Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Laparoscopic treatment of traumatic iliopsoas hematoma JING Jue-hua, QIAN Jun, TANG Jian, TIAN Da-sheng, ZHANG Ji-sen and CHEN Lei Department of Orthopaedics, the Second Hospital of An Hui Medical University, HeFei, 230601, China. ( JING Jue-hua. Tel: 86-551-3869504. Email: [email protected].) (QIAN Jun, TIAN Da-sheng, ZHANG Ji-sen and CHEN Lei ) Correspondence to : Dr. TANG Jian . Department of Orthopaedics, the First Affiliated Hospital of An Hui Medical University, HeFei, 230032, China. (Tel: 86-551-3869506. Email: [email protected] ) Key words: Iliopsoas hematoma; laparoscopy; surgery; MRI Traumatic iliopsoas hematoma is rare in adolescents. Hematoma within the iliopsoas muscle causes severe pain and dysfunction of the femoral nerve. Surgical treatment is often recommended. Some open surgeries lead to severe trauma and some minimally invasive surgeries cannot completely clear the hematoma within the iliopsoas muscle. A new treatment protocol for iliopsoas hematoma is discussed. This report introduces a laparoscopic method as a successful treatment for removing iliopsoas hematomas. Laparoscopic surgery may be a safe and effective alternative to open surgery for hematomas with a mixture of blood clots and old liquid blood. Iliopsoas hematoma is often seen in patients with hemophilia and in those taking anticoagulant medications. 1 It also occurs following a closed injury of the iliopsoas muscle, such as hyperextension of the hip joint during a fall. Hematomas are more frequently seen in the iliacus muscle than in the psoas. 2 An iliopsoas hematoma may have different symptoms varying in severity, from early local signs, such as lower-abdominal or groin pain to massive bleeding and shock. 3, 4 Iliopsoas hematoma is commonly associated with femoral nerve palsy which produces quadriceps paralysis and paresthesias in the anterior region of the thigh. 5Iliopsoas hematoma has been treated successfully with conservative methods or surgical evacuation, both with successful results. Surgical methods that have been previously reported include transcatheter arterial embolization, percutaneous drainage of the hematoma and surgical decompression of the femoral nerve. 1, 3, 6 No published reports have described laparoscopic hematoma removal to the best of our knowledge. We present two cases of successful removal of iliopsoas hematoma using this technique. CASE REPORTS Case 1 A healthy, 14-year-old boy fell to the ground while riding a bicycle. He recalled that he hyperextended his left hip joint during the fall. He experienced increasing pain in the left groin and was admitted to our hospital six days after the injury. The pain was severe and the patient was unable to walk due to weakness in the left lower extremity. There was no history of pain of the left hip joint before the injury. On physical examination, the patient was found to have grade 3/5 strength in the left of the iliopsoas and thigh muscles and hypoesthesia in the distribution of the left femoral nerve. He had significant pain while attempting active flexion and passive extension of the hip. The patient’s prothrombin time-international normalized ratio (PT-INR) was 1.1; the activated partial thromboplastin time ( APTT ) was 38.4 seconds and the platelet count was 160.0×109 /l. These were all within normal limits. The hemoglobin level was 9.2 g/dl. Radiographs of the lumbar spine, pelvis and thigh were normal. A pelvic magnetic resonance imaging ( MRI ) scan revealed a large, well-defined mass of 21.0×5.3×8.0 cm3 in the left iliacus muscle and psoas major muscle ( Figure 1). This mass was a mixture of low, intermediate and high signal intensities on both T1- and T2-weighted images. These suggested that the hematoma was a mixture of blood clots and liquid blood. The patient was diagnosed with traumatic iliopsoas muscle hematoma. The procedure to remove the hematoma using a laparo- scopic technique performed under general anesthesia was scheduled on the third day after admission. The patient was placed in the lateral decubitus position for surgery. skin. Three incisions were made in the The first incision was in the posterior axillary line just inferior to the inferior margin of the 12th rib; the second incision was in the midaxillary line superior to the iliac crest; the third incision was in anterior axillary line vertically aligned with the first incision ( Figure 3 ). We accessed the retroperitoneal cavity by blunt dissection and placed a balloon in the retroperitoneal cavity. Then approximately 500 ml of gas was pumped into the balloon to expand the retroperitoneal