Almazrua Ibrahim S, Almarshad Abdullah Y, Binzuman Ghadah, Alrabiah Anwar M
Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Orthop Res Rev. 2020 Sep 4;12:127-132. doi: 10.2147/ORR.S272077. eCollection 2020.
Psoas hematoma is an uncommon complication following spinal surgeries. It has been reported in both extreme lateral interbody fusion (XLIF) and posterior spinal fusion with instrumentation. Minimally invasive techniques are gaining popularity in recent years due to the appealing advantages of reduced operative time, blood loss, hospital stay, and faster recovery.
We are presenting a case of a 77-year-old male with chronic low back pain, diagnosed to have multilevel degenerative disc disease with central and foraminal disc protrusion at L2-L3, L3-L4, L4-L5 with secondary spinal stenosis, underwent XLIF at L3-L4, L4-L5 and then 2nd stage with posterior L3-L5 fusion with pedicle screws. On the fourth day post-operatively, the patient had flank pain and dropping hemoglobin with femoral nerve palsy symptoms, a CT scan revealed a large psoas hematoma. Conservative management was decided on; a follow-up CT scan and examination showed complete resolution of the hematoma and femoral nerve recovery.
The approach to iliopsoas hematoma post spinal surgeries remains controversial. Iliopsoas hematoma should be suspected in any patients post spinal surgeries even with delayed presentations. The decision to proceed with either surgical intervention or conservative management depends on multiple factors, including patient hemodynamic status, progression of collection and femoral nerve palsy.
The exact cause of iliopsoas hematoma post different spinal surgery approaches remains vague. In our opinion, other causes including pre- and post-operative anticoagulants should be investigated. Rushing to drain iliopsoas hematomas in case of femoral nerve palsy might not be the ideal option. Instead, monitoring patient responses to resuscitation and taking a watch and wait approach for femoral nerve palsy might be the proper approach.
腰大肌血肿是脊柱手术后一种罕见的并发症。在极外侧椎间融合术（XLIF）和后路脊柱融合内固定术中均有报道。近年来，由于具有手术时间缩短、失血减少、住院时间缩短和恢复更快等诱人优势，微创技术越来越受欢迎。
我们报告一例77岁男性，患有慢性下腰痛，诊断为多节段退变性椎间盘疾病，L2-L3、L3-L4、L4-L5节段中央型和椎间孔型椎间盘突出伴继发性椎管狭窄，在L3-L4、L4-L5节段接受了XLIF手术，然后进行了第二阶段L3-L5后路椎弓根螺钉融合术。术后第四天，患者出现侧腹痛、血红蛋白下降并伴有股神经麻痹症状，CT扫描显示巨大腰大肌血肿。决定采取保守治疗；后续CT扫描和检查显示血肿完全消退，股神经恢复。
脊柱手术后腰大肌血肿的处理方法仍存在争议。即使是延迟出现症状，脊柱手术后的任何患者都应怀疑有腰大肌血肿。决定进行手术干预还是保守治疗取决于多种因素，包括患者的血流动力学状态、血肿进展情况和股神经麻痹。
不同脊柱手术方式后腰大肌血肿的确切原因仍不明确。我们认为，应调查包括术前和术后抗凝剂在内的其他原因。在出现股神经麻痹时匆忙引流腰大肌血肿可能不是理想的选择。相反，监测患者对复苏的反应并对股神经麻痹采取观察等待的方法可能是合适的做法。
