Injury, Int. J. Care Injured 45 (2014) 813–815
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case report
Acute erector spinae compartment syndrome: Case report and review of diagnostic criteria Mark E. Rogers a,*, Jason A. Lowe a, Sean C. Vanlandingham b a b
Division of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, United States University of Alabama School of Medicine, Volker Hall – 100, 1720 2nd Avenue South, Birmingham, AL 35294, United States
A R T I C L E I N F O
Article history: Accepted 11 November 2013
Case report A 45-year-old white male presented to the emergency department with 6 h of back pain and dark urine. The patient was awakened from sleep with severe bilateral paraspinal pain that was worse with valsalva and forward flexion. There was no preexisting history of back pain, and no history of acute trauma. The patient elected to seek care when his pain continued to worsen despite overthe-counter pain relievers. Past medical history included erectile dysfunction and hypertension. Medications included tadalafil and amlodipine/valsartan. He reported using cocaine occasionally, with last use occurring one day prior to the onset of symptoms. After initial emergency department evaluation, orthopaedic surgery was consulted to evaluate the patient’s continuing back pain. On exam the patient was in mild distress secondary to pain. He reported a crescendo type pain pattern that was worse with direct palpation of the paraspinous musculature and forward flexion. It was noted that the erector spinae compartments were firm and minimally compressible compared to adjacent muscle compartments. Motor sensory examination demonstrated active contraction of paraspinal musculature, which accentuated his pain and there was documented decreased sensation to light touch to posterior dermatomes of the eighth thoracic to fourth lumbar nerves. Laboratory studies are summarised in Table 1, and revealed an elevated serum creatinine, creatine kinase, ALT, and AST values. Urinalysis revealed 3+ blood, 0 red blood cells and myoglobinuria. Urine toxicology screen was positive for cocaine. Imaging evaluation with anterior–posterior (AP)/lateral lumbar spine radiographs, abdominopelvic computed tomography, and renal ultrasonography was negative with the exception of prominence of the lumbar paraspinal musculature.
* Corresponding author. Tel.: +1 205 930 8494. E-mail addresses: [email protected] (M.E. Rogers), [email protected] (J.A. Lowe), [email protected] (S.C. Vanlandingham). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.012
The clinical exam was suggestive of ACS; however, given the rarity of compartment syndrome in paraspinal compartments the diagnosis was confirmed by measuring compartment pressures. Using a Stryker Intra-Compartmental Pressure Monitor (Stryker, Mahwah, NJ) device, compartment pressures of the erector spinae were measured and found to be 150 mmHg and 120 mmHg on the left and right, respectively. A diagnosis of erector spinae compartment syndrome was made. After review of the current literature on the prognosis of this process, the patient was educated on the risks and benefits of operative versus nonoperative treatment. Given the evidence of concomitant rhabdomyolysis and the risk of prolonged rehabilitation and chronic back pain associated with nonoperative treatment, the decision was made to proceed with bilateral paraspinal fasciotomies. The elapsed time from onset of symptoms to operative intervention was less than 24 h. In the operating room, the patient was placed in a prone position and two paramedian skin incisions were made along the left and right paraspinous muscle groups (Fig. 1). The fascia of the right erector spinae was sharply incised, and the muscle belly was noted to be dusky in appearance and non-contractile. As the contralateral fasciotomy was being performed, the right muscle group demonstrated reperfusion as indicated by return of pink followed by red muscle colour within 5 min; within 10 min the muscle was contracting to manual and electrical stimulation. Similar findings were noted in the left paraspinous compartment. Electrocautery was utilised to stimulate and confirm viability of the tissue. The fascial layer was left open and the incisions were closed primarily in the usual fashion over medium drains. Postoperatively, the patient noted immediate improvement of his pain symptoms and dysesthesias. His postoperative course was uneventful and he was discharged on postoperative day three after improvement of his kidney function and normalisation of laboratory values. He was discharged with restrictions of no lifting weight greater than ten pounds. At two weeks postoperatively the patient presented to clinic for his follow-up appointment. His symptoms had completely resolved and he was recovering from surgery appropriately. His incision site pain was adequately controlled on oral pain medications and he was able to ambulate without difficulty. A physical therapy regimen was initiated for stretching and strengthening exercises, and he continues to recover without sequelae.
