This is an article from Chile about the hernia of the panniculus adiposus (another name for back mice) and its relation to lumbo-ciatalgic pain in cases of lumbosacral fibrositis. They operate 12 patients with good results.
They considered that they had good surgical results, and when facing any lumbar or lumbociatalgic syndrome, the presence of herniae or nodules should be considered and not just be considered as idiopathic pains.
Notes on the article:
[Clinical and therapeutic aspects of hernia of the panniculus adiposus as a cause of lumbosacral fibrositis]
GOMEZ CARPIO M, URQUIETA B, GODOY M, MORALES I
Rev Med Chil. 1957 Oct; 85(10): 583-9. Spanish.
PubMed PMID: 13528102.
Written in Spanish. We could not find any further work from the first author.
This communication was presented in the Sociedad Médica de Santiago, on 6 September 1957. Chile University. Hospital J.J. Aguirre, Santiago.
The non-articular rheumatic pains
The authors start this article commenting about the fact that there are pains that are neither articular, nor peri-articular or systemic. They are of a difficult management. They receive the name of NON-ARTICULAR RHEUMATISM.
They mention “fibrositis” as the most frequent form of non-articular rheumatism.
Previous Copeman’s work about lumbosacral fibrositis
They mention the work of Copeman and Ackerman in 1943 that focused on the cause of dorso-lumbar pain, which the medical community hadn’t paid attention to previously.
They explain that there are dorsal fat pads in certain regions between two aponeurotic layers. The superficial aponeurotic layer presents some holes that are crossed by the three first lumbar nerves and receive the name of “Copeman’s fascia” or “fascia cribosa de Copeman”.
Gomez Carpio et al. mention that in certain circumstances the fatty tissue can protrude through the holes or other weak zones of the aponeurotic layer and present a herniated form. This could happen in the lumbar, sacroiliac and gluteal regions. This would be related to overwork efforts, traumatism and infections.
Zones of localization of the painful spots in the lumbosacral fibrositis
- zone 1 External border of the sacroespinal muscles
- zone 2 Gluteal region along iliac crest
- zone 3 Sacroiliac articulation
- zone 4 Sacrum holes
These painful spots are also known as “myalgic spots” or “trigger points”.
Referred pain to the leg and lordotic posture
In certain chronic presentations the pain can radiate presenting a lumbo-ciatalgic pain, with muscle spasm exaggerating the normal curvature of the column and provoking lordosis.
They think that by maintaining the antialgic position chronically there are new formations of herniae, and then they present multiple nodules.
They found the 3 types of Copeman’s hernia by operating on 9 patients with lumbosacral fibrositis
They mention the three types of COPEMAN’s hernia: pedunculated, non-pedunculated and foraminal.
–pedunculated: They usually present a LONG PEDICLE. And they seem a polyp. They are located in the surface and the pedicle contains fibrotic tissue and blood vessels. At the distal portion they could find necrotic fatty tissue with a strong “reacción plasmocitaria”.
–non-pedunculated: Mainly in lumbar and gluteal region, they emerge through the fascia.
–foraminal: Along the external border of the sacrospinal muscles and the iliac crest. These foramina are the holes that cross the spinal peripheral nerves (LI, LII, LIII). The hernia surrounds the nerve tissue and can become very painful producing ACUTE LOW BACK PAIN. Sometimes they observe the nerve involved in the fatty tissue as they operate on them.
Microscopic findings in lumbosacral fibrositis
Histology shows fatty edematous cells surrounded by fibrotic tissue. Sometimes they observe necrosis. BLOOD vessels are congested and wall is thinned and PERIVASCULAR proliferations exist. Sometimes they see hemorrhage in the fatty masses.
The pain they produce is attributed to the EDEMA of the LOBULES, which increase the tension of the masses.
They studied 12 cases of lumbosacral fibrositis
They studied 12 patients of the department of rheumatology between August 1954 and May 1957, who presented different degrees of lumbo-ciatalgic pain syndrome.
-Sex: 9 female, 3 male.
-Age range: between 23 and 62.
-Surgical: 9 surgical and 3 conservative treatment.
-Precipitating cause: 5 cases could be related with efforts at work.
-Beginning: 5 spontaneous pain, 3 related to trauma, 3 from an acute effort, and 1 from a flexion.
-Pain history: First consult between 15 days to 7 years, most of them had more than one year pain history with no relief by analgesics or physiotherapy.
-Start: Acute start in 5 patients and insidious in 7.
-Referred pain: 7 presented irradiated pain producing a lumbociatalgic pain, 5 just lumbar.
-Incapacity: Complete incapacity in 4 cases, the other 8 partial, they could walk.
-Pain degree: Pain from 1 to 4 crosses.
-Pain zones: 5 pain in zone 1 (bilateral in 2 cases), 7 patients in zone 2 (crest iliac pain, bilaterally in 6 cases).
Operation results: 5 pedunculated, 4 non-pedunculated, 1 foraminal.
-Case number 8 had a foraminal one and the fatty tissue surrounded the peripheral cutaneous nerves, the patient referred an intense lumbociatalgic syndrome.
-In 4 cases they could reduce manually the herniae and pain was attenuated. The NON-REDUCIBLE herniae present more painful syndromes.
-All cases underwent radiological examination to exclude column pathology that could explain the pain.
-All cases show an exaggerated lordosis, they considered it as an antialgic posture.
-They didn’t find neurologic symptoms except in 2 cases with low paresthesias in legs. Blood test didn’t show alterations except for 4 cases where VHS was elevated.
-They notice that the patients can present MULTIPLE herniae -in the case of multiple herniae the pain is not so strong- they hypothesize that it may be a case of distribution of the tension.
-9 cases underwent operation.
-3 were managed with oral 600mg phenylbutazone during 6-10 days (2 got better).
-All went to rehabilitation.
-Novocaine infiltration: Used successfully in 1 case with quick pain disappearance.
-7 of the operated patients got immediate relief, and 5 got transient lumbar pain of lesser degree.
-2 cases of recurrence, with new nodules, one case asymptomatic.
-6 were considered of total cure (observation between 2 months and 3 years), 4 obtained relief and 2 were still with pain (one operated on with new nodules, the other didn’t want to be operated on).
They considered that they had good surgical results, and when facing any lumbar or lumbociatalgic syndrome, the presence of these herniae or nodules should be considered and not just be considered as idiopathic pains.
GOMEZ CARPIO M, URQUIETA B, GODOY M, MORALES I. [Clinical and therapeutic aspects of hernia of the panniculus adiposus as a cause of lumbosacral fibrositis]. Rev Med Chil. 1957 Oct; 85 (10): 583-9. Spanish. PubMed PMID: 13528102.1943
Copeman WS. A Clinical Contribution to the Study of the aetiology of the Fibrositic Nodule. Ann Rheum Dis. 1943 Dec;3(4):222-6. PubMed PMID: 18623701; PubMed Central PMCID: PMC1011547.
COPEMAN WS, ACKERMAN WL. Edema or herniations of fat lobules as a cause of lumbar and gluteal fibrositis. Arch Intern Med (Chic). 1947 Jan; 79 (1): 22-35. PubMed PMID: 20283861
Savage O. Rheumatic Disease in the Forces. Br Med J. 1942 Sep 19; 2 (4263): 336-8. PubMed PMID: 20784439; PubMed Central PMCID: PMC2164164.