Michelle Nguyen, BS
Medical Student
University of California, Irvine, School of Medicine
Yorba Linda, California, United States
Keshin M. Purohit, MD
Resident Physician
University of California Irvine
Garden Grove, California, United States
Armand Ardestani, DO
Chronic Pain Medicine Fellow Physician
University of California, Irvine
Orange, California, United States
Jason Koh, DO
Assistant Clinical Professor
UC Irvine Physical Medicine and Rehabilitation
Long Beach, California, United States
An 83 year-old male underwent posterior cervical fusion and stabilization for atlantoaxial instability and cervical medullary deformation. Postoperatively, he developed orthostatic hypotension but was cleared for rehabilitation with 5/5 strength in all extremities.
On postoperative day (POD) 8, the patient was diagnosed with an acute right peroneal deep vein thrombosis and initiated on therapeutic enoxaparin. His anticoagulation therapy was carefully managed in consultation with neurosurgery, transitioning from enoxaparin to oral anticoagulation on POD 10.
On POD 16, the patient reported right hip pain after some physical activity, followed by weakness in hip flexion (⅖) and knee extension (⅕), and numbness in the right inner thigh. He denied any trauma or fall.
On POD 17, subsequent X-rays revealed no bony abnormalities or hardware failure. A CT scan showed diffuse expansion of the right psoas muscle with a hematoma extending over a craniocaudal span of 20 cm, likely causing femoral nerve compression.
Discussions: Psoas hematomas are uncommon and often present diagnostic challenges due to their insidious onset and nonspecific symptoms. The most concerning symptom in this case was the weakness in the femoral nerve distribution almost a week following anticoagulation therapy, underscoring the need for prompt X-rays and CT scans. The hematoma was likely precipitated by anticoagulation therapy following cervical spine surgery, necessitating close monitoring and multidisciplinary collaboration.
Conclusions: Psoas hematomas are rare but significant complications in patients undergoing anticoagulation therapy, particularly following major surgeries. This case demonstrates the importance of comprehensive, systematic physical examinations and a low threshold for diagnostic imaging when patients report new weakness in the rehabilitation setting.
