An Unusual Case of Hip Pain in a Postacute Care Setting

Pain is a frequent barrier to recovery in postacute care settings.^1,2 It can be related to multiple conditions, including postoperative status, osteoarthritis, neuropathy, visceral pathology, skin and mucosal lesions, fractures, and acute arthritis.³ Pain can delay progress in rehabilitation, prolong length of stay, increase health care costs, and contribute to falls, depression, anxiety, sleep problems, diminished appetite, and poor quality of life.^1,4,5 

A comprehensive evaluation of a patient’s report   of pain is essential for proper management. This evaluation requires a thorough history, physical examination, assessment of the pain characteristics, and determination if the pain results from an exacerbation of a chronic condition or secondary to a new problem. It is also important to recognize that older patients in postacute care settings can report multiple issues of pain, and acute pain may occasionally present atypically. 

The case report describes an unusual case of hip pain secondary to retroperitoneal bleeding in an older patient undergoing postacute rehabilitation for spinal surgery. Retroperitoneal hematomas can be challenging to detect due to an often nonspecific symptom presentation. Clinicians providing postacute care following spinal surgeries must be familiar with this potential complication. 

A 73-year-old man with left hip osteoarthritis, severe kyphoscoliosis, and thoracolumbar stenosis underwent a scheduled L4-L5 and L5-S1 fusion and a T6-pelvis decompression at an outside hospital. Surgery was complicated by blood loss requiring transfusions and vasopressors, atrial fibrillation, and a non-ST segment myocardial infarction that required an intensive care unit admission. Approximately 2 weeks following surgery, he was transferred to our facility for rehabilitation, where he was initially able to tolerate physical and occupational therapies. In the days following, the patient developed severe left hip pain that inhibited his ability to participate in therapies. The location of his pain soon expanded to involve his left gluteal region, left lower back, and anterior thigh. He became unable to move his left lower extremity without eliciting severe pain. Plain radiographs of the hip demonstrated mild bilateral hip joint degenerative changes but no acute findings. The palliative medicine service was consulted at this time to assist with uncontrolled pain. Due to worsening hip pain and persistent postoperative anemia, a computed tomography (CT) abdomen scan was performed, which demonstrated a left-sided retroperitoneal hematoma spanning the L1-S2 levels with intramuscular components expanding the left iliopsoas musculature. The hematoma grossly measured 17 x 12 x 9 cm. At that time, both the neurosurgery and cardiology services were consulted. The neurosurgery service recommended against evacuation of the hematoma due to a lack of neurological deficits. The cardiology service recommended that anticoagulation be held for 1 to 2 weeks in the acute setting of a retroperitoneal bleed. One week later, a repeat CT abdomen scan revealed a decrease in the size of the hematoma. Hemoglobin levels continued to improve during this period. The pain was adequately managed with a combination of sustained-release and short-acting morphine. During subsequent clinic follow-ups with the orthopedic surgery service, the patient demonstrated continued resolution of the hematoma formation and hip pain months following his rehabilitation admission. The patient did not experience any additional medical complications related to surgery following his discharge home.

This case highlights the unusual presentation of acute hip pain secondary to a large retroperitoneal hematoma following spinal fusion surgery. Although there are cases in the literature that link retroperitoneal hematomas with back pain, femoral neuropathy, and intra-abdominal compartment syndrome, only a few cases have documented hip pain as a symptom of a retroperitoneal hematoma following spinal fusion.⁶ 

Lumbar spinal fusion is one of the most commonly performed surgical procedures in the US.⁷ Between 2004 and 2015, the number of elective lumbar spinal fusions in the US increased by 62.3%, with 199 140 cases performed in 2015.⁸ In 2022, over 1.1 million spinal procedures were performed in the US, with 73% comprising lumbar and cervical fusions.⁹  The increase in lumbar fusions has been attributed to an aging population, increasing prevalence of degenerative spinal disorders, and advancements in operative techniques, research, and diagnostics.^7,10  

The surgical management of lumbar spinal disorders in adults carries significant risks of perioperative complications. Several factors associated with an increased risk of complications in adults undergoing spinal surgery include age, obesity, diabetes, poor nutritional status, tobacco use, complete neurologic deficits, revision surgery, use of nonsteroidal anti-inflammatory drugs, posterior surgical approach, increased estimated blood loss, need for blood transfusions, prolonged surgical time, multilevel surgery, and fusion extending to the sacrum.^11,12 Compared with other lumbar spinal surgeries, such as discectomies and laminectomies, fusions involve greater complexity and so are associated with greater complication rates due to prolonged operative times and increased risk of intraoperative blood loss. Potential complications of spinal fusion include infection, bleeding, poor wound healing, pulmonary embolisms, injury to blood vessels or nerves located in or around the spine, and pain at the site of surgery.¹³

