A Case of Occult Compartment Syndrome and Nonresolving Rhabdomyolysis

Abstract

CASE REPORT: A 32-year-old African male presented with 10 hours of severe back pain. Initial computed tomography scan of the back showed no abnormality, and initial laboratory investigations were consistent with rhabdomyolysis. Despite stopping potential causative medications, aggressive intravenous hydration, and urine alkalinization, his creatinine kinase continued to steadily climb. Thirty-six hours after admission, a magnetic resonance imaging of his back was done because of new swelling over the right paraspinal muscles and loss of sensation in this region. Marked swelling of the right erector spinae muscles was observed, and right and left compartment pressure measurements were 108 and 21 mm Hg, respectively. He had urgent fasciotomy after which his rhabdomyolysis and pain recovered.CONCLUSION: Our case highlights the need for early consideration of compartment syndrome as a possible cause of back pain in the setting of rhabdomyolysis. Rhabdomyolysis can present in the absence of late complications such as neurological and vascular compromise.KEY WORDS: occult compartment syndrome; nonresolving rhabdomyolysis; spinae muscles; fasciotomy; neurological and vascular compromise.

Acute lumbar paraspinal compartment syndrome: a case report and detailed literature review

“…Of these, thirteen papers described a single case and two described two cases, for a total of seventeen cases. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] However, upon closer inspection, it was discovered that a single case had been presented twice. 3,4 We therefore have presented here what we believe is only the 17 th case of acute lumbar paraspinal compartment syndrome currently published in the scientific literature (Table 1).…”

“…Among the twelve cases under age 40, ten (83%) had the onset of their symptoms after intense athletic activity, that activity being weight-lifting in six cases, downhill skiing in three and surfboarding in a single case. [3][4][5][7][8][9][10]13,14,17 One of the remaining two under-40 cases was related to a gastric bypass procedure for morbid obesity, and the other secondary to substance abuse, specifically with synthetic cathinone (so-called 'bath salts'). 6,12 Conversely, none of the five older cases (over age 40) involved athletic endeavors, three cases occurring following aortic bypass procedures one secondary to synthetic cathinone abuse, and the single case involving a female secondary to direct trauma to her back.…”

“…In several cases, serum CPK levels continued to rise despite conservative management that included aggressive fluid replacement; in every case, these dramatic post-treatment-initiation related increases (e.g., from 19,000 to 60,800 U/L3) in CPK occurred in a weight-lifter. 3,5,7,8 Categorizing patients into those under versus over age 40, eight of eleven (73%) younger patients ultimately had CPK levels over 50,000 U/L, versus just one of four (25%) over age forty; and the single person > 40 years old who had a CPK peak >50,000 was one whose rhabdomyolysis and consequent compartment syndrome were related to the drug cathinone; this patient's CPK peaked at 162,4956. Categorizing patients into athletes, post-operative patients, drug users, and the single case of direct trauma, both drug abusers had CPK peaks > 100,000 (mean = 256,000 U/L).…”

“…Since that publication, in four papers, an additional five cases of acute paraspinal compartment syndrome have been reported, in addition, our review identified an older (2008) case reported that was somehow neglected in the Nathan et al review. [3][4][5][6][7][8] In this paper, we first present our own case, and then re-analyze the essential characteristics of the now seventeen cases that have been reported in the scientific literature. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] …”

Surgical treatment for muscle injuries

“…Surgical intervention with open fasciotomy is mandatory when CS is confirmed [42]. It is crucial to identify all compartments involved to avoid incomplete or delayed fasciotomies that are associated with muscle necrosis and death [46][47][48]. If rhabdomyolysis occurs, haemodialysis should be considered when life-threatening hyperkalaemia and metabolic acidosis exist [49].…”