Page 76 - JSOM Summer 2024

exceeding 1,000mg daily as well as a recent increase in weight-
lifting, including deadlifting the day prior. His medical history
was notable for left lower extremity compartment syndrome FIGURE 1 Axial T2 magnetic
sustained after a motorcycle accident injury and subsequent resonance imaging at the level of L3
demonstrating hyperenhancement
ruck marching. of the paraspinal musculature,
asymmetrically left worse than right,
Over the course of 28 hours, the patient was evaluated three consistent with myonecrosis.
times in the ED (see summary in Table 1). After being ap-
propriately evaluated and treated twice, he presented a third
time for worsening symptoms that did not respond to previ-
ous therapies. Vital signs on arrival included temperature of
36.6°C, heart rate of 84 beats per minute, blood pressure of FIGURE 2 Axial T2 magnetic
127/84mmHg, and peripheral oxygen saturation of 97% on resonance imaging at the level of L4
room air. Physical examination was notable for exquisitely demonstrating hyperenhancement
of the paraspinal musculature,
tender to palpation left-sided lumbar paraspinal muscles and asymmetrically left worse than right,
positive left-sided straight leg raise to 30°. He also exhibited consistent with myonecrosis.
pain with lumbar flexion and extension as well as passive
stretch lying both supine and prone. A CT scan was unremark-
able, and lab evaluation demonstrated elevations in creatine
kinase (CK), aspartate transferase (AST), and alanine transfer-
ase (ALT), consistent with rhabdomyolysis (see Table 1).
Orthopedic surgery was consulted because of concern for
paraspinal muscle compartment syndrome. MRI of the lumbar
spine demonstrated heterogeneous enhancement and mixed FIGURE 3 Sagittal T1 magnetic
resonance imaging from T10-S1
hypoenhancement of the paraspinal muscles from L3 to S1, left demonstrating hypoenhancement
worse than right, concerning for myonecrosis (Figures 1–3). of the paraspinal musculature,
An orthopedic surgeon performed a bilateral lumbar paraspi- prominent between L3 and S1.
nal fasciotomy from T12 to L5. Compartment pressures were
assessed using a Stryker needle, measuring 36mmHg on the
right and 32mmHg on the left prior to incision. The incision
sites were copiously irrigated and packed with 1g vancomycin
powder prior to negative pressure wound vacuum placement
under 75mmHg continuous suction.
Discharge analgesic prescriptions included hydromorphone,
Throughout subsequent hospitalization, pain control was ibuprofen, gabapentin, and methocarbamol. Outpatient fol-
achieved with hydromorphone patient-controlled analgesia, low-up demonstrated significant improvement of symptoms
and the patient completed daily physical therapy. He was dis- with some residual motor and sensory deficit, including en-
charged on admission day 5 with downtrending CK levels. during paresthesia of the left foot in the S1 distribution.

TABLE 1 Emergency Department Course
Symptoms Physical examination Notable workup Medications Interventions Disposition
Visit 1: • Low back • Lumbar paraspinal • 30mg ketorolac IM • Heat/cold • Discharge with
T=0 pain muscle tenderness • 975mg acetaminophen therapy methocarbamol
(oral) and ibuprofen
• 1,500mg methocarbamol prescriptions
(oral)
Visit 2: • Worsening • Back pain • Scrotal ultrasound: no • 8mg ondansetron • Lidocaine • As above
T+14h low back unchanged from testicular pathology (oral) trigger • Passive
pain previous • 30mg ketorolac IM point stretching
• Left inguinal • New onset left • 975mg acetaminophen injection
pain inguinal pain (oral)
Visit 3: • Intractable • Intractable low • CT AP: no • 2L normal saline • Bilateral • Admission for
T+28h lumbar back pain and nephrolithiasis, • 5mg diazepam IV paraspinal postoperative
paraspinal tenderness some subcutaneous • 15mg ketorolac IV lumbar observation
muscle pain • Pain with back emphysema • 2.5mg hydromorphone IV fasciotomy
• Ambulation flexion and • CK: 27,656U/L • 1 patch transdermal
intolerance extension • AST: 316U/L lidocaine
• Inability to • ALT: 136U/L
ambulate • Cr: 1.03mg/dL
• MRI lumbar spine:
L3–S1 paraspinal muscle
hypoenhancement
concerning for
myonecrosis
CT AP = CT scan of the abdomen and pelvis; CK = creatine kinase; AST = aspartate transferase; ALT = alanine transferase; Cr = serum creatinine;
IM = intramuscular; IV = intravenous.

74 | JSOM Volume 24, Edition 2 / Summer 2024