This work, written in Spanish and titled LUMBOCIÁTICAS POR HERNIAS DE GRASA (back mice), was presented at LA FACULTAD de CIENCIAS MÉDICAS en la Cátedra de Ortopedia y Traumatología (1952) by Américo Nunziata.
Dr. Nunziata explains that, in 1948, they met Dr. Caruso, who told them about the publication from Copeman and Ackerman. Then he operated on the first patient. The nodule of that patient was located at the level of the 12th rib; it was the size of a chickpea and adhered to the deep aponeurosis. They removed it and the patient got better. Then they got excited about it and they operated on more patients. They knew that Dr. Pedro Noti (Mendoza) had operated by then more than 100 cases. They themselves had been operating more than 50 cases. After 3 years, they got no recurrences from the operated patients. Generally, the pain disappeared immediately; in some other cases it took a while.
Generally, they are more present in WOMEN. They are usually more intense in one side, but they seem to be bilateral. Sometimes it starts in the upper gluteal region, but mainly in the lumbar region. After operating the most painful side, the patient asks to operate the other.
Dr. Nunziata says that this entity should be spread to properly treat patients with pain for years, which, with a proper easy treatment, can get so much better.
The article presents many drawings that seem to have been copied from other previous published works.
Notes about the article:
LUMBOCIÁTICAS POR HERNIAS DE GRASA
[Lumbar Sciatica Caused by Fat Hernias]
By Dr. Américo Nunziata
Escuela quirúrgica municipal para graduados Hospital Rawson
Director: Prof. Dr. Ricardo Finochieto
Dr. Nunziata starts his article by saying that this work summarizes their experience with a little-known nosological entity: the lumbosciatic pain due to fat hernias ( back mice).
He thinks that the knowledge of this entity would help to clarify the etiopathogenic mechanism of lumbago or lumbosciatica for the purposes of finding a correct therapy.
History notes about lumbociáticas por hernias de grasa
It was Scudamore, in 1837, the one who spoke of an inflammation that affected the fibrous tissue. In 1816, Balfour mentioned the existence of painful indurated nodules under pressure. In 1904, Gowers proposed the name “fibrositis” and, in the same year, Stockman studied the histology of the same. But it is only in 1944 that Copeman and Ackerman gave shape to a large study about the “fibrositic nodules”. Copeman pointed out that in the dorsal and lumbosacral area, the subcutaneous adipose tissue is arranged in two layers, a superficial one separated by an identifiable fascia and a deep vascular layer; the latter, does not disappear from the body even with the most extreme emaciation. In this deep layer is where the so-called hernias of fat or painful nodules are located.
The nerves of the region come from the posterior branches of the lumbar nerves (cluneal nerves) that divide in two at their entry into the long muscles: an internal branch (that is lost in the muscle) and an external one (that perforates the aponeurosis), together with a vessel following the line that marks the outer edge of the erector muscles from the twelfth rib and overflowing the iliac crest from below.
The aponeurotic orifices through which the nerves emerge are normally occluded by a true valve of the type that possesses the saphenous vein and opposes the exit of fat from the interior of the aponeurotic sheath containing the long muscles.
Possible etiopathogenic factors from the LUMBOCIÁTICAS POR HERNIAS DE GRASA (the cluneal nerve entrapment)
Nunziata announces that the existence of the basic fat described at the level of the dorsal and lumbosacral region, as well as the presence of foramina that give passage to a nerve, allows to understanding a possible explanation of lumbar painful nodules related to these nerves and foraminas.
It is not possible to affirm with certainty the reason for the appearance of the nodules, but often there is a connection in its initial episode with a traumatism and coldness and humidity.
Two eventualities are possible: One we would call the most common, in which fat lobes of the deep layers herniate to superficial ones, another possibility is the formation of a pediculated fat lobule that goes intimate with the nerves and the vessels as it crosses the aponeurosis.
Nunziata wonders about the LUMBOCIÁTICAS POR HERNIAS DE GRASA:
-What factors determine the formation of the fatty nodules?
-Why are they painful?
-How we can explain the sciatic irradiation?
The edema: They observed EDEMA (which has not a clear explained reason) in the biopsias of the FATTY NODULES. This edema would create TENSION by distension of the fatty lobule within its capsule. This theory led Copeman and Pugh to test “dehydration treatments” with temporary reliefs.
Necrosis and hemorrhages: Other authors had found certain hemorrhages or fat necrosis in some of the biopsies. That could also explain the painfulness.
The foramina dysfunction: It has also been described that the malfunction of the valve of the aponeurotic foramina could explain the fat herniation through the foramina. Then the nerve that passes through the same foramina could be entrapped by the fat edematization.
About the pain referred to the leg (cluenal neuropathy)
Nunziata is aware that the sensibility of the lumbar zones is provided by the lumbar nerves, and the sensitivity of the leg is provided by the sciatic nerve. So they are INDEPENDENT territories but, clinically, they are limked by a REFERRED pain mechanism that also explains Dr. Steindler. The pain radiates to the leg by previously sinapting in the medulla.
Macroscopic analysis of the “fatty hernias” (or back mice)
The fatty hernia can appear:
-like a FATTY LOBULE, hard, smooth surface, YELLOW, surrounded by a tense CAPSULE
-like a reddish fatty lobule, with some hemorrhagic points
-like “wax drops” that correspond to focal CITOESTEATONECROSIS
It is usually fatty tissue with dilated blood vessels with different degrees of fibroelastic perinecrobiotic reaction.
The X-Ray findings in patients with “lumbociáticas por hernias de grasa” (or back mice)
Even if the nodule is painful, other bone lesions should be discharged.
Pain syndrome in patients with “lumbociáticas por hernias de grasa” (or back mice)
-The pain can start suddenly or progressively.
-Sometimes it is just lumbar, then gluteal and sometimes all the leg.
-The pain gets worse with the movement and, even in bed, it gets difficult to lie dorsally.
-On physical examination, there is certain degree of limitation of the flexoextension. Also pain on the elevation of the leg by the spasm of the leg muscles (not to be confused with the Lasegue sign).
-There is NOT neurological signs (Lasegue, reflex, sensibility, parestedias).
-On UNIDIGITAL palpation, there is the presence of a nodule form the 12th rib to the iliac crest or lower and that it “coincides” with the external edge of the erector spinae. The nodule is hard and mobile and it wakes up local and referred pain to the leg.
-If the pain syndrome is not treated correctly the SPASMODIC reaction persists and the patient gets an antialgic posture. And maybe it becomes chronic.
-Once the nodule is found, and then it can be anesthetized to confirm that the nodule is the focus of the pain.
The treatment includes: physical exercise, heat, anesthetic injections and surgery
For chronic patients, Nunziata recommends the surgical removal as a simple technique. They always use local anesthesia and leave drainage, 10 days of rest.
Published in Novembre 2018 By Marta Cañis Parera
Nunziata A. [Lumbar Sciatica Caused by Fat Hernias]. Prensa médica argentina. 1953. 40 (26) p. 1613-6. ISSN/ISBN: 0032-745X.