Lumbar Paraspinal Compartment Syndrome

Lumbar Paraspinal Compartment Syndrome

Lumbar paraspinal compartment syndrome most often occurs after excessive exertional activities in patients who do not routinely exercise. Activities associated with lumbar paraspinal compartment syndrome include the prolonged use of exercise equipment, weight lifting, surfing, and skiing.

This syndrome is also rarely seen after direct injury to the paraspinous muscles, and after nonspinal and lumbar spine surgery. The etiopathology of lumbar paraspinal compartment syndrome is post-exertional edema of the lumbar paraspinous muscles causing increased pressure within the closed fibro-osseous paraspinal space.

This increased pressure within the closed space decreases blood flow to the paraspinous muscles. If this increased pressure does not resolve, rhabdomyolysis and necrosis of the paraspinous muscles can occur.

Clinically, patients suffering from lumbar paraspinal compartment syndrome report the acute onset of excruciating low back pain that is made worse with forward flexion and deep palpation of the affected lumbar paraspinous muscles. The pain may be unilateral or bilateral, with the intensity of bilateral pain asymmetrical. Neurological examination is most often normal, although the pain may radiate into the pelvis or groin. Dark colored urine secondary to myoglobin within the urine is usually present.

What are the Symptoms of Lumbar Paraspinal Compartment Syndrome

Patients with lumbar paraspinal compartment syndrome report severe back pain that is made worse with forward flexion of the lumbar spine and deep palpation of the affected lumbar paraspinous muscles. No fever is present. Bowel sounds are often diminished or absent. Neurological examination is invariably normal, although radiating pain into the pelvis and groin is common. Dark, cola appearing urine secondary to myoglobinuria is present in more severe cases.

How is Lumbar Paraspinal Compartment Syndrome diagnosed?

Testing in patients suspected of suffering from lumbar paraspinous muscle syndrome is aimed at ruling out more common causes of acute low back pain including renal and ureteral calculi, dissecting abdominal aortic aneurysm, spinal and paraspinal abscess, and compression of the spinal cord, exiting nerve roots, and plexus.

Testing to aid in the diagnosis includes measurement of serum creatine kinase, which is always markedly elevated, urinalysis for presence of heme, and magnetic resonance imaging and computed tomography of the lumbar spine and lumbar paraspinous muscles, which will appear edematous with areas of myonecrosis in more severe cases.

Measurement of intracompartmental pressures to identify increased pressures and to follow the course of the disease are important to help identify the need for surgical intervention to relieve pressures.

Differential Diagnosis

Lumbar paraspinal compartment syndrome is a diagnosis of exclusion, but a history of recent excessive exertion should raise the examiner’s clinical suspicion.

Based on the clinical presentation and findings, the clinician should consider other causes of acute severe low back pain including renal and ureteral calculi, dissecting abdominal aortic aneurysm, spinal and paraspinal abscess, and compression of the spinal cord, exiting nerve roots, and plexus.

Treatment

The treatment of lumbar paraspinal compartment syndrome is based on the severity of the patient’s symptoms, the level and trending of intracompartmental pressures, as well as the amount of muscle damage as evidenced by assessment of serum creatine kinase, serum creatinine, and urine myoglobin. Aggressive crystalloid administration to preserve renal function is important. Alkalinization of the crystalloid with sodium bicarbonate my speed the renal elimination of the more acidic myoglobin may reduce renal injury.

Opioids may be required for pain relief. If paraspinal intracompartmental pressures remain elevated or are trending upward, surgical paraspinal fasciotomies should be performed sooner rather than later to avoid further myonecrosis and to allow direct examination of the affected muscles to determine muscle viability. Debridement of necrotic muscle can be carried out at the time of fasciotomy. Secondary skin closure after paraspinous muscle compartment fasciotomy is often required.

Complications

Given the rarity of lumbar paraspinous muscle syndrome, it must be considered a diagnosis of exclusion. More common causes of acute severe low back pain must be ruled out when considering a diagnosis of lumbar paraspinal compartment syndrome. Even if myoglobinuria is identified, other causes of myoglobinuria including chemically and drug induced rhabdomyolysis as well as inflammatory, infectious, and traumatic rhabdomyolysis should be considered. Failure to diagnose lumbar paraspinal compartment syndrome accurately may put the patient at risk for extensive myonecrosis of the affected paraspinous muscles. As rhabdomyolysis increases, myoglobinuria may cause significant renal damage.

Clinical Pearls

The diagnosis of lumbar paraspinal compartment syndrome should be considered in any patient reporting severe low back pain after excessive exertion. Rapid diagnosis and treatment will decrease the extent of myonecrosis and reduce the extent of myoglobin-induced renal damage. Surgical fasciotomy should be considered early in the course of the disease given the procedure’s ability to definitively treat lumbar paraspinal compartment syndrome.

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