Advertisement

The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review

  • R.N. Schlegel
    Correspondence
    Corresponding author at: Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author
  • M. Fitzgerald
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia
    Search for articles by this author
  • G. O'Reilly
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author
  • W. Clements
    Affiliations
    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia

    Department of Surgery, Monash University Central Clinical School, Australia
    Search for articles by this author
  • G.S. Goh
    Affiliations
    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia

    Department of Surgery, Monash University Central Clinical School, Australia
    Search for articles by this author
  • C. Groombridge
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author
  • C. Johnny
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author
  • M. Noonan
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author
  • J. Ban
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author
  • J. Mathew
    Affiliations
    Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia

    National Trauma Research Institute (NTRI), Melbourne, VIC, Australia

    Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
    Search for articles by this author

      Highlights

      • Patients with haemorrhage due to bleeding of the lumbar arteries have a higher rate of lumbar transverse process fractures.
      • Patients with lumbar artery bleeding also have a greater number of massive transfusions, higher injury severity score and shock index.
      • Lumbar transverse process fractures in a shocked patient may predict haemorrhage requiring early, aggressive intervention.
      • Lumbar artery bleeds are best managed in Level-1 or Level-2 trauma facilities equipped with angioembolisation facilities or hybrid theatres.

      Abstract

      Purpose

      Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking.

      Materials and methods

      We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009–2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1–4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes.

      Results

      Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH.

      Conclusion

      This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1–4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kauvar D.S.
        • Lefering R.
        • Wade C.E.
        Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.
        J Trauma. 2006; 60: S3-11
        • Akpinar E.
        • Peynircioglu B.
        • Turkbey B.
        • Cil B.E.
        • Balkanci F.
        Endovascular management of life-threatening retroperitoneal bleeding.
        ANZ J Surg. 2008; 78: 683-687
        • Sofocleous C.T.
        • Hinrichs C.R.
        • Hubbi B.
        • Doddakashi S.
        • Bahramipour P.
        • Schubert J.
        Embolization of isolated lumbar artery injuries in trauma patients.
        Cardiovasc Intervent Radiol. 2005; 28: 730-735
        • Daly K.P.
        • Ho C.P.
        • Persson D.L.
        • Gay S.B.
        Traumatic Retroperitoneal Injuries: review of Multidetector CT Findings.
        Radiographics. 2008; 28: 1571-1590
        • Wang Z.W.
        • Xue H.D.
        • Li X.G.
        • Pan J.
        • Zhang X.B.
        • Jin Z.Y.
        Life-threatening Spontaneous Retroperitoneal Haemorrhage: role of Multidetector CT-angiography for the Emergency Management.
        Chin Med Sci J. 2016; 31: 43-48
        • Hung S.-.C.
        • Chen H.W.
        • Wong Y.C.
        • Wu C.H.
        • Wang L.J.
        • Fang J.F.
        • et al.
        Transcatheter arterial embolization of traumatic lumbar artery injury: experience in one institution.
        Chin J Radiol. 2011; 36: 31-36
        • Chan Y.C.
        • Morales J.P.
        • Reidy J.F.
        • Taylor P.R.
        Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?.
        Int J Clin Pract. 2008; 62: 1604-1613
        • Boufi M.
        • Bordon S.
        • Dona B.
        • Hartung O.
        • Sarran A.
        • Nadeau S.
        • et al.
        Unstable patients with retroperitoneal vascular trauma: an endovascular approach.
        Ann Vasc Surg. 2011; 25: 352-358
        • Kim J.Y.
        • Lee S.A.
        • Hwang J.J.
        • Park J.B.
        • Park S.W.
        • Kim Y.H.
        • et al.
        Spontaneous lumbar artery rupture and massive retroperitoneal hematoma, successfully treated with arteriographic embolization.
        Pak J Med Sci. 2019; 35: 569-574
        • Scemama U.
        • Dabadie A.
        • Varoquaux A.
        • Soussan J.
        • Gaudon C.
        • Louis G.
        • et al.
        Pelvic trauma and vascular emergencies.
        Diagn Interv Imaging. 2015; 96: 717-729
        • Tamburini N.
        • Carriel N.
        • Cavallesco G.
        • Molins L.
        • Galeotti R.
        • Guzmán R.
        • et al.
        Technical results, clinical efficacy and predictors of outcome of intercostal arteries embolization for hemothorax: a two-institutions' experience.
        J Thorac Dis. 2019; 11: 4693-4699
        • Yumoto T.
        • Kosaki Y.
        • Yamakawa Y.
        • Iida A.
        • Yamamoto H.
        • Yamada T.
        • et al.
        Occult Sources of Bleeding in Blunt Trauma : a Narrative Review.
        Acta Med Okayama. 2017; 71: 363-368
        • Sclafani S.J.
        • Florence L.O.
        • Phillips T.F.
        • Scalea T.M.
        • Glanz S.
        • Goldstein A.S.
        • et al.
        Lumbar arterial injury: radiologic diagnosis and management.
        Radiology. 1987; 165: 709-714
        • Homnick A.
        • Lavery R.
        • Nicastro O.
        • Livingston D.H.
        • Hauser C.J.
        Isolated thoracolumbar transverse process fractures: call physical therapy, not spine.
        J Trauma. 2007; 63: 1292-1295
        • Nagasawa D.T.
        • Bui T.T.
        • Lagman C.
        • Lee S.J.
        • Chung L.K.
        • Niu T.
        • et al.
        Isolated Transverse Process Fractures: a Systematic Analysis.
        World Neurosurg. 2017; 100: 336-341
        • Maqungo S.
        • Kimani M.
        • Chhiba D.
        • McCollum G.
        • Roche S.
        The L5 transverse process fracture revisited. Does its presence predict the pelvis fracture instability?.
        Injury. 2015; 46: 1629-1630
        • Shahriari M.
        • Sadaghiani M.S.
        • Spina M.
        • Yousem D.M.
        • Franck B.
        Traumatic lumbar spine fractures: transverse process fractures dominate.
        Clin Imaging. 2021; 71: 44-48
        • Ekici Y.
        • Aydogan C.
        • Yagmurdur M.C.
        • Kirnap M.
        • Harman A.
        • Moray G.
        • et al.
        Treatment approaches for spontaneous retroperitoneal bleeding.
        Int Surg. 2009; 94: 171-175
        • Lopera J.E.
        Embolization in trauma: principles and techniques.
        Semin Intervent Radiol. 2010; 27: 14-28
        • Yuan K.C.
        • Hsu Y.P.
        • Wong Y.C.
        • Fang J.F.
        • Lin B.C.
        • Chen H.W.
        Management of complicated lumbar artery injury after blunt trauma.
        Ann Emerg Med. 2011; 58: 531-535