Sonographic Diagnosis of a Thoracolumbar Fascia Hematoma after Surgical Microdiscectomy

Dear Editor, We report the case of a 58-year-old overweight woman (body mass index 26) with arterial hypertension, referred to our physical and rehabilitation medicine department for postoperative rehabilitation following selective endoscopic microdiscectomy for a left L4–L5 intraforaminal disc herniation. The patient had undergone spinal surgery due to persistent neuropathic pain (Numeric Rating Scale [NRS] 8/10) of the left lower limb refractory to a 2-week systemic corticosteroid therapy (i.m. betamethasone, tapered from 4 mg/day to 1.5 mg/day over a total period of 15 days). Upon admission, the radicular pain had improved (NRS 3/10), but the patient also reported new-onset lumbar stiffness and a localized sensation of swelling in the left lumbar region for 2 weeks. Physical examination revealed swelling and tenderness of the paraspinal soft tissues on the left lumbar region. Ultrasound (US) examination (GE Healthcare, Versana Premiere Black, 12L-RS linear probe) was performed using a standardized protocol[1] and it revealed a multiloculated anechoic fluid collection with delamination of the paraspinal fascial layers [Figure 1]. Considering the medical history, physical, and US findings, a postoperative thoracolumbar fascia hematoma, likely resulting from accidental injury to intramuscular branches of a segmental lumbar artery during surgery, was diagnosed [Video 1]. Lumbar massage and fascial stretching were avoided during the first 3 weeks of rehabilitation treatment to promote progressive reabsorption of the intrafascial hematoma. Instead, neurodynamic exercises were prescribed to restore lumbar nerve roots’ gliding and reduce the potential risk of periradicular adhesions.[2]Figure 1: Schematic drawing (a), the transverse (b) and longitudinal (c) ultrasound images show the multiloculated anechoic blood collection (white asterisks) within the swollen thoracolumbar fascia (yellow arrowhead) in the surgical site, with sonographic features similar to a Morel-Lavallée lesion. Compared to the contralateral, healthy side, the left multifidus muscle appears hyperechoic and heterogeneous due to disruption of its muscle fibers. Sp: Spinous process, M: Multifidus muscle, LT: Longissimus thoracis muscle, L: Lamina, Fj: Facet joint {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_yxhqowqx"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The thoracolumbar fascia is a richly innervated structure with nociceptive afferents and perivascular neural plexuses. Herewith, its role as a lumbar pain generator remains under-recognized in the neurosurgical field. Of note, the use of US has significantly revolutionized the rehabilitation of relevant patients whereby static assessment of fascial thickness and echotexture, sonoelastographic evaluation of fascial stiffness, and dynamic examination of fascial sliding would be paramount.[3,4] Finally, some atypical postsurgical complications can also be promptly detected by US, helping to avoid unnecessary interventions and to optimize the postoperative follow-up of healing paraspinal soft tissues. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.