Transcript Acute Exercise Induced Compartment Syndrome

AAPMR Annual Assembly
Sports and Soft Tissue InjuriesMusculoskeletal Case Presentation
Friday, October 2nd, 2015
Jay M. Shah MD, Todd Miller MD, Eathar Saad MD
Dept. of Physical Medicine and Rehabilitation
Montefiore Medical Center/AECOM
No Disclosures
Presenting Patient History
25 year old Male (6’1, 195lbs) with no significant
medical history presented to ED with severe,
acute onset low back and bilateral thigh pain.
Onset of pain was 30-minutes after two-hour
workout (included 500lb deadlift squats)
Pain awoke the patient from sleep, and upon to
arriving to the ED, he reported noticing a very
dark color upon urination.
Denied bowel/bladder incontinence, SA
Presenting Physical Exam
Exam limited by diffuse LBP>BL thigh pain
Significant for diffuse tenderness over the
lumbar paraspinals
Displayed lower abdominal guarding 2/2
bilateral thigh pain
Distal BLE pulses were intact.
Orthopedic Exam Findings
Pain limited lumbar ROM to ~20 degrees
Flexion and 10 degrees Extension
Patient reported intermittent pain radiating down
the bilateral thighs not below knee
Pain limited BLE weakness (3-/5)
Reflexes symmetric and 2+ BLE
Sensation intact BLE
SLR/Slump negative B/L (+LBP only)
Discussion
Differential Diagnosis of Acute
LBP and Bilateral Thigh Pain
Acute HNP w/ Lumbar Radiculopathy
Acute Lumbar Compression Fracture
Rhabdomyolysis
Compartment Syndrome
Acute Lumbosacral Muscle Strain
Pertinent Laboratory Data
Utox:
+Marijuana
*CPK: 127,266
(Normal: 20200)
BUN/Cr:
16/1.1
LFTs
• AST:1034
• (Normal 13-50)
• ALT: 214 (Normal 861)
CBC/CMP:
otherwise
WNL
UA: Tea
colored/+blood
Diagnostic Imaging
Lumbar Spine AP/L X-ray
• WNL, No compression Fx/subluxation
CT Abdomen/Pelvis w/o contrast
• No compression Fx/subluxation
• Well-defined lucent lesions within the
iliac crest bilaterally consistent with
hemangiomas or fibrous dysplasias
Rationale for Further Diagnostic
Testing
Although CPK was trending down, the patient
experienced significant increase in LBP
associated with new onset focal paraspinal
numbness on HD #3
Per Orthopedic recommendation, the patient was
sent for MRI Lumbar spine/Bilateral thighs and
compartment pressure measuring.
Results
Compartment Pressures
(Normal 0-8mmHg)
*Lumbar
Anterior
Paraspinals: Thighs
Medial
Thighs
*Posterior
Thighs
• (R): 103mmhg • (R): 16mmhg
• (L): 94mmhg • (L): 22mmhg
• (R): 13mmhg
• (L): 10mmhg
• (R): 20mmhg
• (L): 25mmhg
MRI Images
*
P
L
M
MRI Images
*
Q
BF
SM
Results
MRI Results
• Bilateral edema and enhancement of
semimembranosus and biceps femoris
muscles and, to a lesser degree, the bilateral
semitendinosus muscles.
• Bilateral edema and enhancement multifidus
muscles, longissimus
• Small amount of fluid in the posterior
compartments is also present bilaterally
• Clinically correlate w/ infectious, ischemic,
inflammatory processes and rhabdomyolysis
from post traumatic/overuse injury
Final Diagnosis
Acute Exercise Induced Compartment
Syndrome (AECS) Involving the Lumbar
Paraspinals and Posterior Thigh
compartments
Associated Rhabdomyolysis
Treatment
A decision was made by Orthopedic surgery to
intervene with emergent fasciotomies of the
bilateral lumbar paraspinals and posterior thighs
Rhabdomyolysis was treated with aggressive
IVF with significant improvement following
fasciotomies
Pain Control w/ taper (PCA)
Outcome
Post-op day #3
• Rhabdomyolysis resolving, CPK
50,000
• Return of most sensation over lumbar
paraspinals
• BLE MMT: 4/5 (mild pain)
• IV Abx completed
• PCAPO opiods
Rehab Consult
Patient was cleared WBAT + Full lumbar
ROM
Upon Rehab Evaluation
• Patient ambulatory with normal gait pattern
and heel/toe walk w/o need of AD
• Improved Lumbar ROM (70 deg flexion, 30
deg ext), BLE WNFL with mild end range pain
in all planes
• Recommendation was given for him to be
discharged home with services (PT for lumbar
ROM, core strengthening, BLE
ROM/strengthening, progressive ambulation)
Upon Discharge
CPK ~3000
DC’d home with Tramadol with strict
instructions to avoid all NSAIDS due to
resolving rhabdomyolysis
No complications upon 2-week Ortho F/u.
• Mild residual numbness over LP
• CPK WNL
• Full strength BLE
Case Discussion
Thank you!!!!
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