Clinical studyRhabdomyolysis and spine surgery: A systematic review of the literature
Introduction
Rhabdomyolysis was first reported in Germany in 1881, but the syndrome was described in detail by Bywaters and Beall during 2nd World War, in the Battle of London [1], [2].
The syndrome is characterized by the rupture (lysis) of skeletal muscles due to a lot of reasons such as strenuous physical exercise, drug addiction, toxins, inherited disorders, infections, trauma, compression and some medications as statins, other antilipid agents, psychiatric agents, antihistamines and anesthetics (halothane, naltrexone, quinidine, propofol, succinylcholine, thiazides) [2], [3], [4], [5], [6].
The cell membrane lysis releases organic and inorganic intracellular components, such as myoglobin, creatinephophokinase (CPK), potassium, lactic acid, purines, aldolase, phosphate as well as electrolytes which can be toxic and life threatening when entering the circulation, after the restoration of blood flow. [1], [2], [4], [6], [7], [8]. CPK levels are the most sensitive indicators of myocyte injury [2], [4], [9].
CPK is a major cytoplasmatic enzyme of muscle, and it is present in three isoenzymic forms, MM (skeletal muscle), BB (brain) and MB (cardiac muscle). The isoenzym MM constitutes more than 90% of total CPK [9], [10].
Conditions of generalized ischemia and hypoxemia, such as shock, are associated with insufficient adenosine triphosphate (ATP) production and sarcolemma dysfunction. The cellular energy supplies are gradually reduced and more than 4 h of ischemia can provoke irreversible damage to skeletal muscle. However, rhabdomyolysis occurs mainly after muscle reperfusion, therefore the reperfusion injury is considered more deleterious than extended ischemia. When reperfusion starts, leukocytes migrate into the damaged area, cytokines and prostaglandins increase whereas free radicals are produced in oxygen’s presence [6].
Clinically, rhabdomyolysis ranges from an asymptomatic illness with elevation of CPK levels to a life-threatening condition with electrolyte imbalances, acute renal failure and disseminated intravascular coagulation [6].The classic triad of symptoms is characterized by myalgia, weakness and brown-red urine because of the myoglobin. In some patients, swollen muscle can appear [3], [4], [5]. The triad is observed in less than 10% of patients, and more than 50% of patients do not complain of muscle pain or weakness [1], [6].
Systemic manifestations may include tachycardia, hypothension, delirium general malaise, fever, nausea and vomiting [1], [4], [6].
There is not a clearly agreed level of serum CPK evident of rhabdomyolysis diagnosis. However, a CPK level higher 5 times than its normal value is accepted by many authors as diagnostic criteria [1], [2]. A CPK concentration more than 5.000 IU/L is closely related to the development of kidney damage. CPK has a half-life of 1.5 days, as a consequence, CPK blood levels remain increased longer than the concentration of myoglobin that has a half-life of 2–4 h [6].
Myoglobinuria does not occur without rhabdomyolysis, but rhabdomyolysis does not necessarily lead to visible myoglobinuria [1]. Plasma myoglobin is elevated early but these findings are not reliable index, because myoglobin is quickly removed through kidneys [4].
Acute kidney injury is the most serious complication of rhabdomyolysis in the days following initial presentation and develops in 33% of patients with a mortality rate between 20% and 50% as a result of myoglobin nephrotoxicity [6], [11]. Thus, the objective of this study was to perform a review of the literature, aiming at a better understanding about the changes in CPK levels and the frequency of rhabdomyolysis in spine surgery, with special attention in posterior lumbar fusion.
Section snippets
Methods
The articles were searched in the electronic database of the Virtual Health Library (VHL), using references of the US National Library of Medicine and The National Institutes of Health (PubMed) and Latin American and Caribbean Database in Health Sciences (LILACS). In addition, reviews and references lists of selected articles were evaluated in order to identify relevant studies. The selection of studies was restricted to research in humans published until March 2019.
