This article about the “lipomatose kreuzbeinsyndrom” is the only German article we found for the time being about the entity  back mice.

The author called it LKS –Lipomatose Kreusbeinsyndrom– (Lipomatose crossbone (sacral) syndrome)

They found 47% of prevalence of lipomatose nodules (what we call back mice) in 153 low back pain patients that had previously other diagnosed entities. The author warns that due to the lack of awareness about these nodules of many doctors the patients are diagnosed with other labels.

The pain was mainly located in the postero-superior iliac spine and could radiate to upper and lower zones.

They used local injections of IMPLETOL with mainly good results.

They removed the nodules in 12 cases from the 72 patients detected.

We consider that the most interesting thing of this article is the detailed histological findings. They described (as other authors did) certain findings related to images of arteritis o periarteritis in the CENTER part of the nodule.

Surprisingly, in the differential diagnose Schmidt-Voight says that the Lipomatose kreuzbeinsyndrom  differs from fibrositis mentioning the histological findings of Stockman “in a simle way” and that fibrositis usually presents unilaterally (but we consider that the lipomatose kreuzbeinsyndrom resambles the entity described as back fibrositis).

Another subject to highlight from this article is that they used IMPLETOL to do a LOCAL INJECTION. Impletol is a mixture of PROCAINE and caffeine. They mainly did a TOTAL of 4-6 injections, being distributed to 2-3 per week. With some complete relief of the symptoms. Injections of Impletol are used in the “neural therapy”.

Another thing to mention about this paper is that they do NOT refer to previous works from other authors.

Notes on the article:

Das lipomatose Kreuzbeinsyndrom. Ein Beitrag zur Pathogenese des Kreuzschmerzes

“The low back pain lipomatose syndrome”

Dr. Jorgen Schmidt-Voigt

Chefarzt des Stadt. Krankenhauses Eppstein i. Taunus, 1953.

Introduction

The pain they talk about is mostly seen by family doctors, orthopedic or gynecologist doctors. They present the term LKS to explain a syndrome related to the presence of lipoma-lumps in the sacral area.

They show a photo were the lipomatose nodules are found.

“Objective Untersuchungsbefund” -Objective findings

-Through palpation they can be found, but not with an energetic palpation.

-The size varies; it can be like a cherry.

-The covering skin moves well over them. And they are barely mobile against the bony surface.

-They have elastic consistency.

-Often bilateral, rarely unilateral.

-They do NOT show “inflammatory phenomena” such as redness, swelling, local increase of temperature.

-The muscles of the region show NO PAIN on palpation.

-The nodules are usually sensitive to the palpation. When palpated they resemble the pain of complaint.

-The rest of physical examination shows no abnormalities except for the nodules.

“Subjective Beschwerden”-Subjective findings

-They can present with several symptoms that make it easy to do the wrong diagnosis.

-Exceptionally they can present as acute lumbago, but usually it presents with gradual pain that can increase with time.

-Completely symptom-free intervals are rare.

-Patients usually explain long history of low back pain.

-It can be unilateral or bilateral. But it is usually more affected on one side.

-Sometimes the pain is restricted to the nodule zone, but most of the times it is irradiated to several regions from shoulder, upper back, abdomen, or legs.

-The pain is described by the patients as: pulling, drilling, tearing, or by a dull pressure. There is NOT a change of intensity as it would be with a renal stone.

-Certain movements intensify the pain: bending or twisting the body (housewives describe the washing and the ironing particularly as days of suffering). Standing or walking can also become painful. Sometimes the walking is so impaired that the patients need a stick.

“Pathologisch-anatomische Befunde” -Pathological-anatomical findings

For some patients surgical removal of the nodules was necessary for therapeutic reasons.

That gave the authors an opportunity to gain insight into the anatomic and histological characteristic of this syndrome.

They removed the nodules in 12 patients surgically, and they concluded that:

-The nodules were always found in the same place, they lie next to the lateral border of the “Michaelis rhombus”. Next to the lumbar pits which correspond to a tract of skin without subcutaneous fat strongly connected with the upper posterior iliac spine (Thus, the skin usually appears retracted to in the fatty area of this region).

-The structures that are palpated AS NODULES are macroscopically ROUNDED or OVAL tumors covered by a delicate connective tissue capsule. The external appearance is of a lipoma of YELLOW ADIPOSE TISSUE. They can be differentiated from the surrounding fatty tissue BECAUSE OF THE CONNECTIVE CAPSULE, because the size and by a MORE INTENSE YELLOWING.

-Histological studies showed a consistent finding: It is adipose tissue enclosed by a delicate connective tissue capsule, the adipose cells are rounded in shape and without any particularities. Between the adipocytes there are CAPILLARIES that show signs of ARTERITIS or PERIARTERITIS NODOSA. THE ENDOTHELIUM REMAINS UNCHANGED. The media shows a hyaline swelling. There can be seen leukocyte infiltrations that are absorbed into adventitia. These leucocyte accumulations form nodular forms in smaller arteries. Specially TOWARDS THE CENTER OF THE NODULE, not the periphery.

