lumbar paraspinous hematoma after RFA

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TIVAndy

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50's cardiac history on warfarin.
had two successful mbb, and then lumbar RFA 2 weeks ago.
post procedure meeting - 2 weeks - complained of severe pain in right low back with hip flexion weakness, i got stat MRI
this is what the MRI shows
20220808_084544.jpg


3cm hematoma in the paraspinous muscles. no impingement in neuroforamen/no hematoma in epidural space. of note, he does have a known 5cm AAA. i think the hematoma is causing the pain - any thoughts? how would you proceed? drain it? leave it until it gets absorbed?
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Leave it. There won’t be anything you can drain. It is the consistency of some delicious vitamin C gummies at this point.

You could have general surgery open it up and suck it out if you didn’t feel comfortable doing that. I would only do that if he is having severe pain or you have fear that the blood agar is infected.
 
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The problem is the hip flexion weakness. How do you explain that without compression of the lumbar plexus or nerve roots? Is this just pain mediated weakness?

The MRI suggests there's still a strong fluid component in it.

I'm okay leaving it if you got a good nonstructural reason, but as he's anticoagulated, I'd also be fine sticking a needle in it to vent him after feeding him some kale and Keflex.
 
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People have hip flexion weakness from back pain all the time, especially L4-5 level. Nerve is fine and psoas is fine.
 
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pmrmd said:
People have hip flexion weakness from back pain all the time, especially L4-5 level. Nerve is fine and psoas is fine.
Click to expand...
I agree, but document that and the consideration to CYA. I would just apply pressure to the hematoma in a back brace at most as long as I felt confident this wasn't related to mass effect.

Case report of this happening after kypho
www.ncbi.nlm.nih.gov

Life-threatening paraspinal muscle hematoma after percutaneous vertebroplasty

Bleeding and hematoma formation is rarely reported in percutaneous vertebroplasty procedure. An 84 year old male presented with a large paraspinal muscle hematoma after a percutaneous vertebroplasty. The patient had neither any prior bleeding disorder ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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Nothing impinging or communicating with the iliopsoas. Hematoma unrelated to weakness of hip flexion. Nothing to do IMO.
 
good discussion. agree about the concern re: hip flexor weakness, but also that all the blue hairs with LBP have hip flexor weakness.

hip flexors are L2, and the psoas/plexus area looks fine. nothing would show up on EMG until weeks out anyway. keep an eye out for worsening legit weakness, but i suspect that as the hematoma resolves, the strength will come back.

you did nothing wrong here.

what guage RF needle did you use?
 
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i was looking for possible psoas involvement, but no mass effect on it. no L1/L2 involvement either. I used 18 gauge for ablation.
i also think the weakness is due to severe pain. didn't realized that large hematoma in paraspinous can cause this much pain but now i've learned
 
SSdoc33 said:
good discussion. agree about the concern re: hip flexor weakness, but also that all the blue hairs with LBP have hip flexor weakness.

hip flexors are L2, and the psoas/plexus area looks fine. nothing would show up on EMG until weeks out anyway. keep an eye out for worsening legit weakness, but i suspect that as the hematoma resolves, the strength will come back.

you did nothing wrong here.

what guage RF needle did you use?
Click to expand...
18 gauge
 
one tidbit i forgot to mention, patient did comment on his blood pressure too. often below systolic 90's. i'm going to bring him in for hgb check and bp check also. he was telemedicine today so we couldnt assess this
 
TIVAndy said:
one tidbit i forgot to mention, patient did comment on his blood pressure too. often below systolic 90's. i'm going to bring him in for hgb check and bp check also. he was telemedicine today so we couldnt assess this
Click to expand...
out of curiosity, was there any significant bleeding noted during procedure itself?
 
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INteresting case

steve and others advocate doing RFA and not stopping anticoagulation. Not sure if you did or not.

