Article written in French and published in 1955 by M. R. Joyeux.
The author presents a CASE REPORT about a singular patient that suffered from a pituitary tumor. The author concludes that the lombo-sciatic pains that the patient suffered were related to the fatty tumors that she presented and compressed the nerves. Since after excision of the fatty tumor the patient improved.
He still has many answers to respond. Especially how an acute LOMBO-SCIATICA could appear so acutely after a misstep and last almost for 2 years. It seemed to him that, after the misstep, a fatty nodule that was around would jam the roots of the sciatic nerve at that moment. Then Joyeux wonders that maybe “this” is what happened when the pain is described as a strain like LERICHE did.
Joyeux thinks that a VASOMOTOR PHENOMENA brings the fatty mass to become turgid, by tissue edema and then cause compression of adjacent nerves, but not intranodular nerves.
This vasomotor process could explain the intermittence of this painful phenomenon. It could be explained by an endocrine disorder that affected the water balance of the adipose tissue.
They relate the “syndrome arthrosique” (or osteoarthritic syndrome) that presented the patient with presence of osteophites and calcification of cartilage to be related to the hypersecretion of the hormone somatotrope.
Notes about the article:
Lipomes et lombo-sciatiques
[Lipomas and Lumbosciatalgias]
By M.R. Joyeux
The role of lipomas in the development of lumbosciatica has certainly been known for a long time. In the Medical Press of July 26, 1952, SICARD mentioned the importance of these small fatty nodules that some patients have in the posterior face of the sacro-iliac joint, and whose removal leads to the disappearance of the pain syndrome (lumbago, sacralgia, sciatica or lombo-sciatica) for which the patient had come to consult.
The hypotheses to explain the association of this episacro-iliac lipoma and pain cannot be drawn from histological examinations that do not have any particular character. In the majority of cases, it CANNOT be said that it is a neurolipoma. It is known that its excision means the healing, but that does not give an explanation of why it is painful.
They thought that it had to do with the proximity of the sacred nerves. But the non-painful lipomas are also proximal to these nerves.
Copeman had the theory that the TURGIDITY OF THE FATTY CELLS enclosed in the capsule close to the nerves could explain the pain. Especially intranodular sensory filaments.
The turgidity of the adipose cells and the edema could be related to a VASOMOTOR disorder.
This process could be only the pathological exaggeration of a normal mechanism of storage of water adipose tissue, under the control of an endocrine disorder.
About the fact of the disappearance of lumbosciatica after extirpation of this small lipoma, Joyeux found it a logical explanation that the excision helps to get rid of the congestion of the zone and, therefore, of the compression of the nerves and other non-painful lipomas that can be present in the same area.
Joyeux’s observation is NOT a small fatty nodule but a LIPOMATOUS MASS
The observation he reported does not concern a small fatty nodule since the lipomatous masses removed weighed not less than 400g, but as it will be seen, he thought that its clinical and therapeutic interest would bring light to the pathogenesis of lombo-sciatica associated with lipomas.
Joyeux’s CASE REPORT
A 45-year-old woman presented the purest type of female hermaphroditism or gynandroid. She weighs 110 kg and had powerful muscles, large bones, and shoulders of porters, male-type extremities, and a certain degree of acromegaly. The biological assessment established to find a syndrome of anterior pituitary hyperfunction by an “adénome chromophile”, accompanied by all the morphological changes due to hypersecretion of somatotropic hormone. (It was diagnosed by professor De SEZE in Paris). The patient underwent x-ray examination of the pituitary gland.
Joyeux operated her three times for large lipomatous tumors, deeply located in the right thigh and right gluteal region, pressing the muscular masses. These tumors were painless, providing only an important alteration on walking and to the return circulation in the right lower limb, which thus presented a heaviness, handicapping the activity of the patient.
The first operation was in August 1946; he removed a lipomatous tumor from the posterior aspect of the thigh and a second from the medial gluteal region. It was huge and diffuse lipomas under the muscles. Two years later, in 1948, he reintervened the patient of a mass sitting on the inside of the thigh and presenting the same characters as the previous painless ones, but hindering the march, because it was constantly striking the inner side of the opposite thigh.
He intervened her a third time in 1950 for another tumor of the same kind in the right trochanteric region. Note that each time, the voluminous tumors could be enucleated but there were small secondary tumors encapsulated. All visible ones were removed. Many much smaller ones had to be removed.
Histologically, all these tumors had the characteristics of a benign lipoma in which, in places, the numerous blood vessels gave an angiomatous aspect. It is undoubtedly this last character that makes it possible to understand the rapid increase in volume of these tumors.
Joyeux never had in his patient a single recurrence in the operated area.
Since 1950 the patient, despite her acromegalic dysmorphism and her hermaphroditism, went about her numerous and arduous business as a shopkeeper.
However, since 1952 she suffered from low back pain with violent painful crises, favorably managed during a certain period of time by radiotherapy and vitamin B treatment. But the painful crises were recurrent and were repeated more frequent and more painful. It was then that, going to the radiographs, the author discovered scoliosis with severe arthritic changes in discs and vertebral bodies, disc pinches.
In September 1953, she consulted professor Séze and the radiographs showed osteophytes and calcification of almost total of all the costal cartilages. This “syndrome arthrosique” (or osteoarthritic syndrome) seems to be related to the hypersecretion of the hormone somatotrope and did not respond to the conventional treatments for rheumatic arthrosis. The only treatment that proved effective was to treat her directly in the glandular imbalance. They prescribed her with high dose of “hormone genitale” (pellet d’oestrodiol, benzo-gynoestryl 5, cyclodine 5mg).
For a year the patient remained stable with 2 or 3 painful crisis.
But then on a month of August, while she was walking on the beach, the patient took a false step and immediately felt the recrudescence of the lumbar pain in the buttock and anococcygeal region. The pain was very acute, it calmed a little after morphine injections.
He then found in the lombo-sacral region there was a lipomatous mass (he already noticed it 2 years before). It remained painless but somewhat deformed the region. Then he performed a rectal tactum, and found a very painful spot that made the patient scream. The author wondered: Was this an abscess or a lipoma? It seemed a tense very painful “collection” but there was NOT TEMPERATURE.
The pain was so acute that they decided to remove the painful mass. He found it was a lipomatous mass the size from a small mandarine to a small hazelnut. ONE OF THE MASSES was passing through the SCIATIC notch, and somehow pushing back the nerve. Another fatty mass was passing through the sacred holes. Joyeux excised all the fatty nodules and the patient remained free from symptoms at least for 3 months.
The analysis of the surgical specimen showed an edema macroscopically. And, histologically, it showed an angiomateux aspect by rich vasculature. But it is curious to notice by the author that the excision of the lipoma did not cause much hemorrhage.
Published in October 2018 by Marta Cañis Parera
R. Joyeux. Lipomes et lombo-sciatiques. Montpellier-Chirurgical. 1955 (9) p 279-282. ISSN-ISBN: 0027-0679