An Unusual Case Of Back Pain

Hx: A 25 yo male complains of back pain. He states the pain began while doing “dead lifts” at the gym 4 days ago. He notes he felt fine during the activity with only the normal muscle soreness, but his low back pain progressed rapidly within 24 hours and is now severe, 9/10, and constant. It has been present for 4 days without improvement and he cannot find a position of comfort. Pain is isolated to the lower back. He has no saddle anesthesia, pain radiation to the legs, urinary incontinence, or fever. He tried ibuprofen and Tylenol without relief. He denies any history of prior back injury.

PMhx: none

Soc Hx: no tobacco or drugs, occasional alcohol.

Exam:

  • General- he is a fit appearing 25 yo male in moderately severe distress, tearful as he describes his pain. As he speaks he is moving from one position to another.
  • Cardiovascular- regular, no murmurs, normal pulses all 4 extremities
  • Lungs- clear bilaterally
  • Abdomen- soft, non-tender, non-distended
  • Musculoskeletal – normal musculature of all 4 extremities. Cervical and thoracic spine is non-tender with normal bony alignment. The lumbar spine demonstrates diffuse paraspinous muscle tenderness with no midline tenderness. Normal bony alignment.
  • Neuro- cranial nerves normal, sensation normal all extremities and strength is normal in both upper extremities. Strength in the legs is limited only by back pain.

Treatment: the patient is given several doses of IV narcotic pain medication and a dose of steroids. His pain improves and he is able to rest, then ambulated without significant difficulty. His exam remains unremarkable with the exception of pain improvement. He is discharged with pain medication and follow up with the neurosurgery clinic. His preliminary diagnosis is acute low back pain with suspected disc herniation.
Bounceback: 36 hours later the patient returns complaining of the same severe low back pain. He notes the pain medication greatly improved the symptoms initially, but pain is now back at 8/10. His exam is unchanged. An MRI of the lumbar spine is ordered. A few hours later the result is back and the next ED physician goes to discuss results. As she enters the room she notes the dark amber urine specimen on the counter. She tells the patient that his MRI showed no disc herniation but did show diffuse swelling of the paraspinous muscles of the lumbar area. At this point the patient admits that he was not just doing “dead lifts” in the gym. He was in fact performing his first “extreme” workout for serveral hours while using an over the counter stimulant/supplement for the first time. His urine dip shows 3+ blood and the astute ED physician orders a creatine kinase level which return at 250,000. The remainder of the patient’s labs are normal including his creatinine, metabolic profile, and complete blood count. He is admitted with a diagnosis of acute lumbar rhabdomyolysis and receives IVF with urine alkalinization over 5 days as the CK level drops to  5000. His renal function remains normal throughout.

Discussion: Lumbar rhabdomyolysis is a rare diagnosis. The patient was initially felt to have a disc herniation based on the history given and exam. However, the patient’s severe persistent pain and amber urine on repeat visit raised suspicion for an alternate cause that was consistent with the MRI findings. Although this patient improved with conservative therapy, there are case reports of this condition progressing to compartment syndrome and requiring lumbar fasciotomy. In all those cases, repeat examination noted worsening pain and edema of the tissues in the paraspinous lumbar area on physical exam with significantly elevated compartment pressures.

Disclaimer

De-identificaiton is undertaken utilizing the Safe Harbor method described by the US Department of Health and Human Services. All remaining patient information required for teaching purposes has been altered to maintain this standard.

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