But this could be a reason to stop anticoag before RFA. I suppose its a r/b/a discussion. I think it will resolve on its own too. Question is is this a risk or could it be a risk of doing RFA without stopping anticoag? Furthermore, could there be a risk of communicating with the epidural space etc somehow. I think that's a concern if one doesnt stop anti coag.....

Thanks for sharing!
 
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PinchandBurn said:
INteresting case

steve and others advocate doing RFA and not stopping anticoagulation. Not sure if you did or not.

But this could be a reason to stop anticoag before RFA. I suppose its a r/b/a discussion. I think it will resolve on its own too. Question is is this a risk or could it be a risk of doing RFA without stopping anticoag? Furthermore, could there be a risk of communicating with the epidural space etc somehow. I think that's a concern if one doesnt stop anti coag.....

Thanks for sharing!
Click to expand...
Rare intramuscular hematoma better than mi/cva/pe
Needle wasn’t in epidural space
 
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PinchandBurn said:
INteresting case

steve and others advocate doing RFA and not stopping anticoagulation. Not sure if you did or not.

But this could be a reason to stop anticoag before RFA. I suppose its a r/b/a discussion. I think it will resolve on its own too. Question is is this a risk or could it be a risk of doing RFA without stopping anticoag? Furthermore, could there be a risk of communicating with the epidural space etc somehow. I think that's a concern if one doesnt stop anti coag.....

Thanks for sharing!
Click to expand...
Come on man...Don't go there.

I'm willing to bet this happens more frequently than we know.
 
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Is it true weakness? Or possibly guarding from pain.. ive seen this before although didnt get MRI.
 
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the only second-guess here is the gauge of the needle. id be tempted to stay with 20g on anti-coagulated patients. definitely woudnt make the patient stop the blood thinners
 
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Gauge, needle approach, number of redirections, and supra-therapeutic Warfarin would be the factors I would consider here. It's not uncommon for patients to get a little too high on their INR.

For example, in this case you could ask him to do 5 days of a slightly lower dose of Warfarin in 6-12 months when you come back to repeat the RFA.
 
This is needle rub against os, and no big deal. I wouldn't change my practice for this.
 
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SSdoc33 said:
the only second-guess here is the gauge of the needle. id be tempted to stay with 20g on anti-coagulated patients. definitely woudnt make the patient stop the blood thinners
Click to expand...
I had this happen once on a MBB. I use 25g for MBBs. Let it resolve, came back and did RFA with the usual 18g needle. No issues. Pt. was on plavix. Didn't stop it (never do).
 
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BobBarker said:
Leave it. There won’t be anything you can drain. It is the consistency of some delicious vitamin C gummies at this point.

You could have general surgery open it up and suck it out if you didn’t feel comfortable doing that. I would only do that if he is having severe pain or you have fear that the blood agar is infected.
Click to expand...

What he said. Just monitor and leave it. It'll fade away.
 
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With several hundred RFA on fully anticoagulated over my career, I have had one clinically significant bleed. Patient on one of those heavy duty newer antiplatelets, I don’t recall the name, was a few years ago.
Was sacral lateral branch RF. 18 gauge, my standard. Continue to bleed in PACU, soaking several 4 x 4‘s with Tegaderm over it. Put on new dressing told patient to leave it on 24 hours. The following morning, called with blood running down her leg… Went to ED. They had to inject patient with some type of localized fibrin product and used a high end foam dressing (don’t recall the details of material) and got transfused several units. Hg had dropped to like 8 or 9. Don’t know baseline.

Fortunately, patient was an RN, so was not freaking out about it, and she still prefered this outcome over having another MI or CVA. And had great relief from the RF!

Fortunately, when needed to repeat a couple years later, only was on aspirin. I must’ve stuck a significant intramuscular vessel. Never really went back and scrutinized the images.

All that being said, when patients ask me if I have ever seen a problem doing this fully anticoagulated I say once in about 10 years after several hundred cases, and still better than MI or CVA.
 
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Did you check an INR before the case? I don't stop Warfarin but I do check INR for </= 3.0
 
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