Acute lumbar paraspinal compartment syndrome: a systematic review

While still a rare entity, acute lumbar paraspinal compartment syndrome has an increasing incidence. Similar to other compartment syndromes, acute lumbar paraspinal compartment syndrome is defined by raised pressure within a closed fibro‐osseous space, limiting tissue perfusion within that space. The resultant tissue ischaemia presents as acute pain, and if left untreated, it may result in permanent tissue damage. A literature search of ‘paraspinal compartment syndrome’ revealed 21 articles. The details from a case encountered by the authors are also included. A common data set was extracted, focusing on demographics, aetiology, clinical features, management and outcomes. There are 23 reported cases of acute compartment syndrome. These are typically caused by weight‐lifting exercises, but may also result from other exercises, direct trauma or non‐spinal surgery. Pain, tenderness and paraspinal paraesthesia are key clinical findings. Serum creatine kinase, magnetic resonance imaging and intracompartment pressure measurement confirm the diagnosis. Half of the reported cases have been managed with surgical fasciotomy, and these patients have all had good outcomes relative to those managed with conservative measures with or without hyperbaric oxygen therapy. These good outcomes were despite significant delays to operative intervention. The diagnostic uncertainty and subsequent delay to fasciotomy result from the rarity of this disease entity, and a high level of suspicion is recommended in the appropriate setting. This is particularly true in light of the current popularity of extreme weight lifting in non‐professional athletes. Operative intervention is strongly recommended in all cases based on the available evidence.     

Lumbar paraspinal myonecrosis after abdominal vascular surgery: a case report

STUDY DESIGN: Case report. OBJECTIVES: Lumbar paraspinal myonecrosis after abdominal vascular surgery. SUMMARY OF BACKGROUND DATA: Lumbar paraspinal myonecrosis does not appear to have been reported previously. METHODS: A patient who had severe back pain after abdominal vascular surgery was observed with computed tomographic scans and histologic examination of a specimen obtained in open biopsy. RESULTS: Computed tomographic scans of the lumbar region demonstrated muscle swelling of the unilateral paraspinal compartment. Histologic examinations of affected muscle revealed fresh ischemic necrosis. A compartmental syndrome was considered from the patient's clinical presentation and radiographic and histologic features. An accompanying secondary infection led to an extensive abscess in the paraspinal compartment. The patient resumed active daily life after aggressive débridements of infected and necrotic muscles. CONCLUSIONS: A compartmental syndrome in the paraspinal muscle should be kept in mind as a potential cause of acute back pain especially after abdominal vascular surgery.     

Une lombalgie atypique : le syndrome de l’homme raide

Stiff-person syndrome was diagnosed in a patient with chronic low back pain. The diagnosis of this rare neurological condition rests mainly on the clinical findings of axial and proximal limb rigidity, increased lumbar lordosis often accompanied with pain, and normal neurological findings apart from brisk deep tendon reflexes. Electromyography of the lumbar paraspinal muscles shows motor unit firing at rest with normal appearance of the motor unit potentials. Titers of antibody to glutamic acid decarboxylase are elevated. Diazepam is the treatment of reference. Physical therapy can substantially improve quality of life.     

Atypical low back pain: stiff-person syndrome

Stiff-person syndrome was diagnosed in a patient with chronic low back pain. The diagnosis of this rare neurological condition rests mainly on the clinical findings of axial and proximal limb rigidity, increased lumbar lordosis often accompanied with pain, and normal neurological findings apart from brisk deep tendon reflexes. Electromyography of the lumbar paraspinal muscles shows motor unit firing at rest with normal appearance of the motor unit potentials. Titers of antibody to glutamic acid decarboxylase are elevated. Diazepam is the treatment of reference. Physical therapy can substantially improve quality of life.     

Acute Paraspinal Compartment Syndrome as a Rare Cause of Loin Pain

A significant proportion of emergency urological admissions are comprised of ureteric colic presenting as loin pain. A variety of alternative pathologies present in this manner and should be considered during systematic assessment. We report the case of a patient admitted with severe unilateral back and flank pain after strenuous deadlift exercise. Clinical examination and subsequent investigation following a significant delay demonstrated acute paraspinal compartment syndrome (PCS) after an initial misdiagnosis of ureteric colic. The patient was managed conservatively. We review the current literature surrounding the rare diagnosis of PCS and discuss the management options.     

Paraspinal arteriovenous fistula presenting with subarachnoid hemorrhage and acute progressive myelopathy--case report

A 60-year-old man presented with paraspinal arteriovenous fistula (AVF) manifesting as subarachnoid hemorrhage (SAH) and acute progressive myelopathy. The patient presented with sudden onset of low back pain and paraparesis. Spinal magnetic resonance imaging revealed a vascular malformation on the lumbar spinal canal. Three-dimensional computed tomography angiography demonstrated a paraspinal AVF in the sacral ventral pelvis. The clinical symptoms were progressing rapidly, so transarterial embolization and surgical drainage ligation were performed. Paraspinal AVF may present with SAH and cause acute progressive myelopathy. Prompt examination and treatment are necessary.     

