What are the implications of a retroperitoneal hemorrhage originating from a lumbar spinal artery?

From the Guidelines

Retroperitoneal hemorrhage from the lumbar spinal artery requires immediate medical attention and intervention, with CT angiography being the diagnostic modality of choice to identify the bleeding source, followed by endovascular embolization as the preferred treatment option due to its lower morbidity compared to open surgical repair. Treatment typically involves hemodynamic stabilization with fluid resuscitation using crystalloids (normal saline or lactated Ringer's) and blood products as needed, targeting a hemoglobin level above 8-9 g/dL 1. Reverse any anticoagulation if present using appropriate reversal agents: protamine for heparin, vitamin K and prothrombin complex concentrate for warfarin, or specific reversal agents for DOACs. Pain management with opioid analgesics such as morphine 2-4 mg IV every 4 hours or hydromorphone 0.5-1 mg IV every 3-4 hours should be initiated.

Some key points to consider in the management of retroperitoneal hemorrhage include:

• The use of CT abdomen and pelvis for initial imaging due to its speed, high spatial resolution, and noninvasiveness, which can help depict blood, localize areas of bleeding, and evaluate for recent or active extravasation of contrast material 1
• The importance of close monitoring in an ICU setting with serial hemoglobin checks, vital signs, and abdominal examinations
• The potential risks and limitations of angiography, including its invasive nature, risks of hematoma or bleeding at access site, iatrogenic dissections, and infection 1
• The role of endovascular embolization in achieving cessation of bleeding, as demonstrated in a study by Fitzpatrick et al, where all angiographic cases were diagnostic of the bleeding vessel with TAE, with success measured by observation of cessation of bleeding and clinical stabilization 1

Overall, the management of retroperitoneal hemorrhage from the lumbar spinal artery requires a multidisciplinary approach, with a focus on prompt diagnosis, hemodynamic stabilization, and definitive treatment with endovascular embolization.

From the Research

Causes and Risk Factors

• Retroperitoneal hemorrhage can be caused by injury to the lumbar arteries, which can occur due to lumbar spinal fractures and/or pelvic fractures 2.
• The use of anticoagulants and/or antiplatelet agents can increase the risk of spontaneous retroperitoneal hemorrhage 3.
• Lumbar transverse process (TP) fractures are associated with a higher proportion of lumbar artery hemorrhage 4.

Diagnosis and Imaging

• Computed tomography (CT) scans can be helpful in diagnosing retroperitoneal hemorrhage by revealing a distinct separation of the lumbar hemorrhage from the hematomas associated with pelvic fracture 2.
• Arteriograms can manifest stasis within lumbar extravasation as globular or streaky accumulations of contrast medium, pseudoaneurysms or diffuse "staining," or opacification of a fracture site 2.
• Multi-slice CT and arteriography are important for diagnosis of retroperitoneal haematoma 5.

Management and Treatment

• Embolization with pledgets of absorbable gelatin sterile sponge can control bleeding in patients with lumbar arterial injury 2.
• Angioembolisation is an effective treatment for hemorrhage from lumbar arteries, especially in patients with lumbar transverse process fractures 4.
• Endovascular treatment involving selective intra-arterial embolisation or the deployment of stent-grafts over the punctured vessel is a treatment option for retroperitoneal haemorrhage 5.
• Open repair of retroperitoneal bleeding vessels should be reserved for cases when there is failure of conservative or endovascular measures to control the bleeding 5.

Outcomes and Prognosis

• The mortality rate for patients with retroperitoneal haematoma remains high if treated inappropriately 5.
• Early detection and aggressive resuscitation may improve outcomes for patients with spontaneous retroperitoneal hemorrhage 3.
• Patients with lumbar artery hemorrhage are more likely to undergo angioembolisation and have a higher incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS) 4.