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Conservative treatment for lumbar compartment syndrome shows efficacy over 2-year follow-up: a case report and literature review

Authors:
Haruhisa Kanaya
Haruhisa Kanaya
Haruhisa Kanaya
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Makoto Enokida
Makoto Enokida
Makoto Enokida
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Shinji Tanishima at Tottori University
Shinji Tanishima
Ikuta Hayashi
Ikuta Hayashi
Ikuta Hayashi
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Background: Since in all studies of conservative treatment of lumbar compartment syndrome the follow-up duration was less than 6 months, it is difficult to draw firm conclusions. Purpose: To report a patient with lumbar paraspinal compartment syndrome who was treated conservatively over a follow-up period of 2 years. Study design: This is a case report of a 23-year-old male college student with lumbar paraspinal compartment syndrome who was treated conservatively. Methods: We report a case of a 23-year-old male college student with lumbar paraspinal compartment syndrome who was treated conservatively. We repeatedly checked his physical examination, laboratory tests, lumbar compartment pressures, and magnetic resonance imaging, and surgical teams were readily prepared to operate should the patient's condition worsen. To prevent complications of rhabdomyolysis, hydration and alkalization were performed. We followed him up to 2 years after discharge. Result: Although the temporal changes on MRI up to the 1-year point, the patient continued to have no symptoms. Conclusions: Conservative therapy can be recommended if rhabdomyolysis is under control.
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TRAUMA SURGERY
Conservative treatment for lumbar compartment syndrome shows
efficacy over 2-year follow-up: a case report and literature review
Haruhisa Kanaya
1
•Makoto Enokida
1
•Shinji Tanishima
1
•Ikuta Hayashi
1
•
Atsushi Tanida
1
•Hideki Nagashima
1
Received: 5 June 2017 / Published online: 20 June 2017
ÓSpringer-Verlag GmbH Germany 2017
Abstract
Background Since in all studies of conservative treatment
of lumbar compartment syndrome the follow-up duration
was less than 6 months, it is difficult to draw firm
conclusions.
Purpose To report a patient with lumbar paraspinal com-
partment syndrome who was treated conservatively over a
follow-up period of 2 years.
Study design This is a case report of a 23-year-old male
college student with lumbar paraspinal compartment syn-
drome who was treated conservatively.
Methods We report a case of a 23-year-old male college
student with lumbar paraspinal compartment syndrome
who was treated conservatively. We repeatedly checked his
physical examination, laboratory tests, lumbar compart-
ment pressures, and magnetic resonance imaging, and
surgical teams were readily prepared to operate should the
patient’s condition worsen. To prevent complications of
rhabdomyolysis, hydration and alkalization were per-
formed. We followed him up to 2 years after discharge.
Result Although the temporal changes on MRI up to the
1-year point, the patient continued to have no symptoms.
Conclusions Conservative therapy can be recommended if
rhabdomyolysis is under control.
Keywords Lumbar paraspinal compartment syndrome
Rhabdomyolysis Conservative treatment Spine
Introduction
Compartment syndrome, occasionally experienced in daily
medical practice, commonly occurs in the extremities but
is extremely rare in the lumbar region. Incorrect diagnosis
or treatment may lead to permanent damage of muscles and
nerve, nevertheless, treatment options for lumbar com-
partment syndrome are controversial. In some papers,
surgical decompression showed a good outcome for this
condition [1–5]. On the other hand, conservative treatment
demonstrated a few complaints on vigorous exertion
[6–10]. Haig et al. found that that muscles became necrotic
after conservative treatment [8]. Since in all of these
studies the follow-up duration was less than 6 months, it is
difficult to draw conclusions. We report that a case with
lumbar paraspinal compartment syndrome who was treated
conservatively over a follow-up period of 2 years.
Case report
A 23-year-old male college student practiced rowing for a
few hours, followed by drinking alcohol. He lay on the
floor and slept without low back pain. The next day, he felt
&Haruhisa Kanaya
hkkupi@yahoo.co.jp
Makoto Enokida
enokida@med.tottori-u.ac.jp
Shinji Tanishima
shinjit@med.tottori-u.ac.jp
Ikuta Hayashi
ikutahayashi@med.tottori-u.ac.jp
Atsushi Tanida
a_tanida@med.tottori-u.ac.jp
Hideki Nagashima
hidekin@med.tottori-u.ac.jp
1
Department of Orthopedic Surgery, Faculty of Medicine,
Tottori University, 36-1 Nishi-cho, Yonago,
Tottori 683-8504, Japan
123
Arch Orthop Trauma Surg (2017) 137:1233–1238
DOI 10.1007/s00402-017-2732-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The lag time in diagnosis ultimately changed the treatment for some patients. Some non-operative case reports note that the timing and "clinical and laboratory improvement" of the patient led to treating that particular patient conservatively without operative intervention [9,10]. The majority of cases treated operatively had 'good' results with minimal issues in the limited postop follow-ups reported. ...
