Case report: A rare case of acute lumbar paraspinal compartment syndrome in a military trainee

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Author: Conner Murphy, MSIV, Ivan Yue, MSIV, and Vivek Abraham, MSIV
Uniformed Services University School of Medicine
AAEM/RSA Publications and Social Media
Committee

INTRODUCTION
Acute lumbar paraspinal compartment syndrome is a rare injury, occurring primarily in male patients and often related to overhead weight lifting activities.[1] It has also been reported following skiing, surfing, blunt trauma, and as the result of reperfusion injury following abdominal aortic procedures.[2] The syndrome occurs when the enclosed fibro-osseous space of the lumbar paraspinal compartment increases in pressure beyond perfusion pressure, leading to ischemia, intractable pain and eventually tissue necrosis if left untreated.[1] Patients generally present with intense acute pain after exercise, physical exam revealing swollen and tense lumbar paraspinal muscles, and laboratory abnormalities including high creatine kinase levels and myoglobinuria, often appearing like or in conjunction with rhabdomyolysis.[2] Muscle tissue may remain viable for up to four hours without irreversible damage, while eight hours of ischemia has been known to cause irreversible necrosis.[3] Early recognition and orthopedic consultation for surgical management decreases prolonged suffering and neurovascular compromise, allowing resolution of rhabdomyolysis and pain, as well as return to baseline athletic activity.[4] In this case report, we present a case of acute lumbar compartment syndrome in a young athletic male in the context of intense military training.



CASE PRESENTATION
A 26-year-old athletic male in active duty military special operations training presented to a military unit’s walk-in clinic for twenty-four hours of progressively worsening severe left-sided low back pain and paresthesia with radiation into the left buttock and thigh. Onset of pain was initially described as mild muscle soreness that occurred during extensive repetitive overhead team log-lifting exercises. The patient’s pain progressively worsened and he was sent by ambulance to a nearby emergency department. There, he reported pain that was refractory to multiple doses of intravenous opiate medications. A lumbar computed tomography (CT) scan was read as normal, and he was subsequently discharged with a diagnosis of a low back strain. On exam back at the military unit’s walk-in clinic several hours later, he was in worsening pain upon movement of the lumbar spine, particularly flexion. The left lumbar paraspinal muscles were grossly swollen, abnormally firm, and extremely tender to palpation. He was again sent by ambulance to a different nearby hospital emergency department. There, laboratory evaluation revealed a creatine kinase (CK) greater than 56,000 mg/dL with myoglobinuria and the patient was admitted for management of rhabdomyolysis. Due to continued worsening of pain over the next thirty-six hours that was refractory to high doses of narcotics, orthopedic surgery was consulted with concern for acute lumbar paraspinal compartment syndrome. A lumbar magnetic resonance imaging (MRI) was performed which demonstrated diffuse edema and myonecrosis of the left paraspinal muscles involving the iliocostalis and multifidus. Compartment pressure testing at this time revealed a left paraspinal compartment pressure of 70 mmHg as compared to the right paraspinal compartment pressure of 12 mmHg, confirming the diagnosis of acute lumbar paraspinal compartment syndrome. The patient was then taken to the operating room and underwent urgent left paraspinal fasciotomy. Patient had a hospital length of stay over two weeks, with residual subjective weakness at four weeks post operation as compared to baseline.

DISCUSSION
To date, there have been fewer than thirty total cases of acute lumbar paraspinal compartment syndrome reported.[1, 3, 5] As in this case, most cases have occurred in young athletic male patients following vigorous physical exertion, particularly repetitive overhead weightlifting.[1] Due to the intense nature of military training with often extensive repetitive exercise, especially special operations selection training, military members may represent a special population at higher risk. This patient’s clinical picture is consistent with other reported cases with pain resistant to analgesics, tenderness, swelling, tense muscle appearance, and paraspinal paresthesia being the most commonly reported signs/symptoms.[1] Laboratory evaluation frequently demonstrates a grossly elevated CK with myoglobinuria, which can be confused for or often found in conjunction with rhabdomyolysis.[1] As such, a high clinical index of suspicion is necessary, as laboratory evaluation may be misleading or distract from making the secondary diagnosis of compartment syndrome. It is recommended that these patients be treated for both rhabdomyolysis and acute lumbar paraspinal compartment syndrome, as there is a high risk for the development of acute kidney injury due to myoglobinuria in both conditions.[1]

Both CT scan and MRI have been reported as useful imaging modalities for risk stratification prior to measuring compartment pressures. However, as this case demonstrates, depending on the time course of the injury, a negative CT scan may be misleading, making MRI the imaging modality of choice.[1]. In previous cases, the most common lumbar CT finding for acute lumbar paraspinal compartment syndrome was swelling of the paraspinal musculature, whereas lumbar MRI demonstrated significant paraspinal enhancement on T2-weighted images, indicating edema. It is important for emergency medicine providers to be aware of and have a high clinical index of suspicion for acute lumbar paraspinal compartment syndrome in suggestive clinical scenarios, as recognition and surgical decompression may prevent further myonecrosis and morbidity. In most previously reported cases, those patients who underwent early surgical decompression within thirty-six hours had rapid resolution of pain and eventual long-term return to baseline level of functioning without significant pain or residual paresthesia.[1] However, even in cases of delayed recognition, between fourty-eight hours and as late as seven days with findings of extensive myonecrosis, patients who underwent surgical management still had good functional outcomes and minimal residual symptoms as compared to those who did not receive surgical therapy. Thus, orthopedic consultation is strongly recommended even in cases with delay to diagnosis.[1]

CONCLUSION
This is the first case report of acute lumbar paraspinal compartment syndrome in the healthy, active-duty military training population. Due to occupational activities, military members may represent a particularly high-risk population. Emergency physicians should be cognizant that acute paraspinal compartment syndrome may occur secondary to or in conjunction with rhabdomyolysis. An early negative CT scan does not exclude the diagnosis and therefore MRI is the recommended imaging modality when determining the need to measure compartment pressures. Early suspicion can lead to swift orthopedic consultation and appropriate surgical management, decreasing patient morbidity and long-term sequelae associated with nerve and muscle necrosis of the paraspinal muscle groups in otherwise healthy, athletic individuals.


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