Lumbar paraspinal compartment syndrome

The purpose of this study was to systematically review the available evidence on lumbar paraspinal compartment syndrome with specific reference to patient demographics, aetiology, types, diagnosis, clinical features, and treatment. This was an Institutional Review Board-exempt study performed at a Level 1 trauma center. A PubMed search was conducted with the title query: lumbar paraspinal compartment syndrome. Eleven articles met our search criteria. Three of the patients with acute paraspinal compartmental syndrome treated with fasciotomy had a full recovery and were able to resume skiing after four months. The aetiology of the onset of lumbar paraspinal compartment syndrome is broadly divided into acute and chronic. Lumbar paraspinal compartment syndrome is one of the causes of back pain with diagnostic clinical features which should be considered in the differential diagnosis of a patient with low back pain. Prospective multicentre trials may provide the surgeon with more insight into the diagnosis and management of lumbar paraspinal compartment syndrome.     

Clinical practice guidelines for the management of acute limb compartment syndrome following trauma

Background: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. Methods: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. Results: Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well‐designed clinical trial evidence. Conclusions: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes.     

Syndromes des loges

The hallmark of any compartment syndrome, whether acute or chronic, is the elevation of soft tissue pressure within a closed space even if the primary event was different. Acute cases are most often trauma-related and can lead to irreversible neuromuscular dysfunction. They require immediate dermofasciotomy to decompress the soft tissue and avoid ischemia. The diagnosis should rely on physical examination and be confirmed by tissue pressure measurement. If not treated in time, they can result in major sequelae and even amputation. Chronic compartment syndromes are mostly exercise-induced and then mainly related to sport practice. Pressure measurements during provocative test are required to ascertain that exercise-related pain is due to a compartment syndrome. Percutaneous fasciotomy is necessary to alleviate symptoms.     

Compartment syndrome after acute rupture of the peroneus longus in a high school football player: a case report

We report the case of a young athlete who sustained an inversion injury to his ankle and presented several hours later with leg pain out of proportion to the injury. Pressure measurements suggested a lateral compartment syndrome and he underwent an emergency fasciotomy. The case is described and recommendations for diagnosis and treatment are given. Acute compartment syndrome of the lower extremity is an orthopedic emergency. Expedient release by emergent fasciotomy can minimize the likelihood of serious consequences such as myonecrosis and ischemic contracture. Most commonly, compartment syndrome is the result of acute high-energy trauma and typically is managed by the orthopedic traumatologist.     

Lower limb compartment syndrome following laparoscopic colorectal surgery: a review

Aim In spite of recent advances in technology and technique, laparoscopic colorectal surgery is associated with increased operating times when compared with open surgery. This increases the risk of acute lower limb compartment syndrome. The aim of this review was to gain a better understanding of postoperative lower limb compartment syndrome following laparoscopic colorectal surgery and to suggest strategies to avoid its occurrence. Method A MEDLINE search was performed using the keywords ‘compartment syndrome’, ‘laparoscopic surgery’ and ‘Lloyd‐Davies position’ between 1970 and 2008. All relevant articles were retrieved and reviewed. Results A total of 54 articles were retrieved. Of the 30 articles in English, five were reviews, six were original articles and 19 were case reports, of which only one was following laparoscopic colorectal surgery. The remaining 24 were non‐English articles. Of these, two were reviews and 22 were case reports, of which only one was following laparoscopic colorectal surgery. The incidence of acute compartment syndrome following laparoscopic colorectal surgery is unknown. The following are believed to be risk factors for acute lower limb compartment syndrome: the Lloyd‐Davies operating position with exaggerated Trendelenburg tilt, prolonged operative times and improper patient positioning. Simple strategies are suggested to reduce its occurrence. Conclusion Simple preventative measures have been identified which may help to reduce the incidence of acute lower limb compartment syndrome. However, if suspected, timely surgical intervention with four‐compartment fasciotomy remains the standard of care.     

Acute Compartment Syndrome of the Lower Leg: Retrospective Study on Prevalence,Technique, and Outcome of Fasciotomies

The acute compartment syndrome is caused by bleeding or edema in a closed muscle compartment surrounded by fascia and bone. It is characterized by increased intracompartmental pressure and decreased tissue perfusion. Well-known causative incidents are acute trauma and reperfusion after treatment for acute arterial obstruction. Most commonly the lower leg is involved. Inadequate therapy of the syndrome usually leads to muscle ischemia, rhabdomyolysis, and renal insufficiency. Perioperative morbidity and mortality are high. Although compartment syndromes can be caused by various factors, up until now no comparative studies have been published on clinical outcome of compartment syndromes of different origin. In this retrospective study we analyzed 40 successive cases of fasciotomy for acute lower leg compartment syndrome to study whether different causes of the syndrome lead to different clinical outcomes. We also studied other predictive factors for clinical outcome. The causes for the compartment syndromes were trauma, vascular deobstruction, cardiac surgery, and gastrointestinal surgery in lithotomy position. Clinical outcome showed a mortality of 15% and serious overall morbidity. Multivariate analysis showed the only significant predictive determinant of outcome to be the age of the patient. Fasciotomy for acute compartment syndrome is associated with serious morbidity and mortality. No correlation between causative factors and clinical outcome could be found.     

