Muscle biopsy adverse advents are infrequent and unpredictable (10). While utmost care is taken to avoid major vessels and nerves of the lower limb, it is difficult to avoid smaller vessels or nerves. In the event a smaller vessel or nerve is hit, there are negative consequences for the participant. Unfortunately, to date, there is limited information about 1) the recovery period following muscle biopsy adverse events and 2) possible methods to minimize risk of percutaneous muscle biopsy adverse events. To help shed some light on one of the possible muscle biopsy adverse events, we have followed the time course of recovery for an individual living with a percutaneous muscle biopsy induced hemorrhage/hematoma.
Pain. The discomfort associated with the muscle biopsy induced hemorrhage/hematoma appears to have been most severe for the participant while the heterogeneous mass was pulsatile (Table 1). During the pulsatile period (Day 0–8), pain was described most as throbbing, aching and tender with periods of sharp and shooting pain (see Table 1). Following the pulsatile period (non-pulsatile period = Day 9+) pain dropped dramatically (Fig. 3) and was described primarily as throbbing, aching and tender. Sharp and shooting pain was absent during the non-pulsatile period (Table 1).
Physical activity. During the pulsatile phase, any physical activity requiring the lower limb was severely limited. The participant was limited to walking on flat surfaces. Despite the reduced pain during the non-pulsatile period, physical activity remained challenging for 20 days post-cessation of the pulsatile flow. It is likely that the hematoma led to increased intramuscular pressure, making leg flexion more difficult and uncomfortable.
No chronic consequences. 28 days after the muscle biopsy induced hemorrhage/hematoma the participant was back to his normal routine. A one year follow up was conducted where the participant reported no noticeable limitations and the hematoma was no longer noticeable via ultrasonography. Therefore, there appears to be no chronic consequences to a muscle biopsy-induced hemorrhage/hematoma.
Muscle biopsy adverse event risk mitigation. Although the prevalence of the muscle biopsy-induced hemorrhage/hematoma is low (10), it can be debilitating and therefore adverse event risk mitigation is warranted. To help mitigate biopsy-mediated adverse events, ultrasound guided biopsy needle insertion is commonly used (14, 15). With direct visualization of the target muscle during the biopsy procedure, the risk of adverse events should be minimized (14, 15). We therefore advise that, when feasible, ultrasound should be used to identify areas of muscle with minimal risk for arterial bleeding. Unfortunately for many, the ultrasound guided technique may not be feasible. When ultrasound guidance is not feasible (and even when it is), we recommend that compression of the biopsy site be completed for up to 15 minutes (16) immediately post biopsy needle removal – minimizing bleeding and hematoma development. Participants should be closely monitored for up to 72 hours, paying close attention for swelling, increased pain, extension of tenderness from the biopsy site and prolonged restricted range of motion (17). These symptoms would indicate the development of a hematoma, and therefore exercise and physical activity should be discouraged until the participant can move their limb while respecting their pain (17). Additionally, while the mass is pulsatile, compression should be applied immediately to minimize the size of the developed hematoma (16).
Conclusion And Key Clinical Messages
Although the micro-biopsy technique makes smaller cuts in the muscle compared to the Bergstrom technique, there remains a risk of unintentional damage to neighboring vessels or nerves. The present case report demonstrates that the inadvertent hemorrhaging of a neighboring vessel can be debilitating. The recovery of the hemorrhaged vessel can be rapid, though the recovery from the remaining intramuscular hematoma can take much longer. Although chronic consequences do not appear to be evident, the acute consequences were severe for this individual and therefore risk minimization for future participants is warranted. When feasible, to minimize the risk of muscle biopsy-induced hemorrhage/hematoma, we advise ultrasound to identify a biopsy location with minimal risk for arterial bleeding. When ultrasound guided biopsy needle insertion is not feasible, post biopsy compression is recommended for up to 15 minutes and careful post-biopsy follow-up should be completed for up to 72 hours – paying close attention for swelling, increased pain, extension of tenderness from the biopsy site and prolonged restricted range of motion (17). When any of these symptoms are evident, the participant should avoid exercise and physical activity and compression should be applied while the mass is pulsatile – minimizing the size of the developed hematoma.