This is an article about herniation of fascial fat or back mice published by surgeons in 1948.
Notes on the article:
Herniation of fascial fat; a cause of low back pain.
HUCHERSON DC, GANDY JR.
Am J Surg. 1948 Nov;76(5):605-9. PubMed PMID: 18891320
This article is signed by Denman Carter Hucherson (1909-1969) and Joe R. Gandy, medical doctors from the Department of Orthopedic Surgery, Baylor University College of Medicine, and Southern Pacific Hospital, Houston Texas.
Hucherson and Gandy’s comment on the previous work
They start mentioning the previous work of Herz, Copeman and Ackerman about the painful fatty tumors causing low back pain. They present the result of the operation upon 42 patients that have corroborated the findings of Copeman and Ackerman about the tumors being herniations of fat through the fascia of the back.
The “pain pattern” and the subfascial fat distribution
The “pain pattern” of these fatty tumors corresponds with the distribution of fat beneath the posterior fascia.
–In the back: from above downward the lateral border of the sacroespinalis muscle from the costal margin to the iliac crest.
–In the gluteal region: posterior superior spine, along the crest of the ilium and about 5 cm below it. And along the line of the sacroiliac junction.
Hucherson and Gandy’s medical cases related to herniation of fascial fat
They studied patients that complained of backache of varying degree and intensity. The patients localized the pain within a definite area. Frequently, they referred sciatic or radicular pain associated. Three patients complained of testicular pain.
The patients always wince involuntarily and explained referred pain with palpation of the mass. These trigger points usually occur in the sites described as “pain pattern” by Copeman and Ackerman.
The injection of 1% novocaine gives temporarily relief and it was used as a diagnostic procedure.
They never observe any sensory changes, reflex phenomena or muscular weakness associated in patients.
Hucherson and Gandy’s pathological findings
The Pathology Department of Baylor University College of Medicine did the microscopic examination of the tissue from all the cases reported. All sections consisted entirely of NORMAL adipose tissue. None showed evidence of EDEMA or INFLAMMATORY reaction. Nerve tissue was observed in some sections, but not as a consistent finding.
Hucherson and Gandy’s operative technique to remove herniation of fascial fat
-Infiltration of 1%novocaine in a transverse line over the nodule.
-Cutting the skin and superficial fascia.
-The mass POPPED INTO THE WOUND and it was larger than what was expected by palpation.
-Removing by blunt and sharp dissection.
-If doubts about limits, remove the surrounding fat freely.
-Important to control the bleeding since formation of hematomas would delay the convalescence and mask the result.
-The wound is closed with interrupted sutures and a rubber tissue drain is left for 48 h.
-Local anesthetic is of value (instead of general anesthesia) to help localize the mass by the patient.
Hucherson and Gandy’s results
Discussion about herniation of fascial fat with 3 doctors
–Charles Francis Wood (Louisville, Ky): He confessed that he had never recognized this condition. He admits that it is an interesting entity. He comments that Dr. Clarence Heyman of Cleveland did a work on posterior fasciotomy that Dr. Clarence thinks it was in the same localization of the fat hernias.
–Dr. Frederick Leet Reichert (San Francisco, California): He questions about how the referred pain could come from this little fat pad. He explains that they use 2% procaine (instead of 1%) and manage to relieve the trigger spots PERMANENTLY. Dr. Reichert thought that referred pain is due to irritation of the sympathetic fibers that would be in the fat pad. And may be in the microscopic examination they are missing the fibers. He suggests that the technique of injecting 2% procaine and, afterwards, holding and massaging the area for ten or fifteen minutes could save the patient from operation. The massage for ten or fifteen minutes would avoid hemorrhage which would make the patient worse.
–Wilbert Hersman McGaw (Cleveland, Ohio): He admits that this work could lead to a contribution of a cause of the whole problem of back pain. He knew about the work of Dr. Herz. He has doubts:
-Did Dr. Hucherson operate any patient without previous anesthetic injection diagnostic test?
-Did Dr. Hucherson believe that the fatty masses arise from an hernial opening through the deep fascia?
–Denman C. Hucherson replies:
-He emphasized that the injection of anesthetic to the nodules sometimes gave an entirely relief. Yet they didn’t do enough following up study to know if it was a permanent relief. They operated them if the pain recurred after the third injection. He estimated that 1/4 of cases would need operation.
-He had talked with Dr. Herz, who explained him that he operated 67 out of 220 cases.
-They found the masses to arise between the potential space between the superficial and the deep fascia of the back. They did not repair the fascia, but they enlarged it.
-He admitted that they did not have the explanation about the pain mechanism. But they were pleased with what they considered were EXCELLENT RESULTS.
-Most of the cases were industrial cases, and many had returned to full duty, in section labor.
Hucherson and Gandy’s final comment
They believe that herniation of fascial fat is one more definite cause for back pain that has added to the causes of this perplexing problem.
They hope there would be more interest in this condition. And, finally, they caution against overenthusiasm.
References:
- Copeman, W.S.C. and Ackerman, W. (1944) . Quart.J.Med. 13,37.
- Copeman WSC and Ackerman. . Fatty herniation in low back pain. Lancet. 1947 Aug 2;2(6466):188. PubMed PMID: 20255787.
- Herz. Herniation of fascial fat as a cause of low back pain with relief by surgery in six cases. JAMA. 1945;128(13):921–925.
