The Iliopsoas compartment: A pictorial review of anatomy and common pathologies

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1 The Iliopsoas compartment: A pictorial review of anatomy and common pathologies Poster No.: C-456 Congress: ECR 2009 Type: Educational Exhibit Topic: Abdominal and Gastrointestinal Authors: M. Kaduthodil, H. Ganesh, S. Rajaram, R. Vijay; Sheffield/UK Keywords: Iliopsoas DOI: /ecr2009/C-456 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 30

2 Learning objectives The iliopsoas compartment is an important anatomical landmark in the abdomen and can be the site of a variety of pathological processes. Here we review the anatomy and the spectrum of pathologies affecting the iliopsoas compartment with emphasis on cross sectional imaging. Background The iliopsoas compartment is an important anatomical landmark in the abdomen and can be the site of a variety of pathological processes. Patients with psoas disease present with a variety of symptoms that are often non-specific, resulting in delayed diagnosis. A detailed knowledge of the anatomy and imaging appearances can help increase diagnostic accuracy, and CT in particular is useful not only in delineating pathology but also can help in image guided intervention. We review the detailed cross sectional anatomy and the common disease processes affecting the iliopsoas compartment using cross-sectional images. Imaging findings OR Procedure details The iliopsoas compartment is an extraperitoneal space containing the psoas major, psoas minor and iliacus muscles and covered by the iliopsoas fascia. The psoas major muscle arises from the anterior surfaces of the lower borders of the transverse processes and vertebral bodies of T12 - L5 and inserts into the lesser trochanter. The psoas minor muscle if present lies in front of the psoas maor, arising from the sides of the T12 and L1 vertebral bodies and inserts into the pectineal line and iliopectineal eminence, its lateral border merging into the iliac fascia. The iliacus muscle arises from the upper 2/3rds of the iliac fossa and inserts into the lateral aspect of the psoas major tendon and the anteroinferior aspect of the lesser trochanter. ( 1,2) Page 2 of 30

3 The fascia covering the iliopsoas muscle is continuous with the transversalis fascia which forms the posterior border of the retroperitoneum making the iliopsoas not a true part of retroperitoneum although its included in the discussions due to its close relationships. Superiorly the fascia is continuous with the endothoracic fascia and inferiorly with the fascia lata of the thigh enabling the spread of infections from thoracic cavity and vice versa. Page 3 of 30

4 Fig.: psoas muscle on plain film Page 4 of 30

5 Fig.: psoas orginating from T12 - L1 vertebra Page 5 of 30

6 Fig.: psoas muscle belly Page 6 of 30

7 Fig.: iliacus & psoas Page 7 of 30

8 Fig.: psoas insertion into lesser trochanter Common pathologies Lesions in the iliopsoas compartment are usually due to inflammatory causes, haemorrhage or tumour. Infection Historically, paraspinal spread of tuberculous spondylitis was the commonest cause of psoas abscess [2].Nowadays psoas infection is mostly pyogenic in orgin. Almost all are secondary, resulting from direct spread of infection from contiguous vertebra, kidneys, Page 8 of 30

9 aorta, bowel or pancreas. Primary pyogenic abcess are extremely rare and are usually idiopathic. A psoas abscess usually manifests as a hypodense near fluid density lesion causing enlargement of the psoas muscle. Rim enhancement of varying thickness is seen after intravenous contrast. Secondary findings include inflammatory obliteration of surrounding tissue planes, gas bubbles, and bone destruction can also be seen. Low attenuation is said to be a common feature of abscesses especially compared to tumour and haematoma [3]. Fig.: fig 7 Page 9 of 30

10 Fig.: fig 8 Page 10 of 30

11 Fig.: fig 9 Page 11 of 30

12 Fig.: fig 10 Axial CT showing an abnormal right psoas muscle in a lady who presented with back pain [fig 7]. Sagittal bony reconstruction showed vertebral end plate irregularies at T3T4 level [fig 8]. MRI showed a high lesion in keeping with discitis at this level with a paraspinal abcess extending into the right psoas [fig 9 & 10]. A CT guided biopsy grew staphylococcus aureus. Page 12 of 30

13 Fig.: fig 11 Page 13 of 30

14 Fig.: fig 12 Page 14 of 30

15 Fig.: fig 13 A left iliopsoas abscess [fig11]. arising from an obstructed, infected left renal system due to a proximal ureteric stone [fig12]. This patient also had evidence of diverticulitis [fig 13] which made it it difficult to pin down the cause. Culture of fluid from ultrasound guided aspiration grew escherichia coli. Page 15 of 30

