# Bilateral Leg Compartment Syndrome Complicating Prolonged Spine Surgery in the Kneeling Position

Authors: Rafael Ballesteros; Javier Francisco García-Lázaro; Jesús Moreno; Marta Chacón; Olivia Málaga; Marcus Lee
Journal: Scholarly Research Exchange
 (2009)

---

## Abstract

A case of bilateral compartment  syndrome of the legs complicating
prolonged spine surgery in the kneeling-90-90 position. Aggressive treatment
of the reperfusion injury prevented severe rhabdomyolysis, acute renal failure,
and sepsis, although it could not avoid the permanently disabling muscular
necrosis. Close postoperative surveillance facilitate an early diagnosis
and  expedite appropriate treatment.


---

## Body

## 1. Introduction

Compartment  syndrome (CS) has  been
associated to prolonged periods in several surgical positions including spine
surgery, but there have been no previous reports of bilateral leg CS following surgery in the kneeling-90-90
position. A case of revision lumbar surgery and L1-S1 decompression and
instrumented fusion was complicated by bilateral leg CS. Aggressive treatment
of the reperfusion injury prevented severe rhabdomyolysis, acute renal failure,
and sepsis, although it could not avoid the permanently disabling muscular
necrosis. The development of bilateral
leg CS following lumbar spinal surgery may be due to the
combination of hypotension, venous congestion, direct compression on the calves
and, perhaps, a tight elastic stocking. We must assume that although the
kneeling position is generally safe, it can cause external compression of the
legs, especially in lengthy procedures. Close
postoperative surveillance and a high index of suspicion facilitate an early
diagnosis and expedite appropriate treatment, although they not always can
avoid consequences of devastating effects.


## 2. Case Report

A 49-year-old man (84 kg, 164 cm, body mass
index of 31.23 kg/m2) presented with progressively
incapacitating lumbar pain and sensory-motor changes from L4 to S1. He was
known to have Klippel-Feil syndrome, and had in the
past undergone a previous L4 to S1 fusion. Magnetic resonance imaging
(MRI) showed severe cervical stenosis, a large thoracic dural fistula, and
lumbar stenosis with severe fibrosis over the lumbar arthrodesis.It was decided to revise the fusion
and decompress the lumbar spine in order to ameliorate neurological function. Under
general anaesthesia, the patient was placed in a
kneeling position with the hips and knees flexed to90°. The patient
wore thigh-length compression hosiery. Hypotension was induced and
maintained at the surgeon’s request; renal function remained stable throughout.
Haemoglobin concentration was maintained over 26 g dL−1 in the perioperative
period. Oxygen saturation remained at 100%, with a respiratory frequency of 12 m−1 and respiratory volume 7 l m−1.Surgery progressed
uneventfully albeit
slowly (10 hours 40 minutes) owing to the severe fibrosis. Removal of the previous
lumbar instrumentation, decompressive laminectomy (L3-L4), and instrumented
posterolateral fusion of the lumbosacral spine (L1-S1) were performed applying
distraction to the proximal segments. Postoperatively, the patient was
transferred to the recovery room.Eleven hours after
surgery, the patient developed bilateral sensory and motor loss below the
knees, without pain. He
had complete active range of motion of the hips and knees. Both lower legs were
tense and swollen, but nontender. No pain was elicited on passive dorsiflexion
of the ankles and toes. The extremities were warm, with normal pedal pulses and
capillary refill. Perineal and rectal examination was normal.The working diagnosis
was canal compromise by the instrumentation or excessive dural distraction. A
methyl prednisolone infusion was commenced. Image studies showing a malpositioned
screw, placed medial to the L3 pedicle in the vicinity of the thoracic dural
fistula, in an area with severe fibrosis.The patient was transferred
immediately to the operating room to remove the L3 screw. Further examination
showed that his legs remained tense and swollen. Compartment pressures were
measured using an intracompartment slit catheter (Stryker Medical Intra-CompartmentPressure Monitor System-Indwelling Slit Catheter, Kalamazoo, Mich, USA) in all four leg compartments bilaterally, and was diagnostic of CS (increased intramuscular pressure bilaterally in
all four leg compartments >30 mm Hg). Bilateral four leg
compartments fasciotomies were performed. The muscles were ischaemic and
non-contractile to stimulation with electrocautery.The patient required
nine subsequent interventions for wound debridement, with muscle-loss bilaterally within all four compartments. Renal function remained stable and
sepsis was avoided. A further six procedures were necessary for soft tissue
coverage.