“Vorkommen, Geschlechts-und Altersvertellung” -Occurrence, sex and age distribution

They refer that the frequency with which they encounter the lipomatose kreuzbeinsyndrom  in medical practice is surprisingly large. This is the case if the doctor has made as a rule to do an examination of the lumbar area.

They examined 153 patients with low back pain and found that 72 patients could be related to the presence of the lipomatose nodules (47% of the patients).

They found patients in both sexes, but more cases were women (57).

The youngest patient was 17 years old and the oldest 75 years old. They did not find it in children.

 “Differentialdiagnose”- Differential diagnosis

They mention that this syndrome was previously unknown as cause of low back pain. That’s why patients are diagnosed with other diseases with similar symptoms. In some patients more than one disorder may be present.

–“Ischias” or sciatica: since in the lipomatose kreuzbeinsyndrom the pain usually radiates in the distribution of the sciatic nerve, it can go all the way to the legs. However, there are NO NEUROLOGICAL FINDINGS as in the sciatic neuritis (sensory disturbance, reflexes loss).

–Prolapso discal: but there would be NO radiographic findings.

–Spondylosis deformans

–Lumbago, Myalgie and muscular rheumatism

–Fibrositis: The authors say that the lipomatose kreuzbeinsyndrom differs from fibrositis if the histological findings and explanations of Stockman are taken into account. And that fibrositis is usually in one side.

–Kidney illnesses: pielonefroitis, renal stones. The pain resembles urological pain. Nevertheless, the urological findings are normal.

-In women, they confuse it with gynecologic causes annexitis or uterus retroversion. Sometimes they end up doing laparotomy.

-Apendicitis rerocecal

-Vertebral fracture

-Spondylolistesis

The authors present 3 medical cases of lipomatose kreuzbeinsyndrom

 1-Georg, 42-year-old. 3 years with low back pain. The intensity had been increasing. Pain in the left sacroiliac zone to the superior leg. It had sciatic radiation. First, they thought it was a sciatic affection. He first received injections of “betaxin-spritzen” without improving. It referred pain with certain movements. Both sides of the sacral dimples had nodules the size of peas. It was treated with local injection of 2 cc of impletol, after 5 injections pain resolved completely at least for 12 months.

2-Anita, 17-years-old. Half a year of low back pain, worsened by binding over. She noticed a swelling on her right back. The pain was radiating to the upper back. After 4 weeks of increasing pain, she was not able to bind over. After that, she felt the swelling on the left side. Finally, they found out that she had several nodules. The patient underwent surgery to remove them. Histological findings in photo 4. She was free of pain after a month.

3-Anna, 46-years-old. She has been on low back pain for 7 years, first on her right side. She had felt herself a nodule the size of a cherry bone. She described the pain “as someone pulling her bones”, pain worsened specially lying over. After a while, the nodules became a bit bigger. She was treated like it was a sciatic pain with tablets. HOWEVER, it referred pain to the shoulder. Then they though it could be rheumatism. She applied “Analgit cream” without any improvement. Later, she was treated with baths and full massage in rheumatic clinic for 8 weeks, pain decreased during a while; later, it came again. She was incapable to lift things. At certain point, the pain became unbearable and referred to the right leg. Her house doctor assumed that it was an infection on the sciatic nerve. She then got intramuscular injection and it became worse. She was totally limited with movement. Right leg was cold and tender. After 3 weeks, she needed a stick to walk. Then, she noticed several nodules the size of a cherry bone on the right side got bigger. She was treated with several methods in the clinics without improvement. Once authors discovered the syndrome, the nodules were removed and she got pain-free for at least 10 months.

They use local injection with IMPLETOL as main therapy

The causes of the lipomatose kreuzbeinsyndrom are still unknown. Nevertheless, they can be treated in certain ways.

Different treatments in the health resorts didn’t give positive results.

Local injections with IMPLETOL or NOVOCAINE 1% (procupin Woelm). 2 to 3 injections per week with a total of 6 injections, 2 cc of which under-in-and AROUND the nodules.

The results of these injections are amazing already after a few minutes of the first injection. In total 4-6 injections would be needed and would result in success. In some cases 1 or 2 injections are enough. AFTER EACH injection, there has been time relapse of improvement. If the local injection doesn’t work, then the diagnosis of lipomatose Kreuxzbeinsyndrom should be doubted.

For a permanent solution surgical removal may be necessary.

The majority of patients were treated conservatively. Of 72 patients, only 12 underwent surgery. 52 patients resolved by local injection. In 5 patients it wasn’t possible to give an accurate diagnosis.

Operative technique: It is quite simple. Done with local anesthetic. Cut on skin of 3 to 5 cm of lenght. They separate the skin, and the nodules become visible, they PROTRUDE in the opening. They are cut. It is necessary to avoid pain from periostio with new local anesthetic. To avoid hemorrhage a few cases need coagulation. They leave drainage.

Published in July 2018 by  Marta Cañis Parera    

References

• 1953 Schmit-Voight, J. Das lipomatose krebsbein-syndrom. Ein Beitrag sur pathogenese des Dreuz-schmerze. Die Med. 1953. june 6 p 722-775.