Postoperative retroperitoneal hematoma following transforaminal percutaneous endoscopic lumbar discectomy

Clinical article

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The purpose of this study was to demonstrate the clinical characteristics of postoperative retroperitoneal hematoma (RPH) following transforaminal percutaneous endoscopic lumbar discectomy (PELD) and to discuss how to prevent the complication of unintended hemorrhage.


The medical records of 412 consecutive patients treated with transforaminal PELD between January 2005 and May 2007 were reviewed. A total of 4 patients (0.97%) experienced symptomatic postoperative RPH. The clinical outcomes were evaluated using the visual analog scale and the Oswestry Disability Index.


The common symptom in all patients with a hematoma was inguinal pain. The mean hematoma volume was 527.9 ml (range 53.3–1274.1 ml). Two patients with massive diffuse-type RPHs compressing the intraabdominal structures required open hematoma evacuation performed by general surgeons, and the other 2 patients with small, localized RPHs of < 100 ml were treated conservatively. The mean follow-up period was 21.3 months (range 13–29 months). The mean visual analog scale score for radicular leg pain improved from 7.6 to 1.8 and that for back pain improved from 4.3 to 2. The mean Oswestry Disability Index improved from 58.8 to 9.1%. The preoperative symptoms improved after the second treatment without significant neurological sequelae in all patients.


Although transforaminal PELD is a minimally invasive and safe procedure, the possibility of RPH should be kept in mind. Adequate technical and anatomical considerations are important to avoid this unusual hemorrhagic complication, especially in the patient with underlying medical problems or previous operative scarring. A high index of suspicion and early detection is also important to avoid the progression of the hematoma.

Abbreviations used in this paper: ICU = intensive care unit; ODI = Oswestry Disability Index; PELD = percutaneous endoscopic lumbar discectomy; RPH = retroperitoneal hematoma; VAS = visual analog score.

Article Information

Address correspondence to: Yong Ahn, M.D., 47-4 Chungdam-Dong Gangnam-Gu, Wooridul Spine Hospital, Seoul, Korea. email:

© AANS, except where prohibited by US copyright law.



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    Case 1. Axial MR image revealing left L4–5 disc herniation (A). Diffuse postoperative RPH can be seen (arrowheads) on T2-weighted axial (B) and sagittal (C) MR imaging.

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    Case 2. Axial MR image revealing right L4–5 recurrent disc herniation (A). Axial T2-weighted (B) and coronal (C) MR imaging of the L4–5 level demonstrating a diffuse postoperative RPH (arrowheads). An extraforaminal bleeding focus (arrow) is prominent.

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    Case 3. Axial MR image revealing left L4–5 disc herniation (A). A hematoma located in the retroperitoneal space and psoas muscle (arrowheads) is prominent on postoperative MR imaging (B).

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    Case 4. Axial MR image revealing a herniated disc at L3–4 and L4–5 underwent transforaminal PELD (A). Localized postoperative RPH (arrowheads) was detected with weakness of hip flexion (B).

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    Schematic diagram depicting the lumbar extraforaminal arterial anatomy during PELD. The segmental lumbar artery (L) gives rise to a number of perforated branches extending to the corpus. It extends the spinal branch (sb) to the intervertebral foramen and moves to the dorsal branch (db). Precise needle placement is mandatory to prevent vascular injury. Approach along the surface of the superior facet is safe (A). Needle placement that is too anterior may injure the terminal branches of the segmental lumbar artery (B).



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