A 62-year-old male presented to A&E with a two-week history of undulating lower back pain. Whilst fixing his spring-loaded bed, a metal part detached and hit the patient’s chest, which caused him to lose balance and fall on to his back. He reported immediate lumbar back pain but was able to mobilize after the injury.
In the lateral lumbar radiograph (Figure 1), there are fractures of the superior and inferior endplates of the L4 vertebral body with loss of height of the anterior vertebral body of approximately 40%. Part of the anterior vertebra is displaced and angled anteriorly.
In the post-contrast CT coronal images (Figure 2), there are bilateral well-defined low-density lesions within the anterior aspect of both psoas muscles at the L4/L5 level. Both contain high densities in the superior aspects compatible with acute blood. The bleeding seems to be from the segmental arteries arising from the aorta. The left measured 1.5 cm (AP) x 2 cm (W) x 6 cm (CC) and on the right 2.3 cm (AP) x 2.3 cm (W) x 4 cm (CC).
In the T2 weighted MRI lumbar spine axial images (figure 3), bilateral high signal well-defined lesions corresponding with haematomas and the low-density lesions seen on the CT.
Spinal fractures are important trauma-related pathologies that should not be missed in A&E due to the significant impact on daily living activity, leading to significant primary and secondary socioeconomic cost burden [1]. At the initial injury, he did not report any leg weakness, paresthesia or incontinence and, hence, was treated conservatively without imaging. However, days later, he reported worsening focalized pain, mainly in the lumbar area, and right anterior thigh pain, despite taking regular analgesia with associated paresthesia on the posterior aspect of both thighs, knees and lower legs. He had no past medical history and was not on any medication. He attended his local A&E and was discharged with general back pain advice and physiotherapy referral. Due to ongoing pain, he went to see his GP, who, on examination, demonstrated only L4 region tenderness on palpation with normal power, reflex, sensation in both lower limbs with down going plantars and normal anal tone. He was then re-referred to A&E for imaging.
An initial lumbar radiograph demonstrated an acute displaced fracture of the L4 vertebral body (Figure 1). Considering this, a trauma CT was obtained and demonstrated indeterminate bilateral psoas hypodensities adjacent to the burst fracture (Figure 2). His blood tests were unremarkable. He was then placed in a lumbar brace and transferred to the trauma centre for further management. Following this, an MRI was performed for further characterization, which demonstrated focal high T2 signal in both psoas muscles in keeping with hematomas and confirmed a burst L4 fracture with retropulsion of bony fragments into the central canal but no spinal cord injury (Figure 3). Given he had no acute neurology and after neurosurgical discussion, he was given the option of conservative or operative (spinal fixation) treatment.
Psoas hematomas are rare occurrences occurring up to 0.1-0.6% with risk factors including being on anticoagulants, old age and undergoing hemodialysis [2] and can pose a mortality rate of up to 30 % [3]. The psoas muscle is covered by multiple layers of fascia reinforcing its strength, thus with any insult causing intramuscular bleeding will lead to the expansion of the psoas muscle, increase in intra-compartmental pressure and nearby nerve effacement, which may cause pain [4].
In the literature, exclusively unilateral psoas haematomas are reported. For example, patients on anticoagulants or with a history of liver cirrhosis developing a unilateral psoas haematoma due to vertebral compression fracture [5,6]. Consequently, cross-sectional imaging is essential in diagnosing psoas haematoma early on in trauma. Treatment of traumatic psoas haematomas, depending on severity, include conservative management, surgical intervention or percutaneous intervention, specifically transcatheter arterial embolization.
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Psoas muscle haematomas
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In the anteroposterior and lateral X-ray of the lumbar spine (Figure 1) for this case, a distinct fracture line is observed in the L4 vertebral body, with fragments partially protruding posteriorly into the spinal canal, consistent with the imaging characteristics of an acute burst fracture. Subsequent CT scans (Figure 2) further confirm the posterior fragments of the L4 vertebral body intruding into the spinal canal, along with bilateral low-density areas in the psoas muscles, which have relatively clear but irregular boundaries and suggest possible hematomas or fluid accumulations. MRI (Figure 3) shows markedly high signals in the bilateral psoas muscles on T2-weighted images, consistent with hematoma, and bony fragments within the spinal canal are visible without obvious spinal cord compression or injury.
