Dr Moes wants to recall attention to an INSUFFICIENTLY recognized cause of low back pain –fat herniation or back mice-. His personal experience suggested that the lesion is a fatty mass which, due to another cause, has seen its blood supply altered. The mass can produce REFLEX PAIN (Steindler theory).
Diagnosis of this entity is made by reproduction of the symptoms by pressing the nodule or relief of the symptoms by injecting the nodule with procaine. He also warns that if the nodules are NOT PAINFUL they shouldn’t be infiltrated, since they are NOT the cause of pain.
On surgical removal, the nodule can sometimes be difficult to discern. In certain cases, they marked the nodule prior to incision.
Dr. Moes presents 2 CASE REPORTS that obtained a dramatic cure after surgical removal. In one case they did not find herniation signs, that’s why maybe Moes titled the article “Nodulation or Herniation of Fat”. On the other case report, they found clear signs of herniation through the thoracolumbar fascia. (Personal note: many other authors have reported that sometimes the connection with the underfascial tissue with a stalk can be present or absent).
About the author: he is known because of some books about early physicians in California.
He presents 3 references
- Steindler (1938)
- Copeman and Ackerman (1944)
- Herz (1945)
The article DOES NOT HAVE any IMAGES.
Personal notes about the article:
Nodulation or Herniation of Fat As a Cause of Low Back Pain
By Robert J. Moes, M.D.
From California, US
Moes’ introduction: cause of low back pain
Dr. Moes starts his article insisting that low back pain sometimes radiated to leg is common, STILL many times with an incorrect etiological diagnosis, sometimes the cause remains obscure. The patients then just receive some symptomatic treatment and may be suffering for years.
”Unfortunately, there is a tendency to explain ALL CASES on the basis of the currently popular diagnosis”
(Current explanation of ALL back pain: Pressure by herniated nucleus puposus can produce back pain with sciatic radiation, OLD EXPLANATION of ALL back pain: sacro-iliac derangement).
Moes admits that in the differential diagnosis of low back pain many visceral, traumatic, structural and inflammatory diseases should be considered, BUT there is also one entity that had received little attention: HERNIATION OF FAT.
“Moes FEELS THAT herniation of fat warrants further discussion and recognition”.
Dr. Moes: tender points (trigger points) in painful backs?
Dr. Moes states that “every physician” who sees many painful backs has observed the not infrequent presence of sharply localized points of tenderness. Pressure in one of these produces radiating pain that often duplicates the type and course that patient is suffering.
Furthermore, it has been known that injection of procaine in such area may give COMPLETE though TEMPORARY relief.
Dr. Moes: Theories to explain the relief by procaine injection?
The procaine infiltration has been an empirical therapy that has become widely used. Several theories have been offered to explain this trigger point tenderness and its temporary relief by procaine injection.
Theories: local musculo-aponeurotic injury, ligamentous injury, “rheumatic nodules” or local fibrositis.
In 1938, Steindler advanced 5 postulates to prove when such pain and its radiation could be regarded as being due to localized SUPERFICIAL LOW BACK PATHOLOGY. He explained the mechanism of pain on a REFLEX BASIS through the posterior divisions of the spinal nerves.
A practical explanation came by the “magnificent” investigation from COPEMAN and ACKERMAN (1944) who, under the war circumstances, reported their findings with detailed information. Later, Herz confirmed their findings.
Dr. Moes summarizes Copeman and Ackerman’s findings
Copeman and Ackerman dissected a number of bodies, paying attention to the regions that were the common site of the “trigger points”. They found a basic constant fat pad; they called it “the basic fat pad”, which CORRELATED with the “pain pattern” of the trigger points.
They also found that bits of this fat could herniate through fascial deficiencies and tears, and then they could incarcerate and cause pain.
A palpable nodule then can be felt, the pressure on it reproduces the pain the patient complains about.
The injection of procaine in the nodule can give temporary relief. The excision of the nodule can lead to the complete cure.
Dr. Moes’ medical cases:
Dr. Moes says:
“Like many others I had obtained temporary benefit in selected cases of back pain by infiltration of the trigger points with procaine solution. After reading the articles of Copeman /Ackerman and Herz I have found a number of patients with SUBCUTANEOUS NODULES in the described areas BUT lacking the trigger point tenderness and the typical relief on injection. Two of the cases, however, presented a dramatic cure”.
Case 1: 46-year-old male. The patient presented a SHARP pain as he was throwing up a heavy package. The following 3 days he could just work for certain hours because of the pain. Two days after the occurrence he had to suffer aching pain in his left leg. The family physician examined him, took x-rays and treat him with diathermy. He did the treatment for 3 weeks until the doctor told him he had a “ruptured disc”. Dr. Moes visited the patient 4 weeks after it started. The site of his discomfort was the UPPER LEFT SACROILIAC AREA radiating down through the left buttock into the posterior portion of the left thigh. A nodule the size of the “distal phalanx of the little finger” was palpable adjacent to the left side of the upper margin of the sacrum. It was freely movable, but its medial portion appeared to be attached to the surrounding structures. It was exceedingly tender and its manipulation produced discomfort. Injection of the nodule and surrounding tissues with 10 cc of 2% procaine relieved the patient discomfort for several hours.
Then they decided to operate him under spinal analgesia. Transverse incision was made over the nodule. THE PALPATED NODULE was found to be merely a firmer area in the surrounding subcutaneous fat. It lay over the posterior layer of the lumbodorsal fascia somewhat cephalad to the origin of the gluteus maximus. No definite imperfection in the fascia could be demonstrated.
Dr. Moes admits that the findings were DISAPPOINTING, and without great hope, the “nodule” and the fatty tissue were excised.
THE PATIENT cured and did not have any recurrence beside a few days of soreness in the surgical wound.
Case 2: a 48-year-old female. The patient fell on her knees, apparently straining her back. Immediately, she had vague discomfort in the right side of her back. The pain increased in severity for the next days, it localized in the right lumbar area into the right buttock, into the flank and groin. She was treated for a time with local heat and massage. Careful examination revealed a small firm nodule deep in the very thick layer of the subcutaneous fat to the right of the fourth lumbar vertebra. The nodule could be best palpated by rolling or impinging it beneath the examining fingers, and then the patient would suffer sharp discomfort. Injection of the nodule relieved her symptoms for a few hours, but they returned with INCREASED severity.
They operated her under spinal analgesia. They marked the nodules with gentian violet (there was a thick fatty layer). A transverse section was made and the nodule was separated from the surrounding fatty tissue. It was found to be PEDUNCULATED and around 6 cm of length. The stalk seemed to be normal, but the superficial portion was firm and nodular. IT HAD UNQUESTIONABLY PROTRUDED through a small rent or defect in the posterior layers of the lumbodorsal fascia. EXTRUDING from the fatty layer between that fascia and the underlying sacrospinalis muscle. The nodule with the surrounding fatty tissue was excised. The imperfection of the lumbodorsal fascia was closed with chromic catgut.
Histological examination showed that one part was COVERED with slightly thickened and fibromembranous tissue. Sections showed the presence of scattered small or medium sized “foci of cellular vascular fibrous tissue”. The patient cured with no recurrences.
Published in September 2018 By Marta Cañis Parera
MOES, R. J. Nodulation or Herniation of Fat As a Cause of Low Back Pain. Ann West Med Surg. 1947 Mar; 1(1): 15-7. PubMed PMID: 20238925.