This is a long italian article of 37 pages with an extended reference list about the lipoma episacroiliac or the “lipomi episacroiliaci”. .

We couldn’t find any information from the authors in Internet.

The article shows many photos of the “lipomi episacroliiaci” extracted by surgery.

Notes on the article of:

[Anatomicoclinical picture of episacroiliac lipomas].

NOCENTINI P, ROSATI I.

Acta Chir Ital. 1956; 12(3): 345-80. Italian. PubMed PMID: 13372094.

 

The Nocentini and Rosati’s study

Nocentini and Rosati working in “Instituto di Patologia Speciale Chirurgica di Firenze” present a study based on 9 observations of patients of what they called “lipomi episacroiliaci”. In all cases, the patients underwent surgical removal with full recovery.

Nocentini and Rosati review previous studies

They start explaining that there is a new pain syndrome that has been studied lately. Known as “sindromi lombo-sacralgiche e lombo-sciatalgiche” and related to neoformations in the lumbar region similar to lipoma.

They say that it is E. Ries’ merit to be the first who reported them in 1937 as “lipoma episacroiliaici“. They also mention the work of Hoffmann, MacDermot, Copeman, Ackerman, Hittner, P.Florentin, Donati, and Bidone.

Biological behaviour of the “lipomi episacro-iliaci”

–Age: The “lipomi episacro-iliaci“ appears mainly in adult life (according to previous studies).

–Sex: In both sexes.

–Localization: Sacroiliac region.

–Symmetric: Usually bilateral and symmetrical, sometimes unilateral.

–Morphology: Rounded or oval, smooth surface, poli-lobulated of diverse volume. Sometimes there is a collection of liquid (maybe product of “steoato-necrosis”).

–Size: From an olive to a small mandarin or bigger.

–Consistence: Elastic, pseudo-fluctuating.

–Histology: Adipose tissue, with interstitial oedema, focal haemorrhage, fibrous tissue thickened in the reticular layer. Sometimes there is a thick connective capsule around the “neo-formation”. The vessels are also thickened with perivascular cellular proliferation. Nervous fibers can also be found. Formations that look like “Aschoff nodule”, which would suggest a “lipofagic granuloma”, have also been described.

Theories about the etiopathogenesis of “lipomi episacro-iliaci”

Nocentini and Rosati admit that there is still a lot of uncertainty about this entity’s etiopathogenesis.

–Theories about endocrine dysfunction: suggested by female predominance or by its relation with menopause (A. Campiglio, P. Florentin, and P. Louyot).

–Theories about protein metabolism dysfunction: as suggested by W. A. Blanc.

–Theories about fat herniation: from traumatic lesion (Copeman and Ackerman).

– Theories about dysfunction in water metabolism: that results in water retention, which would produce oedema of the adipose tissue. The pain would be related to the tension in the lobule capsule and compression of the nervous fibers (Copeman and Ackerman).

Clinical profile of Nocentini and Rosati’s observations (from Instituto di Patologia Speciale Chirurgica di Firenze)

PAIN FINDINGS

-Many patients are unaware of the existence of the “lipomi episacro-iliaci“; sometimes it’s a casual discovery.

-The painful ones can present various forms.

-Pain can start slowly and accentuates with time, worst at rest and with certain movements.

-Sometimes the pain is localized in the neo-formation, whereas other times it refers to other regions:

•    Lumbo-sciatalgic type
•    Lumbo-sacralgic type
•    Irradiates to testicle (Hucherson and Gandy)

-Even if the neo-formations are bilateral, they are usually just painful in one side.

-Sometimes, pain refers to leg, usually until the knee, or to ankle.

PALPATION FINDINGS

-It can be palpated as a tumefaction around the sacroiliac region, tender on palpation.

-Elastic consistency.

-Deep location.

-Transversal axis.

-Mobile or fixed.

-Some are just symptomatic when they are pressed, and sometimes the mass is not felt and just a trigger point is the only finding (Copeman).

COMMON FINDINGS in majority of Nocentini and Rosati’s observations

-Clinical presentation: lumbar pain referred to leg, of long duration and increased intensity. Sometimes it limits flexo-extension.
–On palpation: mass with