A 31-year-old man with a history of heroin abuse was found unresponsive at a drug rehabilitation facility after ingesting 80 mg oxycodone. Admission serum creatine phosphokinase was 37,000 IU/L. Examination 2 days later showed that the right gluteal region was tense, swollen, and painful to palpation and passive motion. The leg abductors, knee flexors, foot plantar and dorsiflexors, evertors, and invertors were paralyzed. The right Achilles deep tendon reflex was absent and there was sensory loss over the right foot and lateral leg below the knee. Magnetic resonance imaging of the pelvis (Fig. 1) showed the right gluteus maximus, medius, minimus, and piriformis muscles were enlarged and edematous (arrowhead), compressing the sciatic nerve (arrow). This patient was treated conservatively because he presented greater than 48 hours after his overdose. At 6-month follow-up, his examination revealed severe persistent weakness of the distal peroneal innervated muscles with improved strength proximally.
Gluteal compartment syndromes are rare and described in instances characterized by prolonged compression, usually intraoperatively but also secondary to falls, drug overdose,or gluteal artery rupture in Ehlers-Danlos syndrome.1–6 If recognized early, permanent sciatic nerve damage, rhabdomyolysis, and subsequent renal failure may be thwarted by prompt fasciotomy and decompression. Peroneal innervated muscles are more severely affected in sciatic neuropathies in comparison to muscles with tibial innervation resulting from the composition and anatomic location of the nerve. The common peroneal nerve fascicles are larger, fewer in number, and supported by less connective tissue making them more susceptible to external pressure. Whereas the tibial nerve is loosely fixed, the common peroneal nerve component is anchored at the sciatic notch and fibular neck, thus predisposing it to traction injury.7 This case demonstrates that a severe sciatic mononeuropathy may occur as a complication of a gluteal compartment syndrome resulting from regional rhabdomyolysis after opioid overdose.
1. Henson JT, Roberts CS, Giannoudis PV. Gluteal compartment syndrome. Acta Othop Belg. 2009;75:147–152.
2. Liu HL, Wong DS. Gluteal compartment syndrome after prolonged immobilization. Asian J Surg. 2009;32:123–126.
3. David V, Thambiah J, Kagda FH, et al.. Bilateral gluteal compartment syndrome. A case report. J Bone Joint Surg Am. 2005;87:2541–2545.
4. Ferrie R, Loveland RC. Bilateral gluteal compartment syndrome after ‘ecstasy’ hyperpyrexia. J R Soc Med. 2000;93:260.
5. Klockgether T, Weller M, Haarmeier T, et al.. Gluteal compartment syndrome due to rhabdomyolysis after heroin abuse. Neurology. 1997;48:275–276.
6. Schmalzried TP, Eckardt JJ. Spontaneous gluteal artery rupture resulting in compartment syndrome and sciatic neuropathy. Report of a case in Ehlers-Danlos syndrome. Clin Orthop Relat Res. 1992;275:253–257.
7. Stewart JD. Focal Peripheral Neuropathies, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:431.