Correspondence and communications
References 1. Poly implant prothese (PIP) breast implants: final report of the expert group https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/146635/dh_134657. pdf.pdf. 2. Lahiri A, Waters R. Locoregional silicone spread after high cohesive gel silicone implant rupture. J Plast Reconstr Aesthet Surg 2006;59:885e6. 3. Cawrse NH, Pickford MA. Cutaneous manifestation of silicone dissemination from a PIP implant e a case for prophylactic explanation? J Plast Reconstr Aesthet Surg 2011;64:208e9. 4. Bartsich S, Wu JK. Silicone emboli syndrome: a sequela of clandestine liquid silicone injections. A case report and review of the literature. J Plast Reconstr Aesthet Surg 2010;63: e1e3. 5. Berry MG, Stanek JJ. The PIP mammary prothesis: a product recall study. J Plast Reconstr Aesthet Surg 2012;65: 697e704.
T. Tickunas S. Howarth Y. Godwin Department of Plastic and Reconstructive Surgery, Morriston Hospital, Heol Maes Eg Lwys, Morriston, Swansea SA6 6NL, UK E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.028
Acute exertional lumbar paraspinal compartment syndrome treated with fasciotomy and dermatotraction: Case report
425 A 30-year old man who had not exercised regularly visited the emergency department with a chief complaint of severe acute onset back pain, which occurred after weight training. One day before admission, he performed 55 repetitions of deadlift, bench press and back extension, respectively, for 2 h. In addition, he performed lower leg exercises for 2 h on the very day of admission. After finishing exercises, he developed abrupt back pain. He complained that it progressed and was aggravated when rising or turning his back. The patient had no underlying diseases, medical history, trauma history and any similar episodes of back pain. Physical examinations showed firmness, fullness and localized tenderness of paraspinal area. Initial laboratory examinations revealed elevated serum creatinine phosphokinase (CPK) of 67,200 U/L, myglobin of more than 1000 ng/mL, aspartate aminotransferase (AST) of 632 IU/L, alanine aminotransferase (ALT) of 133 IU/L and lactate dehydrogenase (LDH) of 3048 IU/L. Urinalysis showed elevated myoglobin of 932 U/L and microscopic proteinuria, indicating acute kidney injury. A T2-weighted magnetic resonance imaging (MRI) scan showed an increased signal intensity and a diffuse swelling in the bilateral paraspinal muscles without fluid collection (Figure 1). The patient underwent massive hydration after being diagnosed with rhabdomyolysis. Eight hours after admission, he underwent fasciotomy on bilateral paraspinal muscle because he was suspected of having acute paraspinal compartment syndrome. In this patient, we made a bilateral paramedian incision via a Wiltse approach4 centered over the paraspinal muscles extending from T10 to L5 level. The paraspinal muscles had a partial necrosis with a focal gray color. Two days after the decompression, he achieved an improvement of pain and a gradual stabilization of elevated serum biochemical markers. Because approximation of incision wound was challenging for us
Dear Sir, Acute compartment syndrome of lumbar paraspinal muscles occurs after exertional activities such as, skiing, weightlifting and surfing. It is a very rare condition that nine articles and ten patients have been reported worldwide until now.1e3 This can cause necrosis and irreversible injury of muscle and surrounding tissue because of increased pressure of closed fibro-osseous space. Therefore, immediate diagnosis and decompression with fasciotomy should be performed.1e3 We report two cases of acute exertional lumbar paraspinal compartment syndrome which were treated with fasciotomy. In addition, we achieved a successful secondary closure of wide fasciotomy site using dermatotraction with Kirschner and steel wires.
Figure 1 A T2-weighted MR image of lumbar spine of case 1. It shows bilateral edema with diffuse increased signal intensity in paraspinal muscles.
426
Correspondence and communications by Volkmann in 1881. Moreover, it is a very rare condition that occurs in the paraspinal space, located close to the fascial space and supported by thoracolumbar fascia anteriorly, posteriorly and laterally, spinous process medially and attachments of interspinous ligaments and thoracolumbar fascia.1,2 Nathan et al.1 reported the diagnostic criteria for acute lumbar paraspinal compartment syndrome Including symptoms, signs, history, clinical features, laboratory and MRI findings. Both cases of ours met the criteria. Conservative management including aggressive hydration, pain control and urine alkalinization is the first line of treatment choice. In patients with increased intramuscular pressure on pressure measurement or an evidence of rhabdomyolysis, however, urgent surgical decompression should be considered.1e3 Acute exertional lumbar paraspinal compartment syndrome has a rarity but it is of clinical significance in that delayed diagnosis and management of it can cause fatal complications. Therefore, clinicians should be aware of it as a candidate condition in making a differential diagnosis of patients with back pain that occurred after exertional activities.