Paralumbar compartment syndrome, a rare sequela of deadlifting: a case report and review of current literature
Article
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  • Jun 2024
  • J Orthop Surg Res
Background Compartment syndrome is a well-known phenomenon that is most commonly reported in the extremities. However, paralumbar compartment syndrome is rarely described in available literature. The authors present a case of paralumbar compartment syndrome after high intensity deadlifting. Case presentation 53-year-old male who presented with progressively worsening low back pain and paresthesias one day after high-intensity deadlifting. Laboratory testing found the patient to be in rhabdomyolysis; he was admitted for intravenous fluid resuscitation and pain control. Orthopedics was consulted, and Magnetic Resonance Imaging revealed significant paravertebral edema and loss of muscle striation. Given the patient’s lack of improvement with intravenous and oral pain control, clinical and radiographic findings, there was significant concern for acute paralumbar compartment syndrome. The patient subsequently underwent urgent fasciotomy of bilateral paralumbar musculature with delayed closure. Conclusion Given the paucity of literature on paralumbar compartment syndrome, the authors’ goal is to promote awareness of the diagnosis, as it should be included in the differential diagnosis of intractable back pain after high exertional exercise. The current literature suggests that operative cases of paralumbar compartment syndromes have a higher rate of return to pre-operative function compared to those treated non-operatively. This case report further supports this notion. The authors recommend further study into this phenomenon, given its potential to result in persistent chronic exertional pain and irreversible tissue damage.
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... Nevertheless, the literature describes an increased recovery time and overall poor outcome with conservative treatment compared with surgical treatment. But no clear treatment recommendation can be given [5,8,13,14,[16][17][18]. Moreover, fasciotomy is associated with good outcomes in all reported cases, even with a significant delay from the time of symptom onset (up to 7 days) [5,8,14]. ...
Acute Lumbar Paraspinal Compartment Syndrome after a Tug of War: A Case Report and Review of the Literature
Article
Full-text available
  • Dec 2020
Compartment syndrome of the upper and the lower extremities is a well-known entity in emergency medicine and traumatology. However, compartment syndrome of the paraspinal musculature is a very rare cause of acute back pain and may be missed at presentation despite its clinical importance. Therefore, we present a case of paraspinal compartment syndrome embedded in an overview of the actual literature. A 21- year-old woman presented with acute back pain refractory to analgesia with opiates after a tug of war match. A CT-scan of the abdomen demonstrated paraspinal swelling and an MRI ruled out intra-spinal pathologies. A compartment measurement yielded a pressure of 135mmHg. Even though conservative treatment attempts are often described, an emergency fasciotomy was carried out. Further rehabilitation was uneventful. Nevertheless, the timing of fasciotomy in the paraspinal region is under discussion, especially due to very rare experiences. Even if surgery is delayed by more than 24 hours following symptom onset, favourable postoperative outcomes have been observed.
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... Fibrosis, calcification, and muscular atrophy can be seen as a sequel in the chronic phase. Some authors consider the decreased uptake of gadolinium as a sign of necrosis, which suggests irreversible damage and demands emergent surgical intervention (8), whereas other authors have suggested observing if the rhabdomyolysis is in control (9). The MRI findings of our case showed no definite complications of infarction, hemorrhages, or liquefactive necrosis that may be seen as bright signal intensities on a T2-and high or low signal intensity on a T1-weighted image. ...
