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An NCAA football player developed an acute paraspinal compartment syndrome after a weight-lifting strain. The patient presented with myone-crosis (CK up to 77,400 U/L), and myoglobinuria. Treatment consisted of forced diuresis and six sessions in the hyperbaric oxygen chamber.
Acute compartment syndrome is defined as the pathologic elevation of the hydrostatic tissue pressure within a closed compartment inducing ischemia and myonecrosis. Acute paraspinal compartment syndrome, although rare, has been well described in a few case reports.1,3 In addition, exertional compartment syndrome, well described in the extremities, rarely progresses to the acute form. Both operative and non-operative modalities have been described as treatment alternatives.2 Hyperbaric oxygen therapy has been successfully used for the treatment of extremity compartment syndrome.6,7 In our review of the literature, we were unable to find a description of the use of HBO in acute paraspinal compartment syndrome. We report a case of acute exertional paraspinal compartment syndrome managed successfully with hyperbaric oxygenation.
A 23-year-old African-American NCAA football player presented to the emergency room with a 36-hour history of rapidly-increasing low back pain. The pain was described as throbbing, and started acutely during a weight-lifting session (squats). The intensity of the pain increased rapidly until it became unbearable.
Four hours after the incident he was taken to his local emergency room and admitted for pain control. His past medical history was uneventful, and no previous episodes of back pain were documented. He was then transferred to our institution, arriving approximately 12 hours later.
Upon admission, initial examination revealed severe pain and tenderness in the lower aspect of the back. Fullness and tenderness of the paraspinal muscle compartments was noted, particularly on the left side. Due to the acute and unbearable nature of the pain, an MRI was ordered: The T2-weighted MRI of the lumbar spine (Figure 1) revealed significant edema throughout the paraspinal muscles, particularly of the erector spinae. The volume of the medial muscle compartment at the level of the L4 vertebral body was measured as 22cm2 on the left, in sharp contrast with 14cm2 on the right, a greater than 50% increase in volume.
The patient's laboratory studies revealed negative sickle cell screening, and normal electrolytes, CBC, CRP and ESR. The urinalysis revealed myoglobinuria, and the creatine kinase (CK) upon admission was 64,863 U/L. He was admitted and treated with forced diuresis, and pain was only poorly controlled with opioid analgesics. The CK was repeated 12 hours later, and continued to increase until it reached a maximum of 77,440 U/L (Figure 2).
With the diagnosis of paraspinal compartment syndrome, treatment was commenced in the hyperbaric oxygen chamber on the second day. After the first session, the CK had decreased to 68,010 U/L (Figure 2), and after the second session the pain was much better controlled. The patient was able to mobilize with only moderate discomfort after the third session. He underwent a total of six sessions, and was discharged after one week with a CK of 8,805 U/L. His renal function remained unchanged.
Over the next four months the patient was periodically followed. Within this time period, the CK was completely normalized and the back pain continued to progressively improve. He was able to resume physical activities, and complained only of pain upon exertion which slowly improved during this period.
Acute, exertional, paraspinal compartment syndrome should be suspected in young athletes who present with acute-onset back pain following intense physical activity. Anatomical studies have demonstrated a well-defined paraspinal compartment within the thoracolumbar fascia, consisting of the erector spinae muscles.4,5 In a manner similar to that which occurs in extremity compartments, prolonged increases in tissue pressures within these compartments can lead to myonecrosis. Hyperbaric oxygen (HBO) therapy can provide increased amounts of dissolved oxygen in plasma, improving oxygen delivery and tissue viability in ischemic areas.6 Serum creatine kinase (CK) was utilized as an indicator of tissue ischemia and rhabdomyolysis. As demonstrated in graph 1, initiation of HBO coincided with a rapid and prolonged decline in the level of circulating serum creatine kinase until normal levels were reached. Additionally, the acute and unrelenting pain was well controlled within 24 to 36 hours following institution of HBO therapy.
Previously described cases of acute paraspinal compartment syndrome1,2,3,4related to exertion have occurred in young male athletes; onset of symptoms was also acute and related to recent high-intensity physical activity. Some of these cases were treated with fasci-otomy, while others were treated conservatively with pain management and forced diuresis. All patients were able to resume physical activity, nevertheless, the non-surgical patients continued to experience mild chronic pain with vigorous exercise.
In summary, this case presented as an acute exertional compartment syndrome in the paraspinal muscles in an athlete. Early diagnosis and prompt management with the use of hyperbaric oxygen, close monitoring with clinical examinations, CK levels, and renal function tests allowed effective resolution of the acute problem. We propose HBO therapy as a treatment method for acute exertional paraspinal compartment syndrome. This should be started as soon as the diagnosis has been reached. If the pain is well controlled, and the CK starts to decline, no further treatment methods need to be considered.