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An Uncommon Cause of Low Back Pain

Axial computed tomography of the abdomen/pelvis following intravenous contrast showing no evidence of paraspinal muscle pathology but an incidental finding of left greater than right quadratus lumborum muscle asymmetry.

Axial computed tomography of the abdomen/pelvis following intravenous contrast showing no evidence of paraspinal muscle pathology but an incidental finding of left greater than right quadratus lumborum muscle asymmetry.

A 21-year-old active duty Air Force male without past medical history presented to our Emergency Department with low back pain. The patient had been performing general resistance strength training, including specific exercises focusing on the low back region, for about 2 months. A few hours after a workout session, he developed acute pain to the left lumbar paraspinal region, which was associated with muscle tightness in that area, as well as left leg pain. The patient confirmed usage of whey protein supplements and creatine, but no others. In the Emergency Department, he was found to be in severe pain and was treated with a trigger point injection in the paraspinal area and increasing doses of narcotic pain medications. Physical examination showed marked tenderness to palpation over the left lumbar paraspinal region with tightness of the muscles, but no asymmetry, swelling, or bruising. There was no evidence of radiculopathy. Creatinine kinase (CK) was noted to be elevated at 17,480 U/L. Given this combination of rhabdomyloysis and poor pain control despite high doses of pain medications, the patient was admitted to the Internal Medicine service for further management.

In his early hospital course, he received intravenous fluids for his rhabdomyolysis and a combination of muscle relaxants, intravenous nonsteroidal anti-inflammatory drugs, and intravenous narcotics for his pain. The pain medications had only a small effect in decreasing his pain, but initially, his CK trended down and thus, the course of management was held. Upon re-check, however, his CK started to trend back up and continued to do so despite increasing rates of intravenous fluids. CT scan of the abdomen and pelvis was performed (Figure 1), which did not show tear, hematoma, or other concerning pathology in the paraspinal area, although it did show left greater than right quadratus lumborum asymmetry, felt to be a normal variant. We attempted to perform magnetic resonance imaging of the lumbar spine; however, the patient did not tolerate the test even after high doses of narcotic pain medications. Despite continued medical management, the patient’s CK continued to climb and he developed paresthesia over the left paraspinal area. Orthopedic consultation was obtained and direct measurement of paraspinal compartment pressures showed a markedly increased pressure of 198 mm Hg on the left and 48 mm Hg on the right. Given this, the patient was taken to the operating room for left-sided paraspinal fasciotomy, which confirmed lumbar paraspinal compartment syndrome, with findings as in Figure 2.

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-Daniel M. Golovko, MD, Jeffrey B. Knox, MD

This article originally appeared in the December 2017 issue of The American Journal of Medicine.

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