What is a right psoas hematoma?

Right Psoas Hematoma: Diagnosis and Management

A right psoas hematoma is a collection of blood within the right psoas muscle, typically located in the retroperitoneal space, which can occur spontaneously or due to trauma and may present with pain, neurological symptoms, and in severe cases, hemodynamic instability. 1

Clinical Presentation

• Patients with psoas hematoma commonly present with pain in the groin, lower abdomen, or flank region 2
• Neurological symptoms may include femoral nerve palsy causing weakness in hip flexion and knee extension, sensory deficits in the anterior thigh, and difficulty walking 2, 3
• Physical examination may reveal an iliopsoas sign (pain with hip flexion against resistance), palpable mass in the iliac fossa, and ecchymosis in some cases 3
• Hemodynamic instability can occur with large hematomas due to significant blood loss 1

Etiology

• Anticoagulant therapy is a common cause, with 60% of cases associated with heparin use 3
• Traumatic causes include blunt trauma, falls, or iatrogenic injury during procedures 4
• Surgical complications, particularly from spinal surgeries including extreme lateral interbody fusion and posterior spinal fusion 5, 6
• Spontaneous bleeding can occur in patients with coagulopathies or bleeding disorders 3

Diagnostic Imaging

• CT scan with IV contrast is the preferred initial imaging modality for diagnosing psoas hematoma due to its speed, high spatial resolution, and ability to detect active bleeding 7, 8
• Non-contrast CT is appropriate for expeditiously confirming bleeding, particularly useful in patients with compromised renal function 8
• CT Angiography (CTA) is superior when active bleeding is clinically suspected, providing exact location of hematoma plus vascular information 8
• MRI can be useful for differentiating between blood and underlying neoplasm, and for characterizing bleeding acuity 1
• Ultrasound has limited utility for psoas hematoma assessment due to difficult visualization of retroperitoneal structures 7, 8

Management

For Hemodynamically Stable Patients

• Conservative management is the primary approach for stable patients 1
• Discontinuation of anticoagulants and reversal of anticoagulation if appropriate 2
• Pain control with appropriate analgesics 1
• Regular monitoring of hemoglobin levels to assess for continued bleeding 1
• Serial clinical examinations to monitor for neurological deterioration 1

For Hemodynamically Unstable Patients

• Secure large-bore intravenous access for fluid resuscitation 1
• Blood product transfusion as needed 1
• Invasive blood pressure monitoring for patients with significant comorbidities 1
• Consider arterial embolization if active bleeding is identified on imaging 1
• Surgical evacuation may be necessary for expanding hematomas causing significant compression or in patients who fail to respond to conservative measures 1, 3

Complications

• Femoral nerve palsy is a common complication, occurring in up to 80% of cases 3
• Anemia due to significant blood loss 3
• Infection of the hematoma if left untreated 1
• Compartment syndrome in severe cases 1

Prognosis

• Most patients with psoas hematoma managed conservatively have good outcomes with complete resolution of the hematoma 5
• Femoral nerve palsy typically resolves with conservative management, though recovery may take weeks to months 3, 5
• The 30-day mortality rate for retroperitoneal hematomas can be as high as 10% in cases with significant bleeding 2

Follow-up

• Serial imaging (CT or ultrasound) to monitor hematoma resolution 1
• Physical therapy may be necessary for patients with residual weakness 1
• Once bleeding is controlled, standard venous thromboprophylaxis should be considered as patients rapidly develop a prothrombotic state 1