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Computed tomography (CT) is an ideal method for the imaging of the psoas muscle. The authors present 13 cases of patients with psoas abnormalities diagnosed by CT. The CT features of the different pathologic entities and comparison of CT with other imaging modalities are discussed.
A 69-year old farmer developed Aspergillus myositis in the right psoas and paravertebral muscles extending to the retroperitoneum and the fifth lumbar vertebra. The infection appeared after two local instillations of steroid for back pain. Although the patient was not immunocompromised, surgical drainage and antifungal therapy failed to cure him; he died of a bacterial pulmonary superinfection while cultures of the abscess drainage fluid grew Aspergillus. The likely portal of entry in this patient was direct inoculation during infiltration of the steroid; the steroid probably caused a local impairment in host defenses. Only six cases of Aspergillus myositis have been reported previously. All of them occurred in severely immunosuppressed patients and the outcome was fatal in all cases.
Two cases of iliopsoas haemophilic pseudotumours are presented. In one patient a fistula developed between a pseudotumour and the large bowel. This resulted in an abscess involving the pseudotumour and adjacent tissues. It resolved after 5 years of therapy involving percutaneous drainage and closure of the fistula. The second patient had a massive pseudotumour that had obstructed both ureters. Later he suffered a fatal mixed Gram negative septicaemia probably related to erosion into the colon.
A 27-year-old man with a diagnosis of Buerger's disease presented with vasospastic symptoms of coldness and pain at rest of his right foot. Physical examination of his affected limb revealed absent popliteal pulse, cool skin hyperhidrosis and dry gangrene of the big toe. He had been operated on for a ruptured liver and liver abscess 20 years ago. He was scheduled for totally extraperitoneal laparoscopic lumbar sympathectomy on July 26, 1994. The technique was performed under general anesthesia and the patient was put in a supine position with slight extension between the rib and the iliac crest. The working space was created by digital blunt dissection and direct insufflation of carbon dioxide. The right sympathetic trunk was found between the medial edge of the psoas muscle and inferior vena cava. The L2, L3, L4 sympathetic ganglia were identified above the vertebral column and meticulously dissected cephalocaudally. Based on the concept of traditional approach, we believe that this laparoscopic technique is relatively safe and should become the procedure of choice in the future.
The retropsoas recess, a previously undescribed normal anatomic variant, is reported. In most individuals, the space posterior to the belly of the psoas muscle contains fat within the posterior pararenal space. However, a retrospective review of 250 consecutive CT examinations of the abdomen revealed 11 cases (4.4%) in which bowel loops extended at least partially posterior to the psoas muscle. Unilateral left-sided occurrence was present in seven, with four bilateral. Colon was invaginated in five, small intestine in four, and both colon and small intestine in one. There was no age or sex predominance. A paucity of retroperitoneal fat is the primary predisposing factor for development of a retropsoas recess. Although recognition of this normal variant is generally not difficult, the CT appearance may mimic a retroperitoneal mass or abscess in less-than-ideal examinations or targeted studies. The potential presence of bowel loops in this location should be considered during interventional procedures.
Presentation of the sonographic findings of 170 retroperitoneal masses: primary and metastatic neoplasms, abdominal aortic aneurysms, hematomas and abszesses. A typical diagnostically reliable sonographic pattern was seen only in retroperitoneal hematomas in the area of the psoas and in aortic aneurysms, provided the aorta itself could be visualized. In all the other masses the ultrasound pattern did not provide reliable clues as to their histology; ultrasound, however, proved to be highly successful in demonstrating the presence and location of the lesion.
AIM: To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder. MATERIALS AND METHODS: A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records. RESULTS: Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27-70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of low-density enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6-12 months). CONCLUSION: Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal.