cavity. The laparoscopy lens and the operating handle were placed into the retroperitoneal cavity through three trocars of different diameter. After visually localizing the hematoma, we exposed it and removed approximately 700 ml of clots and old liquid blood through a large-diameter suction catheter ( Figure 4). We then placed a drainage tube in the hematoma cavity and fed it through the incision just superior to the iliac crest, removed the trocars and closed the incisions. Upon waking after surgery, the patient observed that his left groin pain felt immediately improved. Two weeks after surgery, sensation in the femoral nerve distribution was improved and lower extremity strength was restored to grade 4/5. Six months later, the patient had full strength but sensation in the femoral nerve distribution did not fully recover. However, he was able to return to unrestricted activities without any previous symptoms or post-surgery functional limitations. A CT scan, performed six months after surgery, showed the left iliacus and psoas muscles had been restored to their normal shape ( Figure 2 ). Case 2 A 13-year-old boy was examined that had a five day history of pain in his right thigh which worsened when he extended his right knee. The pain began while he was exercising and had hyperextended his right hip. On the sixth day after the onset of pain, he was unable to walk because of pain in the right thigh and was admitted to our hospital. Physical examination revealed extreme tenderness to palpation in the groin. quadriceps was grade 4/5. The power of the Passive extension and active flexion of his right hip were painful. Sensation along the anterior aspect of the right thigh was normal. Blood tests, including coagulation time, prothrombin time, bleeding time, and platelet counts were within normal limits. The hemoglobin level was 12.1 g/dl. Radiographs of the pelvis were normal. A pelvic MRI scan revealed a hematoma measuring 8.2×4.5×7.0 cm3 in the right iliacus muscle ( Figure 5). Using the laparoscopic technique described in Case 1, we removed approximately 240 ml of clots and old blood from the hematoma. eliminated. A week after surgery, the patient's right thigh pain was completely He was able to lie on his back with the hip and knee in full extension two weeks after surgery and to walk without any limitations six weeks after surgery. A CT scan performed at six weeks showed that the right iliacus and psoas muscle had returned to their normal shape ( Figure 6 ). CLINICAL OVERVIEW Most cases of iliopsoas hematoma are caused by anticoagulant therapy or hemophilia but some are secondary to trauma. Iliopsoas hematoma originates from tears in iliacus and psoas muscle fibers and capillary damage. 7, 8 Both of our patients had a clear history of trauma; their APTT, PT-INR and platelet counts were normal. Whether iliopsoas hematoma should be surgically or conservatively treated is debatable. 9 Treatment decisions depend on the speed of onset, hematoma volume, and degree of neurological impairment. 10 Conservative treatments are suggested if the hematoma is relatively small and the neurological symptoms slight. 11, 12 Conservative treatments include bed rest, analgesics, hemostatics, and correction of deregulated anticoagulant therapy. 13 large and cause severe neurologic dysfunction. 14 Surgery is necessary if the hematomas are very The surgical treatments including trans-catheter arterial embolization, percutaneous drainage and surgical decompression of the femoral nerve have been reported in the literature. 1, 3, 6 STRATEGIES This paper describes two cases in which iliopsoas hematomas are removed using a laparoscopic technique. CT and MRI tests confirmed that both blood clots and old liquid blood are present within the hematomas. The clots and old liquid blood were removed through laparoscopic ports to achieve surgical decompression. The choice to use a laparoscopic approach was based on two factors. the operation is minimally invasive and produces little tissue damage. First, Secondly, with this technique, both blood clots and old liquid blood are removed resulting in a thorough decompression of the femoral nerve. In addition, the risk of infection associated with both old liquid blood and open surgery can be reduced with this technique. The laparoscopic technique, like open surgery, also allows identification and cauterization of the bleeding source. After using this technique, our patients experienced immediate relief from the pain they experienced from their injuries before surgery. Recovery of neurological function was incomplete in both cases at the time of discharge