M.E. Rogers et al. / Injury, Int. J. Care Injured 45 (2014) 813–815
814 Table 1 Pertinent laboratory studies. Laboratory test
Value
Normal range
Serum creatinine Creatine kinase WBC ALT AST
1.4 mg/dL 178,000 IU/L 14 103/mL 234 IU/L 1026 IU/L
0.4–1.2 mg/dL
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case report
Acute erector spinae compartment syndrome: Case report and review of diagnostic criteria Mark E. Rogers a,*, Jason A. Lowe a, Sean C. Vanlandingham b a b
Division of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, United States University of Alabama School of Medicine, Volker Hall – 100, 1720 2nd Avenue South, Birmingham, AL 35294, United States
A R T I C L E I N F O
Article history: Accepted 11 November 2013
Case report A 45-year-old white male presented to the emergency department with 6 h of back pain and dark urine. The patient was awakened from sleep with severe bilateral paraspinal pain that was worse with valsalva and forward flexion. There was no preexisting history of back pain, and no history of acute trauma. The patient elected to seek care when his pain continued to worsen despite overthe-counter pain relievers. Past medical history included erectile dysfunction and hypertension. Medications included tadalafil and amlodipine/valsartan. He reported using cocaine occasionally, with last use occurring one day prior to the onset of symptoms. After initial emergency department evaluation, orthopaedic surgery was consulted to evaluate the patient’s continuing back pain. On exam the patient was in mild distress secondary to pain. He reported a crescendo type pain pattern that was worse with direct palpation of the paraspinous musculature and forward flexion. It was noted that the erector spinae compartments were firm and minimally compressible compared to adjacent muscle compartments. Motor sensory examination demonstrated active contraction of paraspinal musculature, which accentuated his pain and there was documented decreased sensation to light touch to posterior dermatomes of the eighth thoracic to fourth lumbar nerves. Laboratory studies are summarised in Table 1, and revealed an elevated serum creatinine, creatine kinase, ALT, and AST values. Urinalysis revealed 3+ blood, 0 red blood cells and myoglobinuria. Urine toxicology screen was positive for cocaine. Imaging evaluation with anterior–posterior (AP)/lateral lumbar spine radiographs, abdominopelvic computed tomography, and renal ultrasonography was negative with the exception of prominence of the lumbar paraspinal musculature.
* Corresponding author. Tel.: +1 205 930 8494. E-mail addresses: [email protected] (M.E. Rogers), [email protected] (J.A. Lowe), [email protected] (S.C. Vanlandingham). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.012
The clinical exam was suggestive of ACS; however, given the rarity of compartment syndrome in paraspinal compartments the diagnosis was confirmed by measuring compartment pressures. Using a Stryker Intra-Compartmental Pressure Monitor (Stryker, Mahwah, NJ) device, compartment pressures of the erector spinae were measured and found to be 150 mmHg and 120 mmHg on the left and right, respectively. A diagnosis of erector spinae compartment syndrome was made. After review of the current literature on the prognosis of this process, the patient was educated on the risks and benefits of operative versus nonoperative treatment. Given the evidence of concomitant rhabdomyolysis and the risk of prolonged rehabilitation and chronic back pain associated with nonoperative treatment, the decision was made to proceed with bilateral paraspinal fasciotomies. The elapsed time from onset of symptoms to operative intervention was less than 24 h. In the operating room, the patient was placed in a prone position and two paramedian skin incisions were made along the left and right paraspinous muscle groups (Fig. 1). The fascia of the right erector spinae was sharply incised, and the muscle belly was noted to be dusky in appearance and non-contractile. As the contralateral fasciotomy was being performed, the right muscle group demonstrated reperfusion as indicated by return of pink followed by red muscle colour within 5 min; within 10 min the muscle was contracting to manual and electrical stimulation. Similar findings were noted in the left paraspinous compartment. Electrocautery was utilised to stimulate and confirm viability of the tissue. The fascial layer was left open and the incisions were closed primarily in the usual fashion over medium drains. Postoperatively, the patient noted immediate improvement of his pain symptoms and dysesthesias. His postoperative course was uneventful and he was discharged on postoperative day three after improvement of his kidney function and normalisation of laboratory values. He was discharged with restrictions of no lifting weight greater than ten pounds. At two weeks postoperatively the patient presented to clinic for his follow-up appointment. His symptoms had completely resolved and he was recovering from surgery appropriately. His incision site pain was adequately controlled on oral pain medications and he was able to ambulate without difficulty. A physical therapy regimen was initiated for stretching and strengthening exercises, and he continues to recover without sequelae.
M.E. Rogers et al. / Injury, Int. J. Care Injured 45 (2014) 813–815
814 Table 1 Pertinent laboratory studies. Laboratory test
Value
Normal range
Serum creatinine Creatine kinase WBC ALT AST
1.4 mg/dL 178,000 IU/L 14 103/mL 234 IU/L 1026 IU/L
0.4–1.2 mg/dL