Figure 2 Postoperative 1-month photograph shows two parallel depressed scar, but there is no specific wound problems including fluctuation or infection signs.
because of a swelling of tissue and a tension of bipedicled incisional flap, we applied dermatotraction with 1.25 mm Kirschner and 25-gauge steel wires on postoperative day 10. On postoperative day 14, we performed secondary closure. The patient returned to usual activities except weight lifting on postoperative month 1 (Figure 2). Moreover, he was recovered without any residual deficit, which was accompanied by the normalization of laboratory data during a follow-up period of 6 months. A 31-year old man had quit a weight training 3 months before presenting to the emergency department with a severe acute onset back pain. He had exercised 2 h a day since 1-week before admission. The pain was developed abruptly when he raised his back from supine position and then gradually aggravated for several hours. Initial laboratory examinations demonstrated elevated serum and urine biochemical markers such as CPK, LDH, AST, ALT and myoglobin. An MRI scan showed asymmetric enlargement of left paraspinal muscle and increased signal of erector spinae muscles at the thoracic and lumbar levels. The patient underwent fasciotomy at 6 h after admission. We performed partial closure and applied VAC device between postoperative days 5 and 10. After ensuring that edema was subsided and tension was reduced, we performed secondary closure. He returned to usual activities without any complications during a follow-up period of 6 months. Compartment syndrome has been reported in all the anatomical areas of extremities since it was first described
Disclosure The authors have no commercial associations or financial interests that might pose or create a conflict of interest with information presented in this article.
References 1. Nathan ST, Roberts CS, Deliberato D. Lumbar paraspinal compartment syndrome. Int Orthop 2012;36:1221e7. 2. Paryavi E, Jobin CM, Ludwig SC, Zahiri H, Cushman J. Acute exertional lumbar paraspinal compartment syndrome. Spine 2010;35:E1529e33. 3. Wik L, Patterson JM, Oswald AE. Exertional paraspinal muscle rhabdomyolysis and compartment syndrome: a cause of back pain not to be missed. Clin Rheumatol 2010;29:803e5. 4. Wiltse LL, Bateman JG, Hutchinson RH, Nelson WE. The paraspinal sacrospinalis-splitting approach to the lumbar spine. The J Bone Jt Surg Am Volume 1968;50:919e26.
Eun Young Rha Dae Ho Kim Gyeol Yoo Department of Plastic and Reconstructive Surgery, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea E-mail addresses: [email protected], [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.026
References 1. Poly implant prothese (PIP) breast implants: final report of the expert group https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/146635/dh_134657. pdf.pdf. 2. Lahiri A, Waters R. Locoregional silicone spread after high cohesive gel silicone implant rupture. J Plast Reconstr Aesthet Surg 2006;59:885e6. 3. Cawrse NH, Pickford MA. Cutaneous manifestation of silicone dissemination from a PIP implant e a case for prophylactic explanation? J Plast Reconstr Aesthet Surg 2011;64:208e9. 4. Bartsich S, Wu JK. Silicone emboli syndrome: a sequela of clandestine liquid silicone injections. A case report and review of the literature. J Plast Reconstr Aesthet Surg 2010;63: e1e3. 5. Berry MG, Stanek JJ. The PIP mammary prothesis: a product recall study. J Plast Reconstr Aesthet Surg 2012;65: 697e704.
T. Tickunas S. Howarth Y. Godwin Department of Plastic and Reconstructive Surgery, Morriston Hospital, Heol Maes Eg Lwys, Morriston, Swansea SA6 6NL, UK E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.028
Acute exertional lumbar paraspinal compartment syndrome treated with fasciotomy and dermatotraction: Case report
425 A 30-year old man who had not exercised regularly visited the emergency department with a chief complaint of severe acute onset back pain, which occurred after weight training. One day before admission, he performed 55 repetitions of deadlift, bench press and back extension, respectively, for 2 h. In addition, he performed lower leg exercises for 2 h on the very day of admission. After finishing exercises, he developed abrupt back pain. He complained that it progressed and was aggravated when rising or turning his back. The patient had no underlying diseases, medical history, trauma history and any similar episodes of back pain. Physical examinations showed firmness, fullness and localized tenderness of paraspinal area. Initial laboratory examinations revealed elevated serum creatinine phosphokinase (CPK) of 67,200 U/L, myglobin of more than 1000 ng/mL, aspartate aminotransferase (AST) of 632 IU/L, alanine aminotransferase (ALT) of 133 IU/L and lactate dehydrogenase (LDH) of 3048 IU/L. Urinalysis showed elevated myoglobin of 932 U/L and microscopic proteinuria, indicating acute kidney injury. A T2-weighted magnetic resonance imaging (MRI) scan showed an increased signal intensity and a diffuse swelling in the bilateral paraspinal muscles without fluid collection (Figure 1). The patient underwent massive hydration after being diagnosed with rhabdomyolysis. Eight hours after admission, he underwent fasciotomy on bilateral paraspinal muscle because he was suspected of having acute paraspinal compartment syndrome. In this patient, we made a bilateral paramedian incision via a Wiltse approach4 centered over the paraspinal muscles extending from T10 to L5 level. The paraspinal muscles had a partial necrosis with a focal gray color. Two days after the decompression, he achieved an improvement of pain and a gradual stabilization of elevated serum biochemical markers. Because approximation of incision wound was challenging for us
Dear Sir, Acute compartment syndrome of lumbar paraspinal muscles occurs after exertional activities such as, skiing, weightlifting and surfing. It is a very rare condition that nine articles and ten patients have been reported worldwide until now.1e3 This can cause necrosis and irreversible injury of muscle and surrounding tissue because of increased pressure of closed fibro-osseous space. Therefore, immediate diagnosis and decompression with fasciotomy should be performed.1e3 We report two cases of acute exertional lumbar paraspinal compartment syndrome which were treated with fasciotomy. In addition, we achieved a successful secondary closure of wide fasciotomy site using dermatotraction with Kirschner and steel wires.