The descriptors used were in
Results
Of the articles 33 articles found in the VHL database, 5 were excluded by idiom, 1 was excluded by type of research (animal study), 7 were excluded by title, 11 were excluded by abstracts and 9 had full text reviewed.
From 9 of the total articles reviewed, 8 described alteration of CPK levels of associated to lumbar spine surgery and 1 was excluded due to study was not associated with lumbar spine surgery. In addition, 11 studies were selected on the references lists. Nineteen studies were
Discussion
Muscle injury is most commonly due to direct trauma caused by mechanical compression, ischemia, or compartment syndrome. The etiology of postoperative rhabdomyolysis is potentially multifactorial and has been documented in several types of surgery, such as in abdominal surgeries (bariatric surgeries), intracranial surgeries and spinal surgery [3], [13], [14].
The influence of age, gender and body mass index (BMI) presents controversial results among different studies [15].
In addition to the
Conclusion
Despite the rarity of rhabdomyolysis, it is important for spine surgeons to be familiar with possible complication.
The best available evidence points out to the prognosis depend on the extension and clinical severity of rhabdomyolysis, as well as on the early and prompt medical intervention.
The continuous monitoring of vital signs, diuresis, electrolytes and CPK values are extremely important, as well as the control of compartment pressures and cardiac status during surgeries.
It is worth noting
Funding
None of the authors has received or will receive financial support of this study.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References (30)
Rhabdomyolysis: a review of the literature
Netherlands J Med
(2009)- et al.
Rhabdomyolysis. The role of diagnostic and prognostic factors
Muscle Ligaments Tendons J
(2013) - et al.
Rhabdomyolysis and acute renal failure following minimally invasive spine surgery. Report of 5 cases
J Neurosurg Spine
(2011) - et al.
Rhabdomyolysis updated
Hippokratia
(2007) Rhabdomyolysis in lumbar spine surgery. A case report
Spine
(2003)- et al.
Rhabdomyolysis: pathogenesis, diagnosis and treatment
Ochsner J
(2015) - et al.
Insuficiência renal e rabdomiólise induzidas por exercício físico
Rev Port Nefrol Hipert
(2003) - et al.
Rhabdomyolysis
J Am Soc Nephrol
(2000) - et al.
Whiplash: a biochemical study of muscle injury
Eur Spine J
(2002) - et al.
Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis
Spine
(1996)
A rare case of rhabdomyolysis and acute renal failure following spinal surgery
J Neurosurg Spine
Bilateral gluteal compartment syndrome and severe rhabdomyolysis after lumbar spine surgery
Eur Spine J
Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial
Eur Spine
Fatal rhabdomyolysis following spine surgery in a morbidly obese patient: a case report
Korean J Spine
Serum creatine phosphokinase as an indicator of muscle injury after various spinal and nonspinal surgical procedures
J Neurosurg Spine
Cited by (6)
The top 100 most cited articles on rhabdomyolysis: A bibliometric analysis
2020, American Journal of Emergency MedicineCitation Excerpt :The distribution of keywords indicates that RM was associated with acute renal failure, crush syndrome and statin CoA reductase inhibitor. Acute kidney injury is a potential complication of severe RM that occurs in 33% of patients with a mortality rate between 20% and 50% [27,28]. RM caused by crush injury is very common in earthquakes and acute kidney injury (AKI) was an important complication of traumatic RM in different earthquakes [30,31].
Rhabdomyolysis following Nuss Procedure: A Prospective Study in Children
2023, European Journal of Pediatric SurgerySerum Myoglobin Is Associated With Postoperative Acute Kidney Injury in Stanford Type A Aortic Dissection
2022, Frontiers in MedicineRhabdomyolysis after Retroperitoneal Laparoscopic Radical Nephrectomy in the Lateral Decubitus Position
2022, Journal of Nippon Medical SchoolAdmission serum myoglobin and the development of acute kidney injury after major trauma
2021, Annals of Intensive CareSuccessful management of rhabdomyolysis with acute infection resulting from chronic sacrococcygeal pressure ulcers in a paraplegic patient: a case report
2021, Journal of International Medical Research