Retroperitoneal Hemorrhage Masquerades as Exacerbation of Chronic Spinal Stenosis: A Case Report

Case Diagnosis: A 93-year-old female with spinal stenosis presented with acute progression of lower extremity weakness and was found to have a retroperitoneal hemorrhage.

Case Description or Program Description: She presented with acute onset left leg weakness and pain. Her initial exam revealed decreased strength in left hip flexion, knee flexion, and knee extension, with reduced sensation in the L3-S1 dermatome and reduced reflexes. Previous neurological exams documented 5/5 strength without sensory changes. A lumbar spine MRI demonstrated severe tricompartmental stenosis at L3-4 with grade 1-2 spondylolisthesis causing mass effect and neural foraminal stenosis. Steroid treatment improved her pain and weakness over two days while she awaited placement at a skilled nursing facility (SNF). During this time, a slow but steady hemoglobin drop was observed. On hospital day 4, she developed hypotension and altered mental status due to a large left retroperitoneal hemorrhage near the left psoas muscle.

Setting: Acute care hospital while the patient was pending placement at a SNF.

Assessment/Results: The patient underwent embolization of the left iliolumbar artery with gel foam. Her condition improved with transfusions, steroid taper, and PT. Retrospective analysis of admission imaging could not evaluate the bleeding site appropriately, but the clinical presentation and timing cannot be ignored.

Discussion (relevance): This case describes a unique presentation of a retroperitoneal hemorrhage that has not been previously described in existing literature. It reinforces the notion that continuous, unbiased examination of a patient’s presentation is imperative for proper evaluation and treatment. Utilizing such methods may prevent anchoring bias, encourage the consideration of other possible pathologies, and create an environment where the highest quality care can be provided to all patients.

Conclusions: This large left retroperitoneal hemorrhage likely contributed to the patient's initial focal radicular symptoms. A delay in diagnosis could be attributed to anchoring bias and a unique presentation of an uncommon problem.