AAPMR Annual AssemblySports and Soft Tissue Injuries- Musculoskeletal Case PresentationFriday, October 2nd, 2015

Jay M. Shah MD, Todd Miller MD, Eathar Saad MDDept. of Physical Medicine and RehabilitationMontefiore 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+ BLESensation intact BLESLR/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: 20-

200)

BUN/Cr: 16/1.1

LFTs• AST:1034• (Normal 13-50)• ALT: 214 (Normal 8-61)

CBC/CMP: otherwise

WNL

UA: Tea colored/+bloo

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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

Results

Compartment Pressures (Normal 0-8mmHg)

*Lumbar Paraspinals:• (R): 103mmhg• (L): 94mmhg

Anterior Thighs• (R): 16mmhg• (L): 22mmhg

Medial Thighs• (R): 13mmhg• (L): 10mmhg

*Posterior Thighs• (R): 20mmhg• (L): 25mmhg

MRI Images

M

L

*P

MRI Images

SMBF

*Q

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• PCAPO opiods

Rehab ConsultPatient was cleared WBAT + Full lumbar ROM

• 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 Rehab Evaluation

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!!!!References

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