The lumbar facet syndrome

A clinical study was undertaken to formulate better criteria for accurate diagnosis of the lumbar facet syndrome and for predicting treatment response to facet joint injection. Twenty-two consecutive patients with a clinical diagnosis of lumbar facet syndrome, made by conventional diagnostic criteria, who were then treated with facet joint injection, were reviewed for their treatment responses. New diagnostic criteria were formulated based on a scoring system derived from the values observed in this review study. The scoring system has a total of 100 points, allocated as follows: back pain associated with groin or thigh pain, 30 points; well-localized paraspinal tenderness, 20 points; reproduction of pain with extension-rotation, 30 points; corresponding radiographic changes, 20 points; and pain below the knee, -10 points. A score of 60 points or more indicates a very high probability of satisfactory response to facet joint injection (100% prolonged response in this study). When only the conventional criteria were used, the overall results of prolonged relief of pain after facet joint injection was 50%. A "scorecard" system is proposed that may give a higher degree of diagnostic accuracy and predictability of successful response to facet joint injection.     

Chondroblastoma of the lumbar spine with cauda equina syndrome

STUDY DESIGN: Case report. OBJECTIVE: To describe the clinical presentations, radiological features and clinical progress of a rare case of chondroblastoma of the lumbar spine. SETTING: Regional Hospital, Hong Kong, China. METHOD: A 54-year-old male patient presented with low back pain and left sciatica. X-ray and MRI revealed tumour infiltration of the fifth lumbar vertebrae and left paraspinal muscles, which was found to be a chondroblastoma by repeated open biopsies. The tumour was removed surgically by combined anterior and posterior approaches, followed by spinal fusion and instrumentation. RESULTS: The anterior tricortical bone graft was complicated with fracture and nonunion. Surgical re-exploration confirmed local recurrence of tumour macroscopically and histologically. The patient developed symptoms and signs of cauda equina syndrome gradually despite repeated surgery and irradiation. The patient eventually died of complications of local recurrence and neurological deficit at 3 years and 8 months after the first operation. CONCLUSION: This is the first case report of chondroblastoma of the lumbar spine. The clinical profile of this patient and the evidence from the literature review suggests that spinal chondroblastoma has a very aggressive behaviour with high recurrence and mortality rate.     

腰骶部慢性骨筋膜室综合征所致慢性腰痛的诊断和治疗

目的 :探讨由慢性骨筋膜室综合征所致慢性腰痛的临床诊断、手术治疗的方法。方法 :对慢性腰痛患者采用临床检查、影像学检查、腰部竖脊肌骨筋膜室内压测量、骨筋膜室切开、减压手术治疗 ,术后腰、腹肌功能锻炼。结果 :慢性腰痛患者行骨筋膜室切开、减压治疗后较术前下腰痛症状和体征明显好转、步行能力明显增加、ADL得到明显改善 ,腰部骨筋膜室内压在静止、运动中和运动后 6min以内分别在 8、175和 8mmHg以下 (手术前分别为 8、175和 8mmHg以上 ) ,腰部前屈、后伸活动度较术前分别增加 ( 15± 0 .5 )°和 ( 7± 0 .7)° ,多普勒超声腰部骨骼肌内血流量较术前明显增加 ,竖脊肌肌力较术前增加 ( 1.0± 0 .3)kg。结论 :应用临床、影像学检查及骨筋膜室内压测定的方法诊断由慢性骨筋膜室综合征所致慢性腰痛及采用骨筋膜室切开、减压的方法治疗该疾病是非常有效的。     

Lumbar paraspinal compartment syndrome. A case report with physiologic and anatomic studies

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 dis-sections 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.     

Lumbar paraspinal rhabdomyolysis and compartment syndrome after abdominal aortic aneurysm repair

Lumbar paraspinal compartment syndrome is an extremely uncommon condition that is known to occur after strainful exercise or trauma. We report on the original case of a 55-year-old man in whom lumbar paraspinal rhabdomyolysis and compartment syndrome developed after open abdominal aortic aneurysm repair, documented with technetium Tc(99m) bone scan and computed tomographic imaging, and in whom successful complete recovery was achieved with conservative management. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.     

