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Buttock–Crush Syndrome

Tramontozzi, Louis A. III MD*; Gorson, Kenneth C. MD

Journal of Clinical Neuromuscular Disease: June 2012 - Volume 13 - Issue 4 - p 240–241
doi: 10.1097/CND.0b013e31822c34f9
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*Tufts Neurology Residency Program, Tufts University School of Medicine, Tufts Medical Center, Lahey Clinic, St Elizabeth's Medical Center, Neurology Department, Boston, MA.

the Department of Neurology, St Elizabeth's Medical Center, Boston, MA.

L.A.T. has nothing to disclose. K.C.G. receives clinical trial support from Alexion and Baxter Pharmaceuticals.

Reprints: Louis A. Tramontozzi III, MD, Tufts Neurology Residency Program, Tufts University School of Medicine, Tufts Medical Center, Lahey Clinic Medical Center, St Elizabeth's Medical Center, 800 Washington Street, Neurology Department, Biewend 12, Boston, MA 02111 (e-mail: louis.tramontozzi@gmail.com).

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.

FIGURE 1

FIGURE 1

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.

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© 2012 Lippincott Williams & Wilkins, Inc.