Vacuum-assisted closure for fasciotomy wounds following compartment syndrome of the leg

This study evaluated the efficacy of vacuum-assisted closure (VAC) for treatment of fasciotomy wounds for traumatic compartment syndrome. The authors reviewed the records of a consecutive series of 34 patients who had compartment syndrome of the leg requiring the standard two-incision release of all four compartments and received the application of VAC therapy until the time of definitive wound closure or coverage. A matched series of 34 consecutive antecedent patients with the same entry criteria, except for the use of the VAC, were also studied and served as a control group. The main parameter of interest was the time to "definitive closure" (delayed primary closure with sutures or skin graft coverage) of the wounds. Of the 68 wounds in 34 patients managed with VAC, the average time to definitive closure for both the lateral and the medial wounds was 6.7 days. For the 70 wounds in the 34 control patients, the average time to definitive closure was 16.1 days. This difference in time to wound closure between the VAC group and the non-VAC group was statistically significant (p < .05). Subatmospheric treatment for compartment syndrome of the leg after fasciotomy theoretically helps to speed the resolution of the swelling and tissue edema that are often components of this clinical entity. Experimental work has shown vacuum-assisted wound management to be effective in hastening the resolution of wound edema, enhancing local blood flow, promoting granulation tissue, and thwarting bacterial colonization. These factors may account for its utility in the management of fasciotomy wounds in the setting of compartment syndrome of the leg.     

Compartment Syndrome of the Lower Leg and Foot

Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary.     

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.     

Lower limb compartment syndrome following lumbar discectomy in the knee-chest position

We report on two cases of compartment syndrome following lumbar discectomy in the knee-chest position. This complication has only been described once since 1953. Seven cases of compartment syndrome following other surgical procedures were found in the literature. Any increases in tissue pressure of a muscle compartment exceeding 35–40 mmHg over a longer period of time can result in this complication for example, too tight cast, space-occupying intrafascial bleeding, or postischemic swelling. The diagnosis is purely clinical and is based on the typical combination of extremely painful edema with rapid onset of sensory loss and subsequent motor deficits. The muscle necrosis leads to myoglobinaemia and myoglobinuria, recognizable by brown urine. The therapy consists of urgent fasciotomy of swollen compartements without skin suture. The prognosis is highly dependent on the time of the surgical decompression: within 6 hours serious deficits are avoidable; after 24 hours irreversible necrosis of muscle occurs. It seems that the possibility of a compartment syndrome is a specific, but a rare risk of a prolonged knee-chest position.     

Acute Compartment Syndrome of the Thigh with Sciatic Nerve Palsy after Femoral Fractures

Acute compartment syndromes of the thigh are rare and have been infrequently reported in the literature. They occur with greatest frequency in association with femoral fractures. Patients who sustained multiple trauma have an increased susceptibility to the development of compartment syndrome of the thigh, and compartment syndromes are often overlooked in these cases. A compartment syndrome in a cooperative patient can be diagnosed clinically, but it presents a special challenge if the patient is multiply injured and unable to cooperate with the physical examination. Left unrecognized, compartment syndromes of the thigh can result in permanent damage to muscle and nerve in that compartment. Early diagnosis through a high index of suspicion and measurement of intracompartmental pressure in each compartment is mandatory. Intraoperative measurement of compartment pressure is recommended in cases of impending compartment syndrome. Immediate fasciotomy is indicated to provide the optimum chance of recovery and to prevent microvascular compromise and necrosis of tissue. We present 3 cases of multiply injured patients in which sciatic nerve palsy followed fracture of the ipsilateral femur und compartment syndrome of the thigh. We found that the extent of myoneural necrosis seems to be dependent on the duration and magnitude of the elevated compartment pressure. A comprehensive review of the literature about compartment syndromes of the thigh is also presented.     