Exercise-induced acute bilateral isolated anterolateral compartment syndrome of the leg: a case report of a rare condition

Acute compartment syndrome of the leg is generally a consequence of trauma. Exercise-induced acute compartment syndrome of the leg is an exceptional clinical entity observed in the context of a chronic compartment syndrome or as an isolated acute syndrome subsequent to an intense effort. Our patient was a young athlete with no history of exercise-induced leg pain. Following a soccer game, he developed an acute leg syndrome involving the anterolateral compartment of both legs. The diagnosis was not suggested by the patient's history (no notion of chronic compartment syndrome) nor the natural history of the condition but was retained on the basis of the clinical presentation and course then confirmed by intramuscular pressure measurements. Emergency treatment by fasciotomy under general anesthesia in the operating room led to cure with no sequela. The fasciotomy was closed on day 9 with simple skin sutures. Surgeons should be aware that acute exercise-induced compartment syndrome (with the risk of severe functional consequences) may be the cause of unexplained intense leg pain. The diagnosis is established on the basis of clinical findings and measurement of intramuscular pressures. Pain is the cardinal sign, sometimes associated with sensorial deficit. The compartment is hard and painful at palpation. Passive stretching exacerbates the pain. Compartment pressure is required for certain diagnosis, most Authors accepting > 30mmHg as a positive test. Emergency fasciotomy is required.     

Lumbar facet joint infection associated with epidural and paraspinal abscess: a case report with review of the literature

A case of lumbar facet joint infection associated with epidural and paraspinal abscess is presented. A 57-year-old man was hospitalized with severe low back pain that radiated into the bilateral buttocks and legs. The patient had a temperature of 37.3 degrees C, and the biochemical inflammatory parameters were elevated. Initially on admission, we administered antibiotics intravenously. However, pain increased, fever elevated gradually, and bladder-bowel disturbance appeared. Magnetic resonance imaging (MRI) showed effusion in the widened facet joint, paraspinal muscles, and epidural space, which compressed the theca severely. We performed an immediate surgical debridement combined with thorough antibiotic therapy and achieved excellent results. MRI was useful for precise diagnosis and operative planning.     

Acute compartment syndromes

BACKGROUND: Acute compartment syndrome is both a limb- and life-threatening emergency that requires prompt treatment. To avoid a delay in diagnosis requires vigilance and, if necessary, intracompartmental pressure measurement. This review encompasses both limb and abdominal compartment syndrome, including aetiology, diagnosis, treatment and outcome. METHODS: A Pubmed and Cochrane database search was performed. Other articles were cross-referenced. RESULTS AND CONCLUSION: Diagnosis of limb compartment syndrome is based on clinical vigilance and repeated examination. Many techniques exist for tissue pressure measurement but they are indicated only in doubtful cases, the unconscious or obtunded patient, and children. However, monitoring of pressure has no harmful effect and may allow early fasciotomy, although the intracompartmental pressure threshold for such an undertaking is still unclear. Abdominal compartment syndrome requires measurement of intra-abdominal pressure because clinical diagnosis is difficult. Treatment is by abdominal decompression and secondary closure. Both types of compartment syndrome require prompt treatment to avoid significant sequelae.     

Septic arthritis of lumbar facet joints without predisposing infection

Septic arthritis of a lumbar facet joint is a rare clinical entity and most articles have reported a single case. There have been few studies that have evaluated the clinical and imaging features of septic arthritis of lumbar facet joints. The clinical data of 5 patients diagnosed with septic arthritis of lumbar facet joints were retrospectively studied. The average age of 5 patients was 73.6 years. All patients had elevated temperature at admission (37.7 degrees C). Leukocyte count was tested in all 5 patients and was elevated in only 2 patients. Erythrocyte sedimentation rate and C-reactive protein were examined and were elevated in all 5 cases. Magnetic resonance imaging was accurate in identifying the septic joint and associated abscess formation. All patients were treated with bed rest and received intravenous antibiotics for an average of 33.3 days. Four of 5 patients had positive outcomes with full recoveries and no evidence of recurrent infections. One patient exhibited evidence of recurrent infection and required open facet arthrotomy and paraspinal muscle debridement after intravenous administration of antibiotics. Septic arthritis of the lumbar facet joint is a rare cause of low back pain. It is important to ascertain the diagnosis at the earliest possible stage and to start intravenous antibiotics therapy as soon as possible. Magnetic resonance imaging is quite a sensitive modality for identifying infection of the lumbar facet joint. Familiarity with its clinical symptoms and radiographic features is necessary to avoid misdiagnosis of this condition.     

Articular facets syndrome: diagnostic grading and treatment options

Approximately 80% of the adult population suffers from chronic lumbar pain with episodes of acute back pain. The aetiology of this disorder can be very extensive: degenerative scoliosis, spondiloarthritis, disc hernia, spondylolysis, spondylolisthesis and, in the most serious cases, neoplastic or infectious diseases. For several years, the attention of surgeons was focused on the articular facets syndrome (Lilius et al. in J Bone Joint Surg (Br) 71-B:681–684, 1998), characterised clinically by back pain and selective pressure soreness at the level of the facets involved. The instrumental framework highlights widespread zigoapophysary arthritis and hypertrophy/degeneration of articular facets due to a functional overload. This retrospective study analyses the patients who arrived at our observation and were treated with a neuroablation using a pulsed radiofrequency procedure, after a CT-guided infiltration test with anaesthetic and cortisone. From the data collected, it would seem that this procedure allows a satisfactory remission of the clinical symptoms, leaving the patient free from pain; furthermore, this method can be repeated in time.     

