Femoral nerve palsy associated with bilateral spontaneous iliopsoas haematomas: a complication of venous thromboembolism therapy

Abstract

We report a case of femoral nerve palsy occurring as a result of spontaneous bilateral iliopsoas haematomas in an elderly patient on treatment dose dalteparin for a suspected pulmonary embolus. There are limited case reports in the literature relating to this rare problem, and their management is controversial. We advocate non-operative treatment in the instance of a delayed presentation in a frail elderly patient with a subsequent good functional outcome.

Bilateral Femoral Neuropathy: A Rare Complication of Drug Overdose due to Prolonged Posturing in Lithotomy Position

“…(a) Stretching and/or prolonged compression of the nerve caused by the self-retaining retractors that can directly compress the nerve against the pelvic sidewall (b) Compression of the iliac vessels causing direct ischemia of the nerve (c) Prolonged compression of the femoral nerves under the inguinal ligament, or (d) Excessive stretching due to excessive abduction and external rotation of the hips during lithotomy positioning [2][3][4][5][6] In addition to the above iatrogenic causes, there are reports of rare cases of bilateral femoral nerve compression and ischemia due to iliopsoas hematomas [7][8][9][10] and iliopsoas swelling secondary to rhabdomyolysis [11,12]. ere are also individual reports of bilateral femoral neuropathy due to vasculitis in the context of disseminated intravascular coagulopathy [13] and due to blunt force trauma [14].…”

Femoral Nerve Palsy Secondary to Iliopsoas Spontaneous Haematoma in a Patient Under Warfarin Treatment

“…Open surgical debridement has also been described as a managing option depending on the severity of the femoral neuropathy and the size of the haematoma [1,4,5]. In cases of haemodynamic instability, blood transfusion and crystalloid administration may be required [7].…”

Bilateral Femoral Neuropathy Following Psoas Muscle Hematomas Caused by Enoxaparin Therapy

“…LMWH, such as enoxaparin, typically have favorable adverse effect profiles and less bleeding risk, possibly due to greater inhibition of factor Xa than thrombin and less platelet inhibition [ 3 , 6 ]. However, severe hemorrhagic complications can occur and there are reports of large abdominal wall hematomas, retroperitoneal hemorrhages, and epidural hematomas developing following enoxaparin use [ 3 ].…”

“…The femoral nerve is the most commonly affected nerve in cases of retroperitoneal masses causing compression, because it is the largest branch of the lumbar plexus originating from the dorsal branches of the L2–L4 ventral rami, running superficially in the groove between the iliacus and the psoas [ 2 – 4 ]. Clinically, femoral neuropathy presents with weakness of the lower extremities, inability to flex the hips or extend the knees, patellar hyporeflexia, and decreased sensation in the anterior thigh; in some cases, paresthesia precedes the motor symptoms [ 2 , 6 – 8 ]. There are 2 proposed mechanisms of nerve injury: decreased blood supply in the iliopsoas gutter causing ischemia and pressure-related damage from compression by the hematoma [ 4 , 8 ].…”

“…Bilateral psoas muscle hematomas as a result of anticoagulation are an even rarer event, with few reports of UFH and dalteparin being the culprit agents. There has never been a report of enoxaparin causing bilateral psoas muscle hematoma [ 6 , 7 ]. We present a case of an elderly woman with bilateral femoral nerve neuropathy following bilateral psoas muscle hematomas caused by enoxaparin.…”