Biomarkers in post‐reperfusion syndrome after acute lower limb ischaemia

Ischaemia reperfusion (I/R) injury refers to tissue damage caused when blood supply returns to the tissue after a period of ischaemia. Matrix metalloproteinases (MMPs), neutrophil gelatinase‐associated lipocalin (NGAL) and cytokines are biomarkers involved in several vascular complications. The aim of this study was to evaluate the role of MMPs, NGAL and inflammatory cytokines in I/R syndrome. We conducted an open label, multicentric, parallel group study, between January 2010 and December 2013. Patients with acute limb ischaemia were enrolled in this study and were divided into two groups: (i) those subjected to fasciotomy and (ii) those not subjected to fasciotomy, according to the onset of compartment syndrome. Plasma and tissue values of MMPs and NGAL as well as plasma cytokines were evaluated. MMPs, NGAL and cytokine levels were higher in patients with compartment syndrome. Biomarkers evaluated in this study may be used in the future as predictors of I/R injury severity and its possible evolution towards post‐reperfusion syndrome.     

Near-infrared spectroscopy identifies compartment syndrome in an infant

Acute compartment syndrome is a surgical emergency requiring immediate intervention to limit tissue and nerve injury. Although the measurement of compartment pressure is frequently performed, there is controversy regarding the pressure at which fasciotomy should be performed. Near-infrared spectroscopy (NIRS) uses the same technology as pulse oximetry to estimate tissue oxygenation. To date, NIRS is used most commonly to estimate cerebral oxygenation during intraoperative anesthetic care. The authors present a 1-month-old infant who developed an acute compartment syndrome of the right lower extremity after cardiac surgery. In addition to the measurement of compartment pressures, the diagnosis of compartment syndrome was confirmed by NIRS with a value of 15% in the involved leg versus 40% to 50% in the noninvolved contralateral lower extremity. The potential use of this modality in identifying compartment syndrome is reviewed.     

Upper limb compartment syndrome after an adder bite:a case report

Compartment syndrome after an adder bite is extremely rare, whose effects are only secondary to the cytotoxic and hemorrhagic effects of venom. Here we reported a case of compartment syndrome in the upper limb following an adder bite in the thenar eminence. Elevated compartment pressure was documented and immediate surgical fasciotomy was practiced. The patient achieved complete recovery with a good functional result. We discussed the controversies on fasciotomy and non-invasive measures in such a situation, and recommended intracompartmental pressure monitoring during the management of compartment syndrome following adder bites.     

Long-term physical outcome of patients who suffered crush syndrome after the 1995 Hanshin-Awaji earthquake: prognostic indicators in retrospect.

BACKGROUND: The 372 cases of crush syndrome that followed the 1995 Hanshin-Awaji earthquake have provided a unique opportunity to investigate the long-term physical outcomes and to establish indications for specific treatments in such patients. The objectives of this study were to identify independent predictors of physical outcome in patients suffering from crush syndrome and to clarify the influence of fasciotomy on outcomes. METHODS: Sensory and motor functions were examined 2 years after the earthquake in 42 patients with a total of 58 compressed lower extremities. The influences of time to rescue, fasciotomy, and radical debridement on lower leg muscle strength were evaluated by stepwise regression analysis. Correlation between the time to fasciotomy and lower leg muscle strength was also analyzed. RESULTS: Severe disabilities related to the lower leg compartment were present in 47% (8/17) of patients who underwent fasciotomy and in 16% (4/25) of patients who did not. The anterior compartment was damaged more severely than the posterior compartment. Severe sensory and motor disturbances occurred at a higher rate in relation to anterior and posterior compartments that were treated by fasciotomy than in relation to those that were not. Stepwise regression analysis showed fasciotomy/debridement score to be an independent predictor of long-term lower leg muscle strength (R = 0.67, p < 0.0001) and showed time to rescue to be an independent predictor when debrided compartments were not included in the analysis (R = 0.36, p = 0.009). In all debrided anterior compartments, muscle contractility was completely abolished. There was a significant negative correlation between time to fasciotomy and lower leg muscle strength. CONCLUSION: Secondary compartment syndrome affects physical outcome in crush syndrome patients. We obtained no evidence that fasciotomy improves outcome. Delayed rescue, delayed fasciotomy, and radical debridement may worsen the physical prognosis. Indications for fasciotomy in crush syndrome during the acute phase need further deliberation.     

Gluteal compartment syndrome. A report of 4 cases.

Four cases of gluteal compartment syndrome are presented, 1 traumatic and 3 after an overdose of sedatives. Associated lesions included sciatic nerve palsy in 2 cases and acute renal failure in 1. Three cases with intramuscular pressure exceeding 60 mmHg underwent emergency fasciotomy. Intramuscular pressure monitoring is useful for evaluating the effect of fasciotomy.     