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Conservative Management of a Rare Clinical Phenomenon: Paraspinal Compartment Syndrome – A Review of Existing Literature
Article
Full-text available
  • Dec 2024
Introduction This review of case series and case reports explores conservative management strategies for paraspinal compartment syndrome (PCS), a rare clinical condition. Extremity compartment syndrome has been shown to be managed most effectively with emergent surgical release of the fascial compartment. Given the rarity of PCS and the paucity of research in the literature, some authors have suggested the possibility of conservative treatment. There has been no study to date that has specifically investigated the cases of non-operative management of PCS. Materials and Methods There are 16 case reports in the literature with 22 cases of PCS treated conservatively. The authors reviewed these cases, specifically viewing the clinical courses, why the decision was made to manage conservatively, and the reported outcomes. Results The etiology of PCS varied, with weightlifting being the primary cause in 11 out of 22 cases, followed by strenuous sporting events and postsurgical complications. All patients in this review were male, aged between 18 and 61 years old. Acute presentations exhibited severe back pain, rigid paraspinal musculature, and subjective paraspinal paresthesias. Magnetic Resonance Imaging findings of the spine revealed profound bilateral symmetric intramuscular edema. Among the cases, 8 explicitly reported a return to normal function, while 8 continued to experience symptoms related to the initial injury. Nine cases chose conservative measures primarily because of delayed presentation, seven instances reported successful outcomes with conservative measures; one case cited concerns about infection risk. Discussion The probability of underreporting related to PCS may result in a substantial number of cases being omitted from medical literature. Pathologically, PCS is characterized by increased intra-compartmental pressure, triggering rhabdomyolysis due to significant soft tissue damage. Emergent surgical intervention is the treatment of choice for any compartment syndrome; however, conservative management of these cases has shown satisfactory clinical outcomes. Hyperbaric oxygen therapy emerges as a potential adjunctive treatment to enhance tissue viability, though its efficacy and accessibility warrant further investigation in the context of PCS management. Conclusion Early recognition and treatment of PCS are critical in preventing chronic pain and permanent complications. Given the limitations identified in non-operative management, further research is imperative to optimize treatment strategies.
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Lumbar Paraspinal Compartment Syndrome: Case Report and Critical Evaluation of the Literature
Article
  • Oct 2021
Background: Lumbar compartment syndrome is a recognized clinical phenomenon, despite receiving less attention as a clinical entity. Given its rarity, the definitive presentation, diagnosis, and management strategies are not completely agreed upon. Materials and methods: A literature search on PubMed of all case reports of lumbar paraspinal compartment syndromes was conducted. All case reports and reviews were analyzed for patient demographic data, presentation, diagnostic evaluation, treatment, and clinical follow-up. Results: A total of 37 cases of lumbar compartment syndrome were identified. Overall, 91.9% occurred in men with an average age of 30.9 years. Weightlifting (n=18, 48.6%) and physical exertion (n=7, 18.9%) accounted for the majority of presentations. In all, 37.8% of cases occurred unilaterally. Creatinine kinase, aspartate aminotransferase, and alanine aminotransferase were notably elevated. Compartment pressure was elevated with an average of 91.8 mm Hg (SD: 44.8 mm Hg). Twenty-two cases were treated operatively (59.5%) and 15 (40.5%) were treated nonoperatively. In total, 19/20 (95.0%) of cases treated operatively reported either resolution of pain or return to baseline activities without limitation, compared with 1/11 (9.1%) treated nonoperatively. This difference between the operative and nonoperative cohort was statistically significant ( P <0.0001). Conclusions: Lumbar paraspinal compartment syndrome is a rare, but well-documented clinical entity. In all, 67.5% of cases occurred after weightlifting or physical exertion. Overall, 40.5% of cases in the literature were treated nonoperatively. Per our analysis, there is a clinically and statistically significant difference in cases treated operatively versus nonoperatively (95.0% vs. 9.1%, P <0.0001).
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Paravertebral compartment syndrome after training causing severe back pain in an amateur rugby player: Report of a rare case and review of the literature
Article
Full-text available
Acute compartment syndrome (CS) of the paravertebral muscles without external trauma is rarely reported in literature. Not all of clinical symptoms for CS are applicable to the paravertebral region. A 30-year-old amateur rugby player was suffering from increasing back pain following exertional training specially targeting back muscles. He presented with hardly treatable pain of the lumbar spine, dysaesthesia of the left paravertebral lumbar region as well as elevated muscle enzymes. Magnetic resonance imaging (MRI) showed an edema of the paravertebral muscles. Compartment pressure measurement revealed increased values of 47 mmHg on the left side. Seventy-two hours after onset of back pain a fasciotomy of the superficial thoracolumbar fascia was performed. Immediately postoperatively the clinical condition improved and enzyme levels significantly decreased. The patient started with light training exercises 3 weeks after the operation. We present a rare case of an exercise-induced compartment syndrome of the paravertebral muscles and set it in the context of existing literature comparing various treatment options and outcomes. Where there is evidence of paravertebral compartment syndrome we recommend immediate fasciotomy to prevent rhabdomyolysis and further consequential diseases.
