This is an article written in French published in a Belgian magazine (Acta Orthopaedica Belgica) by a doctor from Romania titled Copeman and Ackerman Syndrome (another name to designate back mice).
It is a short and interesting article where the author makes the statement that he thinks this syndrome is NOT a local problem but a more LOCAL MANIFESTATION of a generalized problem of the “water balance of the fatty tissue”. The histological findings, like other authors’ work, point out the presence in the back mice of the fibrous capsule and the thickened walls of the vessels.
Among 321 cases of low-back pain, the author found 41.2% of cases with the Copeman and Ackerman syndrome.
It is characterized by low back pain with or without atypical sciatica without any neurological signs and the existence of lipomatous nodules in the sacroiliac region, painful on palpation.
These nodules occur particularly in middle-aged women leading a sedentary life. The radiography frequently shows the coexistence of arthrosis signs.
The operation demonstrates the presence of fibro-lipomatous nodules, more or less adherent to the aponeurosis and, in 38% of the cases, they may herniate through the aponeurosis and there is the presence of a PEDICLE, and in 10% of the cases they are accompanied by a small nerve.
It is possible to alleviate the pain with local xylocaine injections, eventually combined with hydrocortisone.
The article does not have any image or reference. It presents many tables from the statistical results.
About the author: L. Baciu from the Hospital Brincovenesc in Bucarest.
Les lombosciatalgies du type Copeman and Ackerman
By CL. Baciu
From Bucarest, Romania
Among the lombosciatalgias, there are still many syndromes with a confusing etiopathogenesis and which are considered to be mainly an articular rheumatic manifestation.
Table 1 shows the frequency of lumbosciatalgia between 1957-1966 and the types of syndrome related.
The author wants to bring attention to the Copeman and Ackerman syndrome
Copeman and Ackerman insisted a few years ago about a syndrome which has since then been known as the Copeman and Ackerman syndrome. For the English school, this same syndrome is also called sacroiliac lipoma of Lewis.
Subjectively, it is a low back pain or low back pain syndrome. The patient complains of diffuse pain in one or both of the sacroiliac regions, with irradiations on the postero-external surface of the lower limb, usually up to the popliteal fossae, which is difficult to define by the patient himself. As Sicard and Lord had remarked, but sometimes even to the level of the dorsolateral side of the foot, quite like a true lombosciatalgia of disc origin.
Low back pain is almost continuous, but not strong. Sometimes, these basic pains can be overshadowed by lumbosciatic pain, with an atypical, very intense evolution that immobilizes the patient in bed. However, there is no objective sign from the neurological point of view. The patient does not present disorders of Achilles or plantar reflexes, or disorders of sensitivity, in the respective territories. Active and passive mobility of all joints of the lower limb are normal. The sign of Lasègue and the different scoliotic attitudes described by de Sèze, and all the other signs, which may indicate the existence of a herniated disc, are negative.
The only objective sign consists in the existence of one or more ovate nodules, not adherent to the ligaments, in the sacroiliac region, near the lateral fossa of Michaelis’ triangle, and on which the fingers of the examiner slide like on a ball. Sometimes, these nodules are not noticeable in a very clear manner when the patient is raised in ventral decubitus, but they become very clear when the patient is standing, with the bust slightly inclined.
Pathognomonically, the palpation of these nodules causes an exacerbation of pain that persists even a few minutes beyond the palpation.
The presence of these nodules can be observed especially in middle-aged women, who lead sedentary lives and tend to fatten as shown in Tables II and III.
The percentage of men with this disease is only 2.50%. They have never observed this syndrome, neither in young people, nor in old people and especially never in people who lead a very active life.
Baciu thinks that patients do not just suffer one syndrome, but two
Radiographic examination of the region almost always shows the existence of more or less important lumbar degenerative lesions. It can therefore be admitted that almost all patients presenting with this syndrome suffer not from one affection, but from two. The first is lumbar arthrosis, which causes continuous but not so strong back pain. The second affection is the syndrome itself, which, by the presence of this nodule, is at the origin of lumbosciatalgic pains, which often reach a high intensity.
Macroscopic and microscopic findings in the Copeman and Ackerman syndrome
Their operative observations revealed other aspects of the syndrome.
Copeman and Ackerman described the local pathogenic mechanism as a hernia of fat by the fibrous membrane, fascia or lumbosacro-iliac fascia. The pedicle of this fatty hernia is strangulated by the same exit slit, causing a lack of nutrition of this greasy lobule, which triggers a process of fibrosis that includes a small sensory nervous thread, depending on the sciatic nerve trone. They only met this situation in 38% of the diseases. In the other 62%, they found no pedicle, but only fibro-fatty nodules.
The histopathological examination of these nodules made with hematoxylin-eosin stains and Van Gieson showed a mass of fibrous tissue highly “fibropares” with areas in which fibrous elements are highly prevalent. This mass exhibits a diffuse sclerogenic predominantly perivascular reaction. Some vessels have thickened walls and endothelial proliferation. There are also some areas of diffuse hyalinization. They have encountered the existence of nerve fascicles strangled in the mass of this fibrosis in only 10% of cases.
This leads them to believe that the etiopathogenic mechanism of this syndrome goes beyond the conceptions of Copeman and Ackerman. From this conception, only one part remains certain, namely, that it is a matter of cell hydration disorders of the hypodermic fatty tissue, caused by general metabolic disorders of an unknown origin.
The treatment of this affection is medical or surgical. Physiotherapy treatment with any means (Roentgtherapy, ultra-short waves, infra-red, diadynamic currents, magnetodalux, etc.) is totally ineffective, which is a characteristic of this syndrome.
Medically, good transient results can be obtained by making local infiltration, in full nodule and around with xylocaine or novocaine at 1% in a quantity of 10 to 20 cm. 1 or 2 cm hydrocortisone can be added. This infiltration may have a prognostic value on the result that can be obtained by removing this nodule surgically.
The operation is done under local anesthesia. A small incision of 3 to 5 cm at the nodule allows us to isolate this nodule with the index finger and remove it easily. If the nodule presents itself with a pedicle taken in a fascial cleft, it is necessary to ligate the pedicle at the level of the slit before cutting it and suturing the hernia as securely as possible. The nodule has an irregular oval shape, ivory-white in color, obviously tougher than the greasy nodules that surround it, and can reach significant dimensions. In one of theirr cases, the nodule had a length of 1 cm about 9 cm.
High recurrence: 30% of the patients present recurrences
After the surgical procedure, there is a clear improvement in the patient, but after 4 to 6 months more than 30% of the cases come back with the same pains and new nodules. Recurrences are therefore very frequent.
Surgery demonstrates the presence of fibro-lipomatous nodules and these nodules may be herniated through the aponeurosis (38%) and very rarely (10% of the eases) be accompanied by a small nerve emerging from the sciatic nerve (Personal note: by location, probably the nerve were the now called CLUNEAL nerves).
The Baciu’s etiopathogenic theory
The author feels that no local etiopathogenesis is responsible for this entity, which is more part of a general disorder of the hydration of the subcutaneous fat.
Published in October 2018 By Marta Cañis Parera
Baciu C. [Lumbo-sciatica of the Copemann-Ackermann type]. Acta Orthop Belg. 1969 May-Aug;35(3):697-702. French. PubMed PMID: 4261102