Staged minimally invasive plate osteosynthesis of proximal tibial fractures with acute compartment syndrome

PurposeHigh-energy proximal tibial fractures often accompany compartment syndrome and are usually treated by fasciotomy with external fixation followed by secondary plating. However, the initial soft tissue injury may affect bony union, the fasciotomy incision or external fixator pin sites may lead to postoperative wound infections, and the staged procedure itself may adversely affect lower limb function. We assess the results of staged minimally invasive plate osteosynthesis (MIPO) for proximal tibial fractures with acute compartment syndrome.MethodsTwenty-eight patients with proximal tibial fractures accompanied by acute compartment syndrome who underwent staged MIPO and had a minimum of 12 months follow-up were enrolled. According to the AO/OTA classification, 6 were 41-A, 15 were 41-C, 2 were 42-A and 5 were 42-C fractures; this included 6 cases of open fractures. Immediate fasciotomy was performed once compartment syndrome was diagnosed and stabilization of the fracture followed using external fixation. After the soft tissue condition normalized, internal conversion with MIPO was done on an average of 37 days (range, 9–158) after index trauma. At the time of internal conversion, the external fixator pin site grades were 0 in 3 cases, 1 in 12 cases, 2 in 10 cases and 3 in 3 cases, as described by Dahl. Radiographic assessment of bony union and alignment and a functional assessment using the Knee Society Score and American Orthopedic Foot and Ankle Society (AOFAS) score were carried out.ResultsTwenty-six cases achieved primary bony union at an average of 18.5 weeks. Two cases of nonunion healed after autogenous bone grafting. The mean Knee Society Score and the AOFAS score were 95 and 95.3 respectively, at last follow-up. Complications included 1 case of osteomyelitis in a patient with a grade IIIC open fracture and 1 case of malunion caused by delayed MIPO due to poor wound conditions. Duration of external fixation and the external fixator pin site grade were not related to the occurrence of infection.ConclusionsStaged MIPO for proximal tibial fractures with acute compartment syndrome may achieve satisfactory bony union and functional results, while decreasing deep infections and soft tissue complications.     

Delayed presentation of acute compartment syndrome after contusion of the thigh

Acute compartment syndrome has been described as a result of thigh contusion in several contact sports, and emergent fasciotomy has routinely been recommended. However, recent data suggest that thigh contusions in athletes presenting with isolated elevation of compartment pressures in the absence of neurovascular deficits may be treated expectantly. We describe a case of anterior thigh contusion, which initially presented with isolated compartmental hypertension without neurovascular symptoms. Under nonoperative treatment the patient developed delayed acute compartment syndrome from persistent muscular hemorrhage ten days after the initial trauma, requiring operative treatment. This case demonstrates that expanding hematoma formation may result in delayed increase of intramuscular pressures and compromise of myoneural perfusion in patients with severe thigh contusions. Early evacuation of the hematoma may help to prevent late development of compartment syndrome and reduce the risk for long-term complications.     

Compartment Syndrome of the Hand Induced by Peripherally Extravasated Phenylephrine

Background: Compartment syndrome of the hand is a rare and devastating complication of peripheral intravenous extravasation. With changes in critical care research, vasoactive medications are now more frequently administered through peripheral lines in the acute setting. Methods: We present the case of a patient diagnosed with compartment syndrome of the hand secondary to phenylephrine extravasation in the setting of hypovolemic shock. Results: The use of fasciotomy compartment release and intraoperative phentolamine resulted in significant improvement in tissue perfusion postoperatively. Conclusion: With incraesed incidence of peripherally administered vasoactive medications, the hand surgeon should be aware of potential complications and treatment of compartment syndrome with urgent fasciotomy and phentolamine administration.     

小腿骨筋膜室综合征治疗体会

目的:本文介绍43例小腿骨筋膜室综合征的治疗经验和一种新的暂时闭合筋膜切开减压伤口的方法。方法:采用回顾性研究。结果:外伤后直接接受治疗的35例病人中,33例获得优良结果,无后遗症,1例因严重挫伤而截肢,1例手术后死于急性肾功能衰竭和DIC。由外院治疗后转入的8例病人中,5例出现Volkmann缺血性肌挛缩,3例因肢体坏死而截肢。5例筋膜切开减压术后的伤口采用人工皮覆盖,二次手术伤口直接缝合。结论:小腿骨筋膜室综合征早期采用保守治疗对部分病人是有效的,如在治疗过程中症状、体征恶化,应尽早行筋膜室切开减压术。采用人工皮及负压吸引系统覆盖伤口能迅速降低组织压,防止感染。