Lumbosacral plexus injury and brachial plexus injury following prolonged compression

Gluteal compartment syndrome: A systematic review and meta-analysis

INTRODUCTION

Gluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment.

METHODS

International Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes.

RESULTS

139 cases - 13 from our institution and 126 previously published - were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m². Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment.

DISCUSSION

Gluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.

Substance-Related Found-Down Compartment Syndrome: A Systematic Review

OBJECTIVE

To characterize the patient population with substance-related found-down extremity compartment syndrome (FDECS) and report on their treatment and outcome.

DATA SOURCE

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Articles in English language were identified by searching 3 online databases, EMBASE, PubMed Publisher, and Cochrane Central, in September 2019.

STUDY SELECTION

Studies involving substance-related FDECS were included. Exclusion criteria were as follows: patient age <18 years, not original studies, no full text available, technical reports, traumatic acute extremity compartment syndrome, chronic exertional compartment syndrome, and vascular acute extremity compartment syndrome.

DATA EXTRACTION

There were 61 studies included with 166 cases of FDECS. Two investigators screened and extracted data independently according to a standardized template. Disagreements were addressed by an attempt to reach a consensus, and involvement of a third reviewer. Studies were quality assessed with "Quality Assessment tool for Case Series Studies."

DATA SYNTHESIS

Descriptive statistics were reported using Excel.

CONCLUSION

Substance-related FDECS is often occurring in young adults. Data from this review found that most of the patients were already diagnosed with substance use disorders and/or psychiatric disorders. There should be a high index of suspicion of FDECS in patients presenting after prolonged immobilization.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Gluteal Compartment Syndrome Following Abdominal Aortic Aneurysm Treatment: Case Report and Review of the Literature

Compartment syndrome (CS) is a pathological increase of the interstitial pressure within the closed osseous fascial compartments. Trauma is the most common cause, followed by embolization, burns, and iatrogenic injuries; it usually involves the limbs. The major issue when dealing with CS is the possibility to do an early diagnosis in order to intervene precociously, through a fasciotomy, reducing the risk of tissue, vascular and nervous damage. Although it is an infrequent condition, it is potentially life threatening. In our case report, we present a 59-year-old patient, smoker, affected by hypertension, dyslipidemia, chronic renal failure, and morbid obesity who came at our attention for a 6-cm abdominal aorta aneurysm, treated with an aorto-aortic graft. Within 24 hours from surgery, the patient presented acute ischemia of the right lower limb due to thrombosis of the common iliac artery and underwent the positioning of a kissing stent at the aortic bifurcation. In the immediate postoperative period, a relevant increase in serum creatinine, creatine phosphokinase, and myoglobin value was recorded, associated with clinical presentation of swelling in the right buttock with intense pain. The diagnosis of gluteal CS was confirmed by the measurement of the gluteal compartment pressure, which resulted of 110 mm Hg. The treatment of the CS consisted in gluteal dermofasciotomy, surgical debridement of the buttock, and positioning of negative pressure medication, associated with infusive therapy, avoiding hemodialysis. Because of the epidural anesthesia only later on it was possible to observe a persistent plegia of the right lower limb, which was solved within 1 month of neurological and physical therapy. With our experience, we can state that the CS is an extremely severe complication that can occur in vascular surgeries and it should therefore be kept in mind in the short-term postoperative period in order to guarantee a precocious diagnosis and immediate treatment.

Correlates of new onset peripheral nerve injury in comatose psychotropic drug overdose patients

AIMS

To investigate the relationship between the duration of comatose state, severity of rhabdomyolysis and frequency of peripheral nerve injury (PNI) in patients following psychotropic drug overdose.

MATERIALS AND METHODS

Medical charts were retrospectively reviewed for 41 patients admitted for disturbance of consciousness induced by an overdose of psychotropic drugs with rhabdomyolysis between October 2004 and February 2010. Subjects were divided into PNI group (n=9) and non-PNI control group (n=32).

RESULTS

Mean interval between drug ingestion and arrival, frequency of pressure ulcers, CK level at the time of patient's arrival and maximum CK level during hospitalization, duration of hospitalization and morbidity rate were all significantly higher in the PNI group than in the control group.

CONCLUSION

In patients with a psychotropic drug overdose leading to a comatose state, the longer the comatose state, the more likely that pressure ulcers and PNI will occur.

Sciatica caused by pseudomyxoma peritonei

Many etiologies may cause sciatica, and intra-abdominal masses usually affect the lumbosacral plexus by local invasion or distal metastases. Lumbosacral plexopathy caused by compression of intra-abdominal tumors instead of invasion is rarely seen. A 67-year-old woman had a 3-month history of progressive neurogenic claudication, lumbago and left L5 radiculopathy with foot drop. Nocturia and progressive abdominal distension with voiding dysfunction were also noted. Imaging studies showed a huge pelvic mass with severe compression of the left lumbosacral trunk. There was no direct invasion of the lumbosacral plexus by the pelvic mass noted in the preoperative imaging studies or intraoperative findings. Bilateral ovarian borderline mucinous cystic tumor with pseudomyxoma peritonei (PMP) was diagnosed, and the sciatica was improved dramatically after subsequent abdominal debulking surgery. Although rare, neural compression caused by PMP and intra-abdominal masses needs to be considered in the differential diagnosis of sciatica.

Gluteal compartment syndrome following abdominal aortic aneurysm repair: a case report

Compartment syndromes occur when the elevated tissue pressure within a confined limb's myofascial compartment exceeds capillary pressure, with subsequent neurovascular compromise. In order to reduce disability and the consequences of ensuring ischemia, it is essential for early recognition and intervention. This is more commonly recognized in the calf. We report an unusual case of gluteal compartment syndrome after abdominal aortic aneurysm (AAA) repair.