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Excruciating Low Back Pain After Strenuous Exertion: Beware of Lumbar Paraspinal Compartment Syndrome
Article
  • Sep 2015
  • J EMERG MED
Background: Low back pain is extremely common and usually a minor self-limiting condition. Rarely, however, it is a harbinger of serious medical illness. Paraspinal compartment syndrome is a rare condition, but its timely recognition is important to allow adequate treatment. Case report: A 16-year-old boy presented to the Emergency Department (ED) with severe low back pain, necessitating intravenous opioids. Laboratory results showed severe rhabdomyolysis. Magnetic resonance imaging of the lumbar spine showed diffuse edema and swelling in the paraspinal muscles. Aggressive fluid therapy was started but despite narcotic analgesia the pain persisted and creatine kinase (CK) levels increased. Compartment pressures of the erector spinae were found to be increased. The decision was made to proceed with bilateral paraspinal fasciotomies. Postoperatively, the patient noted immediate pain relief with rapid decrease of CK level. The patient is pain free and resumed running and swimming 3 months after admission in the ED. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although paraspinal compartment syndrome is a rare condition, its recognition is of paramount importance to allow adequate surgical treatment, preventing muscle necrosis. Although back pain most often has a benign course, a careful history and physical examination in patients presenting with low back pain allows determination of "red flags." Mandatory further diagnostic tests can identify underlying serious illness.
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Lumbar Paraspinal Compartment Syndrome
Article
  • Nov 1985
A 24-year-old man presented with severe low-back pain and paraspinal muscle spasm after exertion. Elevation in temperature, white blood cell count, serum muscle enzymes, and urine myoglobin, as well as computer tomographic evidence of paraspinal muscle edema and necrosis, were present. No etiology could be documented, and the possibility of an acute exertional compartment syndrome was entertained. Subsequently, cadaveric dissections indicated that the erector spinae muscles are contained within a well-developed fascial sheath. Continuous slit catheter pressure measurements within this compartment in eight healthy male subjects were subsequently carried out. These indicated a physiologic behavior similar to other known compartments for which compartment syndromes have been described. Variation in intracompartmental pressure occurred as a function of body posture, erector spinae isometric contraction, and active intra-abdominal pressurization. We suggest this patient had a paraspinal compartment syndrome and have described pressure characteristics of this compartment in normal men.
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Rhabdomyolysis: Pathogenesis, Diagnosis, and Treatment
Article
  • Apr 2015
Rhabdomyolysis is a complex medical condition involving the rapid dissolution of damaged or injured skeletal muscle. This review focuses on the epidemiology, pathophysiology, causes, presentation, diagnosis, complications, management, and anesthetic considerations related to rhabdomyolysis. Any form of muscle damage--and by extension any entity that causes muscle damage--can initiate rhabdomyolysis. One of the most important treatment goals when rhabdomyolysis is suspected is avoiding acute kidney injury. All clinicians should be aware of common causes, diagnosis, and treatment options.
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Compartment Syndrome After "Bath Salts" Use: A Case Series
Article
  • Jan 2013
In recent years, synthetic cathinones, often labeled as "bath salts" in an attempt to evade drug laws, have emerged as substances of abuse. Sympathomimetic drugs are well known to cause rhabdomyolysis but are rarely associated with acute compartment syndrome. In this case series, we describe 3 patients who presented with sympathomimetic signs or symptoms including hyperthermia and agitation and had confirmed synthetic cathinone use. All 3 patients had severe rhabdomyolysis with delayed development of an acute compartment syndrome. Two patients developed paraspinal compartment syndromes, whereas 1 developed bilateral forearm compartment syndromes. Management included fasciotomy in 2 patients and medical management in the third. Two of the 3 patients made a complete recovery before hospital discharge; the third patient was hemodialysis dependent at 5-month follow-up.
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Acute paraspinal compartment syndrome as an unusual cause of severe low back pain
Article
  • Aug 2012
  • EMERG MED AUSTRALAS
This report describes a case of acute paraspinal compartment syndrome in a 25-year-old man. The diagnosis was significantly delayed, perhaps to some extent because of the rarity of the condition. The patient was managed with forced diuresis, analgesia and hyperbaric oxygen therapy. The discussion addresses an unusual site for compartment syndrome and a diagnosis not commonly considered in the differential of low back pain. Treatment options are discussed and we review previous published case reports.
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