Based on the history of trauma and imaging findings (loss of vertebral height, posterior fragments protruding into the spinal canal, and acute fracture signs), a burst fracture is the primary consideration. This type of fracture often results from an impact causing multiple disruptions of the vertebral structure.
Both CT and MRI reveal hyperintense/low-density areas in the bilateral psoas muscles, consistent with hemorrhage after trauma. While such hematomas are often seen in elderly patients or those on anticoagulants, in this case, the trauma-induced vertebral fracture and associated soft-tissue contusion indirectly led to bleeding.
Differential considerations include paravertebral abscesses or tumor infiltration; however, the trauma history and imaging findings support a traumatic hematoma.
Combining the patient’s age, mechanism of injury (fall leading to a high-impact force), imaging findings (L4 vertebral burst fracture, bilateral psoas hematomas), and the clinical course (only mild sensory abnormalities, no significant nerve deficit), the final diagnoses are:
Currently, there is no clear sign of severe spinal cord or nerve root compression, but close assessment of potential nerve compression and changes in the hematoma is necessary.
Suitable for cases without obvious neurological deficits, where the vertebral body is relatively stable, or if the patient declines surgery. This includes bed rest, the use of orthotic supports (such as a lumbar brace), and periodic imaging follow-up to observe fracture healing and hematoma resolution. Pain medications may be used as needed.
If the vertebral burst is severe, with posterior bony fragments significantly compressing the spinal canal, posing a risk of neurological compromise or leading to spinal instability, surgical intervention (posterior fixation or anterior decompression and fusion) may be considered. In cases of large psoas hematomas causing significant symptoms, interventional embolization or surgical drainage may be performed, depending on the extent of bleeding and clinical presentation.
Given the patient’s advanced age and acute traumatic fracture, both bone quality and cardiopulmonary status must be considered. In the early phase (first 1–2 weeks post-injury), conservative management with bracing is recommended. A phased rehabilitation plan is advised:
– Strict bed rest or limited activity to avoid lumbar loading
– Passive lower-limb exercises under brace protection, such as ankle pumps and isometric quadriceps strengthening, to maintain lower-limb muscle tone
– Frequency: 3–4 times per day, 5–10 minutes each session
– Intensity: Should not provoke significant pain or fatigue
– Gradual standing and short-distance walking with support (e.g., walker) while wearing a brace
– Active flexion and extension exercises of the lower limbs, along with core stability training (e.g., bridge exercises under professional guidance to avoid reinjury)
– Frequency: 3–5 times per week, 15–20 minutes each session
– Intensity: Low to moderate, avoiding excessive lumbar flexion or twisting
– Carefully increase weight-bearing activities (e.g., partial squats with wall support, standing balance exercises)
– Gradually strengthen core and paraspinal muscles (e.g., mini squats against a wall, resistance band exercises, etc.)
– Frequency: 3–5 times per week, 20–30 minutes per session
– Intensity: Progressively advance to moderate intensity, closely monitoring for exacerbation of pain or neurological symptoms
Throughout rehabilitation, regular follow-up imaging and clinical assessment are essential. If there is any significant neurological change or worsening pain, immediate reassessment is advised. For patients with osteoporosis or limited cardiopulmonary function, stricter limitations and close monitoring of exercise intensity and modalities are required.
This report is a reference analysis based on imaging and the patient’s account of symptoms. It does not replace a face-to-face consultation or a comprehensive assessment by a professional physician. Clinical decisions should be made by integrating the patient’s actual condition, laboratory data, and other ancillary tests, with close follow-up and appropriate adjustments in treatment. Specific treatment plans should be determined by a multidisciplinary team, including orthopedics, neurosurgery, and rehabilitation specialists.
Psoas muscle haematomas
