Orthopedics

Case Report 

Successful Treatment of Morel-Lavallée Lesion of the Back With Transcutaneous Transmyofascial Bolstered Progressive Tension Suturing

Daniel B. C. Reid, MD, MPH; Alan H. Daniels, MD; Maahir U. Haque, MD; Mark A. Palumbo, MD

Abstract

The authors describe their experience in successfully treating an isolated Morel-Lavallée lesion of the lumbar spine after delayed presentation. In addition to thorough irrigation, debridement, and pseudo-capsulectomy, surgical management included transcutaneous transmyofascial bolstering with a progressive tension suturing technique to close the cavity over drains in a “quilting” fashion. This was followed by 6 days of incisional wound vacuum treatment and 13 days of drainage through 2 Jackson-Pratt drains. At 6-month follow-up, the patient noted resolution of pain and return to baseline level of functioning. No evidence of recurrence was noted. The Morel-Lavallée lesion of the low back represents a difficult soft tissue injury to treat with substantial risk of complications and recurrence. Diagnosing and treating physicians should be familiar with common injury mechanisms and clinical presentations, as well as a variety of nonoperative and operative treatment options. [Orthopedics. 2019; 42(4):e399–e401.]

Abstract

The authors describe their experience in successfully treating an isolated Morel-Lavallée lesion of the lumbar spine after delayed presentation. In addition to thorough irrigation, debridement, and pseudo-capsulectomy, surgical management included transcutaneous transmyofascial bolstering with a progressive tension suturing technique to close the cavity over drains in a “quilting” fashion. This was followed by 6 days of incisional wound vacuum treatment and 13 days of drainage through 2 Jackson-Pratt drains. At 6-month follow-up, the patient noted resolution of pain and return to baseline level of functioning. No evidence of recurrence was noted. The Morel-Lavallée lesion of the low back represents a difficult soft tissue injury to treat with substantial risk of complications and recurrence. Diagnosing and treating physicians should be familiar with common injury mechanisms and clinical presentations, as well as a variety of nonoperative and operative treatment options. [Orthopedics. 2019; 42(4):e399–e401.]

The Morel-Lavallée (ML) lesion was first described in 1853 as an internal degloving injury.1 It has been further defined as a traumatic separation of the skin and subcutaneous tissue from its underlying fascia, typically caused by a high-energy shearing force.2 Although the lesion is closed, there is a significant disruption of perforating blood vessels and lymphatics, resulting in a substantial “dead-space” that fills with hematoma or seroma. Untreated, this may result in pseudocapsule formation, chronic pain and swelling, skin necrosis, or infection. The ML lesion has been thoroughly described in the setting of pelvic, hip, and thigh injuries, with a reported incidence ranging from 0.7% following motor vehicle collisions to 8.3% in the setting of pelvic trauma.2–7 However, the literature on ML lesions of the lumbar spine is sparse,8–10 making evidence-based clinical decision making difficult. The authors describe their experience successfully treating an isolated ML lesion of the lumbar spine presenting in a delayed fashion.

Case Report

History, Physical Examination, and Radiographs

A healthy 46-year-old man presented to the emergency department with low back pain and ecchymosis after a dirt bike accident. Lumbar spine computed tomography revealed no acute bony or ligamentous injury. After discharge from the emergency department, the patient noted resolution of ecchymosis. However, lumbar swelling and pain progressively worsened until he presented for spine surgical evaluation 3 weeks after injury.

Examination revealed a 15×20-cm mobile lumbosacral soft tissue flap with underlying fluctuance (Figure 1). His pelvic ring was stable, and there was no neurologic dysfunction in the lower extremities. Increased lumbar soft tissue shadow was seen on plain radiographs. Diagnosis of a ML lesion was made without magnetic resonance imaging given clear clinical findings.2 The patient elected to proceed with surgery.

Clinical presentation of patient 3 weeks following injury. A 15×20-cm mobile lumbosacral soft tissue flap with underlying fluctuance is noted.

Figure 1:

Clinical presentation of patient 3 weeks following injury. A 15×20-cm mobile lumbosacral soft tissue flap with underlying fluctuance is noted.

Surgical Procedure

With the patient prone, a 5-cm craniocaudal midline incision through skin and subcutaneous tissue was performed with immediate evacuation of 200 cc of hemolymphatic fluid. A large degloving-type lesion was evident extending in a lateral direction from the dorsal lumbar spine to the level of the bilateral posterior superior iliac spines.

Irrigation and debridement with pulselavage and curettage followed by capsulectomy using electrocautery was performed.10 Two Jackson-Pratt drains were placed through small stab incisions over each flank. A transcutaneous transmyofascial11,12 bolstered progressive tension suturing13 technique with 2-0 nylon was used to close the cavity in a “quilting” fashion.10 Nine such sutures were sequentially tied over red rubber bolsters from lateral to medial (Figure 2).