Delayed presentation of septic arthritis of a lumbar facet joint after diagnostic facet joint injection

We report the case of a 46-year-old, otherwise healthy, man with chronic lower back pain and no evidence of nerve root compression who underwent diagnostic facet joint injections to assist in establishing where his pain sources were located and to try to help his spinal rehabilitation program. He presented with a facet joint infection 2 months after injection, in a manner that was indistinguishable from an acute intervertebral disc herniation. The diagnosis was confirmed on magnetic resonance imaging, and he was successfully treated with surgical debridement and antibiotics. Septic arthritis of a lumbar facet joint with an associated paraspinal abscess is a rare complication of facet joint infiltration with only two similar cases reported in the literature. We propose that this diagnosis be considered in patients who have undergone diagnostic facet joint injection who subsequently deteriorate with back and leg pain without another apparent cause.     

Management of a Patient with Lumbar Segmental Instability Using a Clinical Predictor Rule

The diagnosis of low back pain is a common and costly condition in primary healthcare, which is often grouped into a homogeneous category. It has been suggested that the population of patients with low back pain are not a homogenous group and that they should be classified into subgroups. One subgroup identified in the literature is patients thought to have lumbar segmental instability. The patient in this case report is a 59-year-old female who presented with the four predictors of success demonstrated by Hicks et al. for implementing a lumbar stabilization program for a patient with lumbar segmental instability. With conservative treatment utilizing a lumbar stabilization program, the patient was able to regain strength, lumbar stability, and demonstrate functional improvement evidenced by an improvement in her Oswestry score. It is recommended that knowledge of current literature including clinical predictor rules can help to improve clinical decision making along with treatment of patients.     

双侧小切口椎旁肌间隙入路在下腰椎融合术中应用

[目的]探讨双侧小切口椎旁肌间隙入路在下腰椎融合术中的应用价值。[方法]自2008年6月～2009年10月,选择性对32例单节段下腰椎疾患行椎弓根螺钉加椎间融合器内固定术,均采用双侧小切口椎旁肌间隙即Wilt-se多裂肌和最长肌肌间隙入路。其中男性14例,女性18例;年龄37～65岁,平均51.2岁;病变节段:L3、46例,L4、517例,L5S19例;病种类型:腰椎退行性不稳12例,极外型或椎间孔型椎间盘突出7例,腰椎滑脱5例,椎间盘原位复发5例,椎间盘源性疼痛3例,均表现为严重的下腰痛伴单侧肢体出现放射症状或无双下肢症状。根据Oswe-stry功能障碍指数(ODI)评分和伤口视觉模拟法(VAS)疼痛评分来评估疗效。[结果]手术平均时间106 min,术中平均出血量319 ml,术后平均引流量137 ml,住院平均天数13.5 d。术前ODI评分为(37.3±6.1)分,术后3个月时为(19.1±4.7)分,末次随访时为(11.8±3.7)分;术前VAS疼痛评分为(7.2±1.2)分,术后3个月时为(2.5±0.7)分,末次随访时为(2.1±0.9)分,统计分析显示术前和术后3个月或末次随访时的ODI、VAS评分差异均有统计学意义(P<0.05)。所有病例均获得24个月以上随访,影像学检查示良好的椎间骨性融合现象。[结论]双侧小切口椎旁肌间隙入路行下腰椎融合术能有效地保护椎旁肌,并达到减压、融合目的,是较实用并容易推广的腰椎后路"微创"手术方式。     

Tophaceous gout of the lumbar spine mimicking pyogenic discitis.

BACKGROUND CONTEXT: Gout of the spine is very rare. Forty-one cases of gout affecting the spine have been reported. PURPOSE: To present a patient with tophaceous gout of the lumbar spine mimicking pyogenic discitis. STUDY DESIGN: Case report. METHODS: The medical record, including operative notes, progress notes, discharge summary, clinical notes, radiological study, and pathological studies was reviewed. RESULTS: The patient had acute low back pain and radiculopathy with high spiking fever. Therefore, pyogenic discitis was suspected. However, histological diagnosis revealed tophaceous gout. CONCLUSIONS: Tophaceous gout of the spine is very rare. However, when a patient presents with acute back pain and fever, spinal gout should be considered, particularly in a patient with a previous history of hyperuricemia or gout.