Figure 1 A T2-weighted MR image of lumbar spine of case 1. It shows bilateral edema with diffuse increased signal intensity in paraspinal muscles.
426
Correspondence and communications by Volkmann in 1881. Moreover, it is a very rare condition that occurs in the paraspinal space, located close to the fascial space and supported by thoracolumbar fascia anteriorly, posteriorly and laterally, spinous process medially and attachments of interspinous ligaments and thoracolumbar fascia.1,2 Nathan et al.1 reported the diagnostic criteria for acute lumbar paraspinal compartment syndrome Including symptoms, signs, history, clinical features, laboratory and MRI findings. Both cases of ours met the criteria. Conservative management including aggressive hydration, pain control and urine alkalinization is the first line of treatment choice. In patients with increased intramuscular pressure on pressure measurement or an evidence of rhabdomyolysis, however, urgent surgical decompression should be considered.1e3 Acute exertional lumbar paraspinal compartment syndrome has a rarity but it is of clinical significance in that delayed diagnosis and management of it can cause fatal complications. Therefore, clinicians should be aware of it as a candidate condition in making a differential diagnosis of patients with back pain that occurred after exertional activities.
Figure 2 Postoperative 1-month photograph shows two parallel depressed scar, but there is no specific wound problems including fluctuation or infection signs.
because of a swelling of tissue and a tension of bipedicled incisional flap, we applied dermatotraction with 1.25 mm Kirschner and 25-gauge steel wires on postoperative day 10. On postoperative day 14, we performed secondary closure. The patient returned to usual activities except weight lifting on postoperative month 1 (Figure 2). Moreover, he was recovered without any residual deficit, which was accompanied by the normalization of laboratory data during a follow-up period of 6 months. A 31-year old man had quit a weight training 3 months before presenting to the emergency department with a severe acute onset back pain. He had exercised 2 h a day since 1-week before admission. The pain was developed abruptly when he raised his back from supine position and then gradually aggravated for several hours. Initial laboratory examinations demonstrated elevated serum and urine biochemical markers such as CPK, LDH, AST, ALT and myoglobin. An MRI scan showed asymmetric enlargement of left paraspinal muscle and increased signal of erector spinae muscles at the thoracic and lumbar levels. The patient underwent fasciotomy at 6 h after admission. We performed partial closure and applied VAC device between postoperative days 5 and 10. After ensuring that edema was subsided and tension was reduced, we performed secondary closure. He returned to usual activities without any complications during a follow-up period of 6 months. Compartment syndrome has been reported in all the anatomical areas of extremities since it was first described
Disclosure The authors have no commercial associations or financial interests that might pose or create a conflict of interest with information presented in this article.
References 1. Nathan ST, Roberts CS, Deliberato D. Lumbar paraspinal compartment syndrome. Int Orthop 2012;36:1221e7. 2. Paryavi E, Jobin CM, Ludwig SC, Zahiri H, Cushman J. Acute exertional lumbar paraspinal compartment syndrome. Spine 2010;35:E1529e33. 3. Wik L, Patterson JM, Oswald AE. Exertional paraspinal muscle rhabdomyolysis and compartment syndrome: a cause of back pain not to be missed. Clin Rheumatol 2010;29:803e5. 4. Wiltse LL, Bateman JG, Hutchinson RH, Nelson WE. The paraspinal sacrospinalis-splitting approach to the lumbar spine. The J Bone Jt Surg Am Volume 1968;50:919e26.
Eun Young Rha Dae Ho Kim Gyeol Yoo Department of Plastic and Reconstructive Surgery, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea E-mail addresses: [email protected], [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.026
