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Severe Unrelenting Pain in the Lumbosacral Paraspinal Area after Skiing1
A thirty-five-year-old man on the third day of a skiing holiday presented
to the emergency department because of severe, unrelenting pain in the right
lumbosacral paraspinal area, radiating across the abdomen to the groin. The pain
had been present for four hours and had begun spontaneously with no history of
trauma. In retrospect, the patient had experienced similar but milder pains during
previous ski trips and during long-distance running. There was associated numbness
in the right lumbosacral area.
Positive findings on physical examination were bilateral paraspinal muscle
rigidity associated with swelling, marked tenderness, and loss of the lumbar
lordosis. There was dense loss of sensation in the paraspinal area to the midaxillary
line and altered sensation extending anteriorly to the midline. Reduced abdominal
muscle tone on the right side, resulting in asymmetry, was also noted. Active
movement of the spine was minimal and exacerbated the pain. The patient had mild
tenderness of the abdomen with absent bowel sounds.
The initial differential diagnosis included a renal stone, a herniated disc,
discitis, and a retroperitoneal abnormality. A urine specimen was dark in appearance,
and analysis revealed 3+ myoglobinuria. Blood chemistry studies showed elevation
of aspartate aminotransferase (804 IU/L; normal, 17 to 59 IU/L), alanine aminotransferase
(141 IU/L; normal, 21 to 72 IU/L), lactate dehydrogenase (3823 IU/L; normal,
313 to 618 IU/L), myoglobin (7961 ng/mL; normal, <116.4 ng/mL), and creatine
kinase (48,550 IU/L; normal, 55 to 70 IU/L). Other blood parameters were within
normal limits. A spiral computerized tomography study excluded an abnormality
of the urinary tract. Swelling of the paraspinal muscles and a paralytic ileus
were noted. Angiography showed no evidence of arterial occlusion. The pain was
controlled with opioids, and it was elected to continue treatment with intravenous
rehydration although a definitive diagnosis had not been made.
Twelve hours after presentation, the patient had little improvement. A magnetic
resonance imaging scan revealed a marked increase in signal within the medial
and lateral right paraspinal muscles as well as the left medial paraspinal muscle
(Fig. 1). An increased signal was also noted within the soft tissues adjacent
to the spinous processes and posterior to the paraspinal muscles. There was asymmetry
of the paraspinal muscles, with the right side notably larger than the left.
Some fluid was also noted in the right retroperitoneal region.
Fig. 1 |
Fig. 1 Preoperative T2-weighted magnetic resonance image showing an increase in signal within the medial and lateral right paraspinal muscles and the left medial paraspinal muscle.
For larger view, click on image |
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