HCA Florida JFK Hospital
atraumatic paraspinal compartment syndrome, iv drug use
Internal Medicine | Medicine and Health Sciences | Musculoskeletal Diseases
Introduction: Paraspinal Compartment Syndrome (PCS) is a well-documented complication after trauma and orthopedic injuries though incidence of atraumatic PCS in individuals with substance use disorder (SUD) is not well documented. We present a case of a middle-aged man with acute PCS after intravenous (IV) amphetamine use.
Case Description: 40-years-old male with a history of substance use disorder was brought in for evaluation after being found wandering naked in the streets. He admitted to relapsing and using 0.5 grams of IV amphetamine. He was found to be agitated, energetic, and endorsed visual and auditory hallucinations. Initial physical examination showed no focal neurological deficits and workup showed Creatine Phosphokinase (CPK) of 1345 along with neutrophilic leukocytosis, lactic acidosis and hyperkalemia. The urine drug screen was indeterminate for amphetamines. The following day, he started complaining of severe tension and sharp pain in his back and thighs with radiation down to the knees and was found to have diminished sensation over paraspinal musculature. Repeat CPK level was 101,786. Commuted Tomography of the chest, abdomen, and pelvis showed diffuse hypodense appearance of posterior paraspinal musculature without definite collection concerning for PCS. He underwent emergent paraspinal fasciotomy that revealed bulging but viable muscles in multifidus, spinalis, longissimus and iliocostalis muscle compartments. Following the intervention, he reported significant improvement in his symptoms.
Discussion: Paraspinal compartment syndrome is a rare but serious condition which, if not diagnosed and treated emergently, can lead to permanent disabilities often seen after traumatic injuries. IV drug use has been implicated in the development of epidural, paraspinal and spinal abscesses but the correlation between IV drug use and compartment syndrome is not well established. Our patient relapsed into stimulant use and developed PCS. In patients with active substance use disorder who complain of acute severe pain, we recommend prompt evaluation with CPK, appropriate imaging studies, and when possible, measurement of compartment pressures to decrease the risk of adverse clinical outcomes. Additionally, we recommend a case-control (retrospective) analysis of patients with compartment syndrome in patients with and without substance use disorders to determine statistical and clinical significance.
Lastly, the interplay between addiction, active substance use, and pain is complicated and there are no reliable strategies that allow us to separate true pain from drug-seeking. Nevertheless, when treating patients with a history of substance use, we urge physicians to be mindful of their cognitive biases especially when it comes to pain, and not label it as drug-seeking behavior. Our patient could have suffered devastating clinical outcomes if it was not for judicious evaluation and management.
Rehan, Muhammad and Perry, Jodi, "Pain in the Back – A Rare Case of Atraumatic Paraspinal Compartment Syndrome" (2023). East Florida Research Day 2023. 44.