## 3. Discussion

The success of all
surgical procedures depends upon satisfactory exposure of the operative site,
which sometimes involves the positioning of patients in physiologically
challenging positions. Under anaesthesia, postural insults may occur that would
normally not be tolerated in awaken patients [1]. CS has been described in
spinal surgery
[2–9].CS is a condition in which myoneural
anoxia results from a prolonged increase in tissue pressure within a closed
osseofascial space. This compromises local blood flow of the skeletal muscle,
at the microvascular level, resulting in ischaemia and necrosis. Local blood
flow to the muscle compartments may be impaired by (A) an increase in the
pressure of the compartment, as might occur after the application of a tight
bandage or external direct compression [10]; (B) a decrease in arterial flow,
as might occur after controlled anaesthetic hypotension,
blood loss, hypothermia with vasoconstriction, pre-existing arterial disease,
and anaemia/hemodilution; and (C) an increase
in venous pressure as might occur because of the
prolonged flexion of the knees or for compression of the pelvic blood
vessels, sloping position, and/or infusion of
large quantities of intravenous fluids. Any of
these causes can modify Starling’s formula. The use of compression hosiery for prophylaxis of thromboembolic disease is
universally accepted in orthopaedic surgery, including spine surgery.
Nevertheless, the elastic stocking can produce external pressures greater than
25 mm Hg  [11, 12] and result in a decrease in skin oxygen tension in the supine position [13]. Although not all the compression from the elastic stocking will be transmitted to the muscle compartments, this will have an additive effect to the other factors compromising local blood flow  [14, 15].Warner et al. [16] reviewed 572,498
surgical procedures and in 13 patients no apparent pre-existing cause for CS
was found (2.3 per 100,000 surgical episodes).
Their common feature was a relatively long surgical procedure, with an average
duration of 7.2 hours. The authors suggest that perioperative CS can occur in
apparently conventional conditions of care, and for ill-defined reasons. Our
patient’s history of smoking and hepatic fatty degeneration may have
contributed to increased capillary fragility, mirroring a case report by Stotts
et al. [8].Because CS is a reperfusion injury,
clinical features may develop insidiously rather than immediately. It may
manifest during the postoperative phase when the level of clinical observation
may be less intense if the patient is not in a high dependency area [17]. The
first signs usually occur after the patient has regained consciousness and left
the recovery room [18]. In some series, the average time from the end of
surgery to the first noted symptoms was 40 hours (range, 6–78 hours) [1].Although the canal invasion by the
malpositioned screw apparently did not cause clinical
sequelae, the need for reintervention could have distorted the initial clinical
symptoms (absence of pain) and, besides, could have aggravated or accelerated
its development due to the second procedure in the kneeling position. The diagnosis
of CS in our patient was made within 16 hours, well past the ischaemic threshold [18], and can explain that the
permanently disabling muscular necrosis could not be prevented. Repeated wound debridement and prompt fluid therapy
assisted in averting myoglobinuria and renal
failure. The only systemic complication was
malnutrition and hypoproteinaemia due to pre- and postsurgical fasting as well
as the protein losses sustained through the
surgical wounds.


## 4. Conclusions

That CS occurred after prolonged
surgery in the kneeling position lends support to the idea that the combination
of hypotension, venous congestion, compression on the calf, and, perhaps, a
light tight bandage is sufficient to compromise local blood flow. We must
assume that although the kneeling position is generally safe, it can cause
external compression of the legs, particularly in large patients undergoing
lengthy procedures.The benefits of using compression
hosiery must be weighed against its risks. Although there is no supporting
evidence, it may be safer to avoid compression stockings when the kneeling
position is used in lumbar surgery. Also, it may be safer to monitor calf
compartment pressure during prolonged lumbar surgery.A high index of suspicion of CS
facilitates an early diagnosis and expedites appropriate treatment. The
aggressive treatment of the reperfusion injury can avoid severe rhabdomyolysis, acute
renal failure, and sepsis, although it cannot avoid the permanently disabling
muscular necrosis.The devastating effect of CS, whether
life threatening or permanently disabling, should be considered as another
limiting factor at the time of indicating a spine revision procedure.



---

*Source: 535178-2009-04-05.xml*