Acute Gluteal Compartment Syndrome and Sciatic Nerve Palsy Following Prolonged Immobilization in an Intravenous Drug User: A Case Report

Introduction

Thigh compartment syndrome (TCS), which in some cases also includes gluteal compartment syndrome (GCS), as in our case, is a rare but potentially severe surgical emergency characterized by increased pressure within the fascial compartments of the gluteus and thigh, leading to impaired tissue perfusion and possible muscle and nerve damage [1,2]. Although compartment syndrome is more commonly seen in the lower leg and forearm, TCS can occur in various clinical scenarios, including blunt trauma, vascular injuries, and sports-related contusions [3,4].

The clinical presentation of TCS typically involves patients immobilized for long periods receiving some analgesia, like postoperative patients or IVDUs, crushing their thighs without feeling the pain to warn them of the imminent damage [5]. The classical symptoms include severe pain in both active and passive movements, disproportionate to the mechanism of injury, swelling, and a decreased range of motion in the affected limb [6]. However, the diagnosis can be challenging due to its relative rarity and the potential for delayed symptom onset [4]. Prompt recognition and intervention are crucial, as delayed treatment can result in significant morbidity, including myonecrosis, rhabdomyolysis, and long-term functional impairment [2,7].

In this case, acute gluteal and thigh compartment syndrome occurred due to the pressure effects of immobilization during a period of probable loss of consciousness following intravenous drug use in multiple veins at sites unrelated to the thigh, with no major trauma, and presenting with sciatic nerve palsy and rhabdomyolysis. This mechanism has been previously reported in association with alcohol or substance intoxication. This report describes a 30-year-old male IVDU presenting with acute gluteal compartment syndrome and sciatic nerve palsy after prolonged immobilization and describes the surgical management.

Case Report

A 30-year-old man who uses intravenous drugs presented to the Emergency Department with severe pain, swelling, and hardness in his right thigh and gluteal region. During the initial assessment, he reported illicit substance use and prolonged immobilization after drug use. On physical examination, the patient showed signs of sciatic nerve palsy and had palpable peripheral pulses. Muscle strength in the gluteal and thigh groups was significantly reduced compared to the unaffected side, with 0/5 strength in both the hip flexors and extensors, as well as in the knee flexors and extensors. Tendon reflexes were absent. Laboratory tests revealed a markedly elevated creatine phosphokinase (CPK) level of 73 535 U/L, while electrolytes and renal function remained within normal ranges.

MRI was performed and demonstrated increased dimensions of the right gluteal muscle and posterior thigh groups, with a heterogeneous appearance and small fluid collections in the intermuscular septa (Figure 1).

Based on the clinical presentation, laboratory findings, and imaging results, a diagnosis of gluteal and thigh compartment syndrome with accompanying rhabdomyolysis was established. The patient was positioned in a lateral decubitus orientation on the left side with the affected right leg elevated. The compartment syndrome was confined to the posterior thigh compartment; therefore, a long incision was made over the posterior compartment, providing access to both the gluteus and the posterior thigh compartments. We started the incision from the same point as the Kocher-Langenbeck approach, located a few centimeters distal and lateral to the posterior iliac spine, extending obliquely toward the median posterior line of the thigh to facilitate surgical debridement in case of muscle necrosis (Figure 2). After making the incision, we proceeded with fasciotomy of the muscular compartment and exploration of the sciatic nerve. The sciatic nerve was completely released from the same incision (Figure 3). No neurolysis was performed. The incision and fasciotomy continued distally until the posterior femoral shaft. Utilizing this approach, we were able to decrease the intracompartmental pressure from the posterior compartment of the thigh that led to sciatic nerve palsy. Due to severe muscle swelling, the wound was left open with only some interrupted sutures on both sides of the incision (Figure 4).