from the hospital. However, six weeks after surgery, the motor function was completely recovered in both cases and the sensory disturbance remained only minimally impaired in the case in which it was initially present ( Case 1 ). CLINICAL DIFFICULTIES Trans-catheter arterial embolization and percutaneous drainage can not clear the hematoma within iliopsoas completely. Open surgery results in a major trauma for patients, especially for adolescents. However, the laparoscopic surgery has the advantage such as minor trauma, removal of the hematoma completely and cauterization of the hemorrhagic spots successfully. AUTHORS’ PERSONAL OPINIONS Traumatic iliopsoas hematoma is rare in adolescents 12 and should be suspected in patients with hip pain and neurological dysfunction. A CT scan or MRI are good diagnostic tools to further verify other preliminary physical examinations 15 as these allow rapid identification and measurement of the hematoma. If the imaging demonstrates a hematoma with a mixture of blood clots and old liquid blood, laparoscopic surgery may be a safe and effective alternative to open surgery. REFERENCES 1. Wada Y, Yanagihara C, Nishimura Y. Bilateral iliopsoas hematoma complicating anticoagulant therapy. Intern Med 2005; 44:641-643. 2. Nakao A, Sakagami K, Mitsuoka S, Uda M, Tanaka N. Retroperitoneal hematoma associated with femoral neuropathy: a complication under antiplatelet therapy. Acta Med Okayama 2001; 55:363-366. 3. Holscher RS, Leyten FS, Oudenhoven LF, Puylaert JB. Percutaneous decompression of an iliopsoas hematoma. Abdom Imaging 1997 ;22:114-116. 4. Chevallier X, Parget-Piet B. Femoral neuropathy due to psoas hematoma revisited. Report of three cases with serious outcomes. Spine (Philadelphia, PA, 1976) 1992;17:724-726. 5. Rochman AS, Vitarbo E, Levi AD. Femoral nerve palsy secondary to traumatic pseudoaneurism and iliacus haematoma. J Neurosurg 2005;102: 382-385. 6. Tamai K, Kuramochi T, Sakai H, Iwami N, Saotome K. Complete paralysis of the quadriceps muscle caused by traumatic iliacus hematoma: a case report. J Orthop Sci 2002;7:713- 716. 7. Niakan E, Carbone JE, Adams M, Schroeder FM. Anticoagulants iliopsoas hematoma and femoral nerve compression. Am Fam Physician 1991; 44:2100-2102. 8. Sanders SM, Schachter AK, Schweitzer M, Klein GR. Iliacus muscle rupture with associated femoral nerve palsy after abdominal extension exercises: a case report. Am J Sports Med 2006;34:837-839. 9. Qanadli SD, EI Hajjam M, Mignon F, Bruckert F, Chagnon S, Lacombe P. Life-threatening spontaneous psoas hematoma treated by transcatheter arterial embolization. Eur Radiol 1999;9: 1231–1234. 10. Marquardt G, Barduzal Angles S, Leheta F, Seifert V. Spontaneous hematoma of the iliac psoas muscle: a case report and review of literature. Arch Orthop Trauma Surg 2002;122:109-111. 11. Maffulli N, So WS, Ahuja A, Chan KM. Iliopsoas hematoma in an adolescent Taekwondo player. Knee Surg Sports Traumatol Arthrosc 1996;3:230-233. 12. Patel A, Calfee R, Thakur N, Eberson C. Non-operative management of femoral neuropathy secondary to a traumatic iliacus hematoma in an adolescent. J Bone Joint Surg Br 2008;90:1380-1381. 13. Fealy S, Paletta GA. Femoral nerve palsy secondary to traumatic iliacus muscle hematoma: course after nonoperative management. J Trauma 1999;47:1150–1152. 14. Kumar S, Anantham J, Wan Z. Posttraumatic hematoma of iliac psoas muscle with paralysis of the femoral nerve. J Orthop Trauma 1992; 6:110-112. 15. Bui KL, Ilaslan H, Recht M, Sundaram M. Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol 2008;37:245–249. Figures Figure 1. T2-weighted magnetic resonance images (a, c) and computed tomography scan (b) of the pelvis before surgery in Case 1. Hematoma is observed in the left iliopsoas muscle. Figure 2. Sites for laparoscopic ports in Case 1. (a) Preoperative photograph of right flank with drawing of the surface anatomy of the right 12th rib, iliac crest, and three port locations. Intraoperative photograph of right flank with three laparoscopic instruments in place. (b) Figure 3. Laparoscopic photographs from Case 1 showing the external view (a) and internal view (b) of hematoma. Figure 4. Sections (a,b) from the computed tomography scan of the pelvis in Case 1, six months after surgery. Hematoma has disappeared on the CT scan after six months. Figure 5. T2-weighted (a, b) and T1-weighted (c) magnetic resonance images of the pelvis before surgery in Case 2. Hematoma is observed in the right iliopsoas muscle. Figure 6. Sections (a,b) from the CT scan of the pelvis in Case 2, six months after surgery. Hematoma has disappeared on the CT scan after six months.