Immediate postoperative clinical photographs before (A) and after (B) wound vacuum application. Two Jackson-Pratt drains and 9 transcutaneous transmyofascial bolstered tension sutures are noted.

Figure 2:

Immediate postoperative clinical photographs before (A) and after (B) wound vacuum application. Two Jackson-Pratt drains and 9 transcutaneous transmyofascial bolstered tension sutures are noted.

After deep and superficial midline closure, an incisional vacuum dressing was applied and a 24-hour perioperative course of antibiotics was started. Postoperatively, the incisional vacuum dressing was removed on day 6, the drains on day 13, and the sutures on day 20.

Follow-up

No complications were reported. At 6-month follow-up, the patient noted resolution of pain and return to his pre-injury functional status (Figure 3).

Clinical evaluation 6 months postoperatively. No recurrence of the Morel-Lavallée lesion was observed and the patient noted resolution of pain and return to his preinjury functional status.

Figure 3:

Clinical evaluation 6 months postoperatively. No recurrence of the Morel-Lavallée lesion was observed and the patient noted resolution of pain and return to his preinjury functional status.

Discussion

Morel-Lavallée lesions are caused by high-energy tangential shearing forces that disrupt the anatomic plane between the hypodermis and subjacent muscular fascia, as well as perforate blood vessels and lymphatic channels.10 Hemolymphatic fluid fills this new potential space; in chronic cases, a pseudocapsule may form, preventing reabsorption. A rich medium for bacterial growth, this collection of fluid and devitalized tissue may become infected by hematogenous seeding in closed injuries or by direct inoculation in open injuries. Skin flap necrosis may occur secondary to a combination of initial tissue injury, decreased perfusion, or associated inflammatory reaction. Morel-Lavallée lesions are associated with significant morbidity and a guarded prognosis.

Morel-Lavallée lesions of the lumbar spine have been described, often as part of a larger series.4,14 Little current literature focuses specifically on surgical treatment options of this injury pattern. Seo et al10 described a large ML lesion extending from the buttock to the lumbar back that was treated with surgical debridement and dead-space closure. Similarly, Winters et al15 described a small series of isolated ML lesions of the back in the setting of high-speed professional racing collisions. Although the authors concluded that many such injuries were amenable to nonoperative treatment, all of these patients were diagnosed and treated acutely.15

Given the rarity of this problem, there is no clear consensus on treatment for ML lesions of the back, especially in cases of missed or delayed diagnosis. For ML lesions of the pelvis and thigh, it is generally accepted that open lesions, infected lesions, lesions that fail nonoperative treatment, and large lesions should be addressed operatively,2,16 whereas smaller ML injuries are frequently thought amenable to early compression or serial aspirations.2,5 Unfortunately, given the frequent absence of associated bony injury, lumbar ML lesions may be missed in the emergency department setting, resulting in significant diagnostic delay. Such delay in appropriate diagnosis may preclude the use of nonoperative modalities, including compression and aspiration. By the time patients present or are referred to the appropriate specialists, the injury may be encapsulated and chronic.

Conclusion

Although uncommon, the ML lesion of the low back is a clinically distinct entity from similar lesions in the pelvis and lower extremities. Often diagnosed late and without associated bony or ligamentous injuries, it remains a diagnostic and therapeutic challenge for the physician of initial contact. Presumably, earlier diagnosis and treatment may result in earlier return to baseline function and improved long-term patient outcomes. As such, further education of first-line emergency department physicians and primary care physicians may be helpful. In presentations involving blunt trauma to the low back with immediate onset of swelling and pain, the ML lesion should be considered in the differential diagnosis, even in cases without associated bony injury. Advanced imaging including magnetic resonance imaging to detect fluid collections between the fascia and subcutaneous tissue should be considered in equivocal cases. Although further research is needed, the current authors' case provides evidence that with proper management, even in cases of delayed diagnosis, a positive clinical outcome is possible.

References

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Authors

The authors are from the Department of Orthopaedics, Division of Spine Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island.

Dr Reid has no relevant financial relationships to disclose. Dr Daniels is a paid consultant for Stryker, Spineart, and Orthofix and has received a grant from Orthofix. Dr Haque is a paid consultant for Genesys Spine, Spineology, and Spineart; has received travel reimbursement from Genesys Spine, Spineart, and Spineology; receives royalties from Genesys Spine; receives in-kind support from SI Bone; and has received product development fees from Amendia. Dr Palumbo is a paid consultant for Stryker and DePuy and has received product development fees from Globus Medical and Spineart.

Correspondence should be addressed to: Daniel B. C. Reid, MD, MPH, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, 2 Dudley St, Providence, RI 02905 ( daniel_b_reid@brown.edu).

Received: July 17, 2018
Accepted: October 29, 2018

10.3928/01477447-20190624-08

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