The presentation of retroperitoneal hematoma varies and can be vague. As a result, diagnosis can be delayed, especially if clinicians are unaware of this condition. Patients presenting with uncontrolled bleeding in the retroperitoneum may exhibit subtle clinical signs of hemorrhage. Initial presentation may include lower abdominal, back, or groin discomfort and swelling. This may lead to hemodynamic instability, collapse, and a fall in hemoglobin levels, depending on the severity of the bleeding. Hematomas near or within the iliopsoas muscle can clinically present as femoral neuropathy, including symptoms of groin pain or leg weakness.¹⁴ Severe pain in the affected groin and hip, with subsequent radiation to the anterior thigh and lumbar region, may represent femoral neuropathy caused by a retroperitoneal hematoma. Clinical presentation of iliopsoas muscle spasms may present earlier, followed by the development of paresthesia in the anteromedial thigh as time progresses.⁶

Retroperitoneal hematomas can be defined as bleeding into the retroperitoneal space. The richly vascularized retroperitoneal space is located posterior to the peritoneal cavity. The retroperitoneum can be classified into three distinct zones: The first zone contains the centro-medial retroperitoneum; the second zone includes the lateral perinephric areas; and the third zone consists of the pelvic retroperitoneum.¹⁵ These anatomical classifications describe the location and help guide the treatment of retroperitoneal hematomas. In one institutional study, zone three was the most common location of retroperitoneal hematomas. Notably, most patients with zone three retroperitoneal hematomas were successfully managed with conservative treatment alone.¹⁶

Retroperitoneal hematomas can occur due to iatrogenic, traumatic, or spontaneous causes. Numerous risk factors may cause this bleeding to develop, including anticoagulation use, coagulation disorders, malignancy, invasive procedures, and strenuous activity.¹⁷ These hematomas are typically the result of blood loss due to injury of the vasculature and parenchymal tissue located within the retroperitoneal cavity.^18,19  Retroperitoneal hematomas are well recognized but relatively rare, with an estimated incidence of 0.1% up to 0.6%, with a higher incidence noted for those receiving anticoagulant therapy.²⁰

Imaging is often essential in detecting retroperitoneal bleeds, with CT and magnetic resonance imaging (MRI) being the most common modalities. CT is sensitive, rapidly attainable,^₂₁ and allows bleeding to be seen as extravasation of contrast material.²² MRI is also a highly sensitive and particularly beneficial for patients presenting with femoral neuropathy due to a retroperitoneal bleed. Unlike other imaging modalities, MRI can assist in ruling out nerve root compression.⁶

Management of retroperitoneal hematomas can range from observation, cessation of anticoagulation therapy, transfusion, interventional intra-arterial embolization, and open surgery.²³ Management is often determined based on the mechanism of the bleeding, organ injury severity, and hemodynamic stability. Conservative management is generally recommended for patients who are hemodynamically stable and have no evidence of active bleeding. Conservative management includes withdrawal of anticoagulant therapy, coagulopathy correction, volume resuscitation with intravenous fluids, and supportive measures. Most patients with iatrogenic or spontaneous retroperitoneal hematomas can be carefully monitored and conservatively managed without requiring additional intervention.¹⁴ If a CT study demonstrates active contrast extravasation, endovascular interventions are indicated, including angiography with embolization or stent graft of the bleeding vessels. Indications for embolization are based on the patient's hemodynamic stability and the severity of blood loss.²⁴ For selected cases, such as patients with abdominal compartment syndrome, open surgery may be considered.²⁵

Retroperitoneal hematomas can be challenging to detect on physical examination due to their often vague symptom presentation. Early detection is crucial to minimize the risk of developing severe and potentially life-threatening complications. In this case, the patient’s history of chronic hip pain secondary to osteoarthritis may have lowered clinical suspicion of potentially serious complications and risked delaying treatment. As therapeutic indications for anticoagulation therapy increase—particularly among older adults—and the frequency of lumbar fusions continues to rise, clinicians are likely to encounter retroperitoneal hematomas more often.⁶ Conservative management, including frequent fluids, cessation of anticoagulation, and close monitoring, led to a successful outcome in this case.

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