Psoas abscess

Editor's Notes

1. Iliopsoas abscess is a collection of pus in the iliopsoas compartment.
2. Lies close to sigmoid colon, appendix, kidney, ureters, LS spine, abdominal arota, iliac lymph nodes. • Psoas fascia covers the muscle Iliacus and the psoas muscle insert with a common tendon into the lesser trochanter of the femur. The psoas muscle arises from the transverse processes and the lateral aspects of the vertebral bodies T12-L5. courses downward across the pelvic brim, passes deep to the inguinal ligament and anterior to the hip joint capsule to form a tendon that inserts into the lesser trochanter of the femur. The iliacus muscle joins the psoas to insert via the same tendon. They are located in an extraperitoneal space called the iliopsoas compartment.
3. Iliacus arises from the superior portion of the iliac fossa and again enters the thigh under the inguinal ligament. It inserts again into the lesser trochanter of the femur via the iliopsoas tendon at the iliopubic eminence and secondly into a small area of the femoral shaft below the lesser trochanter. The surface of the muscle is invested in the strong psoas fascia. This fascia runs from the lumbar vertebrae to the iliopubic eminence. It is behind this dense fascia that an iliopsoas abscess forms.
4. primary psoas abscess is due to lymphatic or hematogenous spread from a distant site  Psoas abscess has been reported as a complication of epidural anesthesia.
5. Secondary IPA is due to contiguous extension, more than 90% of the IPA in Asia and Africa are primary in origin It may be difficult to distinguish between primary and secondary abscesses in some circumstances More common than primary (western)
6.  A cold abscess tends to become diffused into adjacent tissues owing to the pressure of the pus, and to form a wandering abscess. Cold abscess is almost synonymous with tuberculous abscess, but there are other causes, in particular deep mycotic (fungal) infections.
7. mortality rate in primary iliopsoas abscess is 2.4% and in secondary abscesses is 19%.13 Ricci et al suggested that the mortality rate in untreated patients is 100% Mortality is low with early diagnosis and appropriate treatment.
8. The presenting symptoms may be nonspecific, and the onset is often subacute; symptoms may be present for a few weeks and up to six month. However, patients may also present with septic shock with only nonspecific clinical features. Symptoms may have features suggesting other diagnoses such as septic hip arthritis or gastrointestinal or renal tract pathology, leading to delayed diagnosis [. In one study, the median time between the onset of symptoms and diagnosis was 22 days; the interval was >42 days for one-third of patients [6]. patients applying with subacute hip pain and walking abnormality are rather rarely observed by physicians engaged in musculoskeletal system supine position with the knee moderately flexed and the hip mildly externally rotated.
9. Tests to elicit iliopsoas inflammation The examiner places his hand just proximal to the patient’s ipsilateral knee and the patient is asked to lift his thigh against the examiner’s hand. This will cause contraction of the psoas and results in pain. With the patient lying on the normal side, hyperextension of the affected hip results in pain as the psoas muscle is stretched.
10. USG – operator dependant; gas shadows obscure retoperitoneum Although CT is the modality of choice when a psoas abscess is suspected clinically, a psoas abscess may also be visualized on nuclear imaging used to identify occult foci of infection
11. Since delayed diagnosis may cause increased morbidity and mortality, time should not be lost with unnecessary examinations.
12. Infections (septic arthritis of hip, necrotizing fasciitis of psoas muscle, pyelonephritis, pelvic inflammatory disease, appendicitis, osteomyelitis, and epidural abscesses), vascular pathologies (femur avascular necrosis, aneurysms), retroperitoneal malignancies, inflammatory bowel diseases, urolithiasis, and discopathies should be suggestive in differential diagnosis of the disease
13.  In patients suspected to have primary iliopsoas abscess, antistaphylococcal antibiotics should be started before the culture results.9 In secondary iliopsoas abscess it is wise to start patients on broad spectrum antibiotics like clindamycin, antistaphylococcal penicillin, and an aminoglycoside
14. Following needle aspiration, a pigtail catheter may be placed in situ to allow further drainage.
15. The indications of operation are (a) failure of PCD, (b) relative contraindication of PCD, for example, clotting disorders, and (c) the presence of an another intra-abdominal pathology which requires surgery. In patients with Crohn’s disease, performing a single operation to drain the abscess and resect the diseased bowel is desirable
16. his method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1-L5. The transverse processes, pars interarticularis and lamina of L1-L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle.
17. mortality rate in primary iliopsoas abscess is 2.4% and in secondary abscesses is 19%.13 Ricci et al suggested that the mortality rate in untreated patients is 100% Mortality is low with early diagnosis and appropriate treatment.
18.  A high index of clinical suspicion, the past and recent history of the patient, and imaging studies can be helpful in diagnosing the disease Delay of the treatment is related with high morbidity and mortality rates.