection in the right iliacus most consistent with hematoma.
After 5 months since onset of symptoms, the patient presented to the pain management office. On exam, he had 4/5 strength in the right quadriceps, reduced sensation along the right medial thigh, calf, and ankle, and absent right patellar reflex. He was diagnosed with femoral neuropathy secondary to retroperitoneal hematoma. He was scheduled for follow-up in 4 weeks to see if his symptoms have improved.
Discussion: Studies have shown that the incidence of spontaneous retroperitoneal hematoma is rare, occurring 0.6-6.6% of the time with <10% of the cases having symptoms of leg pain and weakness. Many cases are only found in case reports. This patient presented with low back pain, leg pain, and secondary femoral neuropathy. From this case, we can learn to keep a broad differential for low back pain particularly when imaging can point to multiple explanations for back pain. The history of present illness over time showed improvement in pain and weakness concordant with hematoma reabsorption. This diagnosis changed management from potential epidural steroid foraminal injection to conservative management.
Comments
Presented by Catherine Linh.