We present a case of a postpartum female with iliopsoas fasciitis in the puerperium. Two days after a spontaneous vaginal delivery at 38 weeks without any complications, the patient complained of pain in the left thigh and hip, associated with a temperature of 38 degrees C. Consequently, she could not walk 4 days after delivery and her body temperature had increased to 39 degrees C. Extreme left flank pain and tenderness in the left pelvic wall were prominent, whereas the tenderness in the pelvis was moderate. Magnetic resonance imaging led us to diagnose iliopsoas fasciitis. This was complicated by sepsis but improved after a protracted antibiotic treatment without any surgical intervention. A literature review revealed that serious complications, including sepsis or permanent functional disturbance, could arise although retroperitoneal fasciitis and/or abscesses are very rare after vaginal delivery. Iliopsoas fasciitis could be considered when patients complain of extreme pain in the pelvic wall, sacroiliac joint region, or thigh-symptoms that are uncommon in uncomplicated endometritis.
STUDY DESIGN: A case report of an extremely rare condition describing lumbar spine tuberculosis associated with concurrent pyogenic infection is presented. OBJECTIVE: To establish that isolation of pyogenic bacteria from an infected spine does not exclude the possibility of spine tuberculosis. SUMMARY OF BACKGROUND DATA: During a MEDLINE data search from January 1960 through October 2001, no cases of combined spine tuberculosis and pyogenic infection were found. METHODS: A 52-year-old man reported left-side gluteal swelling, backache, and fever of 20 days duration. A similar swelling in the same location had occurred 12 years previously, and an operation was performed at that time. Preoperative syringe-aspirated material from a gluteal abscess was sent for ordinary bacteriologic culture (for only aerobic pyogenic bacteria). During the operation, a needle-aspirated specimen of evacuated pus was subjected to direct microscopy and culture. Direct Gram stain for pyogenic bacteria and direct Ziehl-Neelsen stain for mycobacteria were performed. Cultures for aerobes, anaerobes, mycobacteria, and fungi were made. RESULTS: The preoperative specimen culture showed growth of Nocardia asteroids and Moraxella catarrhalis, whereas the operative specimen showed Gram-positive cocci and acid-fast bacilli on direct smears. The operative cultures yielded growth of Nocardia asteroids, Moraxella catarrhalis, and Mycobacterium tuberculosis. Plain lumbar spine radiograph showed psoas muscle calcification. CONCLUSIONS: It is concluded from this case that recovery of pyogenic bacteria from an infected spine does not exclude spine tuberculosis. It is recommended, therefore, that mycobacterial investigations be performed for cases that have evidence of tuberculosis, even when pyogenic microorganisms already have been isolated. The clues that raise suspicion of tuberculosis in patients with pyogenic spine infection include chronic infection that does not respond to ordinary antibiotics, isolated pyogenic bacteria of low virulence, psoas muscle calcification, and immunosuppression.
We report two rare cases of iliopsoas bursitis extending into the retroperitoneal space. The first lesion contained much gas, mimicking a retroperitoneal abscess, and the second was responsible for atypical inguinal pain. The diagnosis was made by contrast-enhanced CT in both cases and arthrography in the first case. Iliopsoas bursitis in these two patients, it is hypothesized, extended into the retroperitoneum, at least in part, by way of intraneural or perineural structures.
PURPOSE: The purpose of this work was to evaluate the use of percutaneously placed lumbar sympathetic plexus catheter placement under CT guidance in patients with complex regional pain syndrome (CRPS) or nonspecified neuropathic pain (NP) of the lower extremity. METHOD: Sixteen lumbar sympathetic plexus catheter placements were performed in seven patients with CRPS and seven patients with NP. A 19 gauge epidural catheter was placed anterior to the psoas muscle at the L2-3 level. Twenty-five to 840 mg of bupivacaine hydrochloride per day was administered for a 1 to 8 day duration. RESULTS: In CRPS patients, there was complete short-term pain relief in one patient, considerable in four, mild in one, and none in one. There was total long-term pain relief in one patient and considerable long-term pain relief in three. In three patients, there was enduring pain relief at last follow-up. In NP patients, the procedure yielded considerable short-term pain relief in four, mild in two, and none in one. There was no enduring long-term in any of these patients. A retroperitoneal abscess developed in one patient and resolved on intravenous antibiotics without sequelae. CONCLUSION: Percutaneous lumbar sympathetic plexus catheter placement is easily performed, achieves short-term pain relief in the majority of patients, and may prove effective in long-term pain relief of CRPS patients.
