This is a short article from a surgeon from New York called Bernard J. Ficarra about what he likes to name PANNICULAR LUMBOSACROILIAC HERNIA (also known as back mice or subfascial fat herniation).

This article was published in 1955 after another previous article from the same author in 1952. In the first article, a CASE REPORT of a woman that presented with low back pain and painful fatty masses astonished Ficarra. She was afraid that it was cancer and asked the doctors to remove them. The low back pain resolved by the surgical removal of the masses. Then Dr Ficarra got interested in this entity and warned it is underrecognized as a CURABLE CAUSE OF LOW BACK PAIN.

He proposes a new name pannicular lumbosacroiliac hernia to designate the subfascial fat herniation as a more accurate denomination. He also warns that the same entity has received other names as fibrositis or myofascitis.

He reviewed extensively the work of Copeman & Ackerman and Herz. He explained the basic pain patterns and the basic fat pads patterns of these authors to explain the etiopathogenic factors.

He presented 6 cases that had an excellent outcome from the surgical removal of the pannicular lumbosacroiliac hernia.

Pannicular lumbosacroiliac hernia

Bernard J. Ficarra, M.D.

Rosyn heights. Long Island, N.Y.

Director of the Department of Surgery, Roslyn Park Hospital

 

Ficarra starts his article by mentioning that there is a lot of interest about “backache” and that every year they held “symposia” about BACKACHE. They featured panel discussions composed of neurosurgeons, radiologists, orthopedists, and psychiatrists. BUT often these meetings terminated without answering all questions concerning low back pain.

It is fitting, therefore, that when there is a cure for “one cause” of backache this entity should be emphasized. He refers an infrequently discussed cause known as subfascial fat herniation or pannicular lumbosacroiliac hernia.

He mentions previous works: Copeman and Ackerman (1944 and 1947), Herz (1945 and 1952). But Ficarra warns that, since then, he CANNOT find many references about this subject.

Ficarra was aware that, unfortunately, there was NO UNIFORMITY of terminology to describe this clinicopathological entity and maybe for this reason some articles may be hidden in the literature under unfamiliar names.

Ficarra proposes a new name instead of subfascial fat herniation: pannicular lumbosacroiliac hernia. The term pannicular emphasizes the fatty nature and lumbosacroiliac the area of the hernia.

Other names that may have received this clinical entity are: fibrositis (Ficarra said that the reason for this wrong name was that it was considered that the nodules were the result of excessive fibrous tissue) and myofascitis.

About the etiology and the pathology of the pannicular lumbosacroiliac hernia

First of all, beneath the deep fascial layer of the back there is a STRATUM OF FAT, this is a NORMAL ANATOMIC LAYER that has NOT been sufficiently stressed by surgical anatomists.

This subfascial fat can come through the deep fascia which confines it, and a hernia results.

-This can be as a result of a trauma that produces a weakened area.

-It can also be related to a sudden loss of weight in obese women.

-It can herniate through the foramina where the cutaneous branches of the posterior rami of the lumbar nerves (cluneal nerves) cross the deep fascia.

-The herniation can be unilateral or bilateral.

 Then Ficarra defines the pannicular lumbosacroiliac hernia as the FAT TISSUE that has passed from its normal anatomic location to a more SUPERFICIAL STRATUM.

 The fatty tissue can assume different shapes; it may be SOLITARY or CLUSTERED like a “bunch of grapes”.

 Copeman and Ackerman classified the hernias as pedunculated, non-pedunculated and foraminal.

 The histological study demonstrates normal fat tissue.

Clinical picture of the patients that present pannicular lumbosacroiliac hernia

The patient affected by pannicular lumbosacroiliac hernia seeks medical care mainly for 2 reasons:

-because of the presence of a mass in the lumbar sacroiliac region

or

-because of the pain in the lumbar sacroiliac region

Pain is more prominent when the fat tissue pushes through the foramina of the posterior cutaneous nerves (cluneal nerves). The pain can then be severe, and the patient is unable to move.

The backache can be mainly localized in a map of trigger points (elicited by palpation) reported by Copeman and Herz. They draw a diagram with the “pain pattern” of the trigger points.

Description: The pattern starts above and goes downward along the lateral border of the sacrospinalis muscle from the costal margin to the crest of the ilium. In the gluteal region the points are found along the crest of the ilium, a little below the crest and at the level of the posterior iliac spine and through the sacroiliac joint.

The pain can BE REFERRED to the sciatic region, thigh, genitals, or elsewhere.

 If the patient feels the mass or masses, they present as PAINFUL NODULES (single or multiple).

FICARRA presents 6 cases of pannicular lumbosacroiliac hernia

In addition to the 6 surgical patients, Ficarra mentions he visited many more that refused surgery and were just treated by local infiltration of anesthesia of 1% procaine hydrochloride (novocaine).

In the six cases the true nature of the pathology was established at the operating table and the results were excellent.

 

 Diagnosis of the pannicular lumbosacroiliac hernia

Once the nodule, or mass, or masses are palpated, Ficarra suggests that the test of local anesthetic injection beneath the nodule can be a valuable diagnostic aid.

It is important to remember to do a proper differential diagnosis since MORE THAN ONE cause “of back pain” may coexist.

The entity panniculitis should also be discarded (as Weber-Christian disease or relapsing nodular panniculitis), which presents as recurrent febrile episodes and the presence of multiple small tender nonfestering subcutaneous nodules, which can result in fat necrosis or fibrosis).

Treatment of the pannicular lumbosacroiliac hernia

Treatment can be non-operative or operative.

–The local infiltration: beneath the nodules. It usually results in a dramatic relief of the pain. It can be repeated as often as necessary for symptomatic relief. But it may represent that an entity that could be cured gets in a chronic prolonged disease.

 –Surgical removal: that can be a permanent solution.

Surgical technique:

After novocaine injection, a transverse section is done over the nodule. As soon as the superficial fascia is cut, the LOBULATED FAT MASS presents itself into the operative site. The mass is usually much bigger than anticipated.

The mass is removed via sharp and blunt dissection.

It is sometimes difficult to delineate the exact extent of the fatty masses, and then they remove the adjacent fat tissue.

When the fat mass is removed, an aponeurotic dehiscence or a foramen through which the fat has emanated can be seen.

It is necessary to OBLITERATE this orifice in order to prevent a recurrence (absorbable surgical sutures).

Bleeding and hematomas should be prevented. Drainage is applied for 48 h.

Sutures are removed after 10-12 days.

Published in July 2018 by Marta Cañis Parera   

References

• FICARRA BJ. Pannicular lumbosacroiliac hernia. AMA Arch Surg. 1955 Feb;70(2):229-32. PubMed PMID: 13227738
• Copeman, W.S.C. and Ackerman, W. Fibrositis of the back (1944) . Quart.J.Med. 13,37.
• COPEMAN WS, ACKERMAN WL. Fatty herniation in low back pain. Lancet. 1947 Aug 2;2(6466):188. PubMed PMID: 20255787.
• HERZ R. Herniation of subfascial fat as a cause of low back pain; report of 37 cases treated surgically. Ann Rheum Dis. 1946 Dec;5(6):201-3. PubMed PMID: 20242353.
• HERZ R. Subfascial fat herniation as a cause of low back pain; differential diagnosis and incidence in 302 cases of backache. Ann Rheum Dis. 1952 Mar;11(1):30-5. PubMed PMID: 14915430; PubMed Central PMCID: PMC1030570.
• HUCHERSON DC, GANDY JR. Herniation of fascial fat; a cause of low back pain. Am J Surg. 1948 Nov;76(5):605-9. PubMed PMID: 18891320.