16 Fig.: fig 14 Page 16 of 30

17 Fig.: fig 15 This patient presented with vague abdominal pain. He had a past history of pancreatitis two months back. CT showed a psoas collection with an associated pancreatic phlegmon. [fig 14,15] Tuberculosis is an emerging disease again especially in the immunocompromised and could become a more common cause in the future [4]. Excessive rim thickening or calcification and minimal new bone formation are features which are more in keeping with tuberculus rather than pyogenic orgin for the abscess. Page 17 of 30

18 Fig.: fig yr old asian lady came with a 4 month history of left sided back pain. She had a history of tuberculosis 2 years ago. CT showed a thick walled left psoas abcess. Fig [16,17]. MRI of lumbar spine did not reveal any paraspinal or bony involvement. A CT guided biopsy was performed. Culture of the fluid grew tuberculus bacilli. Haemorrhage Haemorrhage could be spontaneous or more commonly secondary to anticoagulation, trauma, tumour, recent surgery or bleeding diasthesis, Page 18 of 30

19 The CT appearances vary depending on the age of the haematoma. Recent haemorrhage will appear as a high attenuation mass. A fluid-fluid level may be seen. Chronic haematoma may be seen as a hypodense lesion and can be confused with an abscess [5]. Diagnosis can be difficult and if the patient symptoms are non specific, in some cases aspiration or biopsy may be necessary to differentiate them. Fig.: fig 18 Page 19 of 30

20 Fig.: fig 19 Page 20 of 30

21 Fig.: fig 20 Fig: 18,19, year old man presented with left sided back pain. He was tachycardic and the initial clinical diagnosis was a possible leaking abdominal aortic aneurysm. Unenhanced scan (fig 18) shows an enlarged left psoas muscle and an associated high density. Arterial (fig 19) and delayed (fig 20) shows increasing high density in keeping with active bleeding. This patient was on warfarin for atrial fibrillation. INR was found to be 8.3. Page 21 of 30

22 Fig.: fig 21 Fluid -fluid level is seen in a patient with retroperitoneal haematoma (fig 21). This is due to haematocrit effect. Page 22 of 30

23 Fig.: fig 22 Fig 22: Unenhanced axial CT image shows a leaking abdominal aortic aneurysm Tumour Tumor involvement of the iliopsoas muscle is most often secondary to direct extension of an adjacent tumor. These include abdominal, pelvic or neurogenic tumors, invasion from adjacent lymph nodes and local tumor recurrence. The most reliable CT feature for the diagnosisof iliopsoas malignancy is irregular margins with solid components within it although this can be seen in hemorrhage and abscesses but with less frequency [6]. Page 23 of 30

24 Fig.: fig 23 Page 24 of 30

25 Fig.: fig year old patient with 6 month history of right sided back pain. Fig 23 shows multiple enhancing lesions in the right psoas muscle. The caecum is abnormally thickened, raising the suspicion of a caecal malignancy with metastasis. A colonocscopy and biopsy confirmed this. Page 25 of 30

26 Fig.: fig 25 Page 26 of 30

27 Fig.: fig 26 Patient with a history of melanoma has a surveillance scan which shows high density lesions with minimal enhancement in the left psoas and bladder (fig 25,26). Initially it was thought to be melanoma metastasis, but biopsy proved it to be bladder cancer with metastasis to left psoas. Benign tumours that can involve the iliopsoas include haemangiomas and neurofibromas, but such involvement is very rare. Page 27 of 30

28 Fig.: fig 26 Page 28 of 30

29 Fig.: fig year old man who presented with right sided abdominal pain. Initial ultrasound examination did not show any obvious abnormalities. CT showed the above diffuse lesion in the mesenteric fat (fig 26,27). CT guided biopsy was performed and the results gave a diagnosis of liposarcoma. Conclusion Page 29 of 30

30 The iliopsoas compartment is an important anatomical landmark which can act as a pathway for the spread of diseases to remote areas. A combination of detailed knowledge of anatomy and pathologies and the advanced imaging techniques that are available now will be able to clearly define disease processes affecting the iliopsoas compartment. Personal Information References 1. Pollster JM, Elgabaly M, Lee H, Klika A, Drake R, Barsoum W. Sleletal Radiology 2008 Jan;37(1): Gray's Anatomy. 3.Donovan JP, Zerhouni EA, Siegelman SS. CT of the psoas compartment of the retroperitoneum. Seminal Roentgenology 1981: 16: Rawdha T, Leila S, Hadj Yahia Chiraz B, Leila A, Lilia C, Rafik Z. Internal Medicine. 2008;47(10): ,, Bilateral iliopsoas hematomas complicating anticoagulant therapy. : 2005 Jun;44(6): CT of the iliopsoas compartment: value in differentiating tumor, abscess, and hematoma Jan;162(1): ,,,. Page 30 of 30

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