INTRODUCTION: Over a period of 36 months we prospectively documented infectious, neurological and other complications or adverse events occurring during 3,491 peripheral regional anesthesias via a catheter using computer-based data recording. METHODS: The investigation included 936 axillar plexus catheters, 473 interscalene plexus catheters, 125 vertical infraclavicular plexus catheters, 74 catheters with psoas compartment blocks, 900 femoral nerve catheters, 964 sciatic nerve catheters and 19 catheters in other localizations. The regional anesthesia catheters were inserted under sterile circumstances (hood, facemask, sterile gloves and coat, surgical disinfection and sterile covering of the placement site) and under peripheral nerve stimulation. RESULTS: 3,070 (87.9%) of the regional anesthesias via catheter, were carried out without any complications. Inflammation (two out of three criteria: redness at insertion site, pain on palpation or swelling) was found in 146 patients (4.2% of all cases). Infections (two out of the criteria: CRP elevation, pus on the insertion site, fever, leucocytosis, necessary antibiotic treatment with exclusion of other possible causes) appeared in 2.4% of all cases (83 patients). In 29 patients (0.8%) we observed severe infections (surgical intervention necessary e.g. abscess incision). Risk factors for inflammation or infections included duration of catheter therapy, cervical localization of the catheter and the experience of the anesthesiologist (p<0.05). Bacterial species most frequently found were Staphylococcus aureus (54%) and Staphylococcus epidermidis (38%). In 0.3% (9 patients) we found short lasting neurological deficits and in 6 patients (0.2%) we recorded a nerve lesion that lasted more than 6 weeks. Other complications occurred in 4.2% of all cases. DISCUSSION: Special complications such as infections in peripheral catheter regional anesthesia are rare but can pose severe problems. A close postoperative supervision of all regional catheters has to be ensured under careful consideration of the risk factors for infections and the accompanying symptoms.
Perianal infection in a 40-year-old man resulted in extensive necrotizing fasciitis of the retroperitoneal space and septic shock. Despite the fact that radiography revealed linear streaking in the belly of the psoas muscle due to gas formation, the nature of the infection was necrotizing fasciitis and not myonecrosis. This contradicts Brightmore's contention that such a finding always indicates clostridial myonecrosis. Despite the absence of Clostridium welchii, necrotizing fascitis is none the less extremely serious, usually occurring in the limbs or abdominal wall superficial to muscle layers. The case reported is unusual in that infection affected the fascia deep to abdominal muscles in the retroperitoneal space, where surgical exposure is difficult. An appropriate surgical approach afforded adequate treatment.
The authors reviewed the results of imaging studies performed in 30 patients with diseases involving the iliopsoas compartment (IPC) to assess the role of Ultrasound (US), Computed Tomography (CT) and Magnetic Resonance (MR) in the investigation of these deep seated and often clinically undetectable lesions. 16 (53%) patients had histologically proven benign or malignant IPC tumours with bacterial infection in 12 (40%) and haemorrhage into the IPC in 2 (7%). US correctly detected iliopsoas pathology in only 9 of 17 cases (53%) and was satisfactory only in limited situations, such as abscess formation in children and haemorrhage in haemophiliacs. CT was much more accurate (16/17, 94%) than US and correctly diagnosed 7 cases overlooked on US, while also offering greater information in 5 cases where both studies were abnormal. CT was particularly helpful for the detection of both abscess formation and calcification within mass lesion. MR was accurate in all 9 cases imaged, and was very helpful in the assessment of associated vertebral, disc or spinal canal involvement by tumour or infection. A review of the literature, and the results of this study, suggest that CT and MR often have complementary roles where IPC disease is known or suspected. The accuracy of US in IPC disease is limited, preferably being followed by CT or MR imaging.