Postoperatively, the patient had an immediate reduction in pain and swelling, and he regained the ability to flex and extend his right foot and toes 48 hours after the surgery. Gluteal and thigh muscle groups gradually regained strength during this time. CPK levels gradually decreased, without affecting renal function. The open wound was gradually closed with no. 2 nylon sutures with progressive tension, and when the edema was completely decreased, after 1 month, the wound was closed and healed well (Figure 5).

Discussion

This case illustrates the rare but critical diagnosis of gluteal and thigh compartment syndrome following prolonged immobilization in an IVDU. Compartment syndrome is a serious condition that can lead to severe complications if not promptly diagnosed and treated. Unrecognized and untreated compartment syndrome leads to localized tissue ischemia, acidosis, and muscle necrosis, resulting in myoglobinuria and potentially progressing to renal failure or even death [5]. In our case, the patient presented with disproportionate pain relative to the clinical presentation, in both active and passive movements, which is a hallmark sign of compartment syndrome [8]. This emphasizes the importance of maintaining a high index of suspicion, especially in patients with a history of IVDU [9].

While compartment syndrome is mostly associated with fractures and trauma, there have been a few case reports describing its occurrence in IVDU patients. These cases often involve prolonged immobilization or compression of the affected area, which the patient may not notice due to altered mental status or the analgesic effects of drugs [9,10]. This highlights the need for healthcare providers to be vigilant when assessing IVDU patients, even in the absence of obvious trauma. In these cases, the underlying pathophysiology may not involve the typical increase in compartmental contents and pressure seen with compartment syndrome. Instead, external compression, often occurring when the patient loses consciousness and their limb is crushed, leads to increased pressure within the compartment.

Therefore, diagnosing compartment syndrome remains challenging, especially in cases lacking a clear traumatic cause. In our case, performing an emergency MRI was essential for thorough preoperative planning.

Treatment strategies may vary because, while some clinicians advocate for fasciotomy when compartment pressures exceed 30 mmHg [11–13], others argue that the arterial-compartmental pressure difference ({DP) is a more reliable indicator for surgical intervention [13,14]. McQueen et al demonstrated that using a {DP threshold of less than 30 mmHg resulted in no missed diagnoses of compartment syndrome [15]. This approach may help reduce unnecessary fasciotomies while ensuring timely treatment for those who need it.

The use of analgesia in patients at risk for compartment syndrome is a contentious issue. Regional anesthesia and patient-controlled analgesia (PCA) have been implicated in potentially masking the symptoms of developing compartment syndrome [5,16]. However, recent literature suggests that the focus should be on regular, vigilant monitoring rather than withholding adequate pain management. Breakthrough pain despite nerve blocks or escalating analgesic requirements should raise suspicion for compartment syndrome [17].

The patient’s history of IVDU and prolonged immobilization, in our case, likely contributed to the development of compartment syndrome. This underscores the importance of considering non-traumatic causes in high-risk populations. The hallmark clinical presentation suggested that intracompartmental pressure measurements were not needed.

Early recognition and intervention are crucial to prevent long-term complications such as muscle necrosis, nerve damage, and potential limb loss, while in our case prompt intervention avoided the imminent acute kidney injury and consequent multiple organ failure or death [18,19].

Conclusions

Gluteal and thigh compartment syndrome should be considered in patients with a history of substance abuse and immobilization presenting with pain and neurologic deficits. Prompt diagnosis and early surgical intervention are vital to prevent irreversible nerve damage and systemic complications. It is associated with a high morbidity rate and can be life-threatening if not recognized and treated appropriately. Patients at risk are those who had analgesia either at the hospital or due to the use of IV drugs, crushing their limbs after an operation or an overdose episode.

Vigilant awareness by doctors is recommended when patients with this profile present in the emergency department. It is important to clinically examine the patient, be aware of the hallmarks of this syndrome, which include disproportional pain in both active and passive movements, and assess the need for compartment pressure measurement before fasciotomy is performed. In this case, immediate surgical decompression, fasciotomy, and sciatic nerve release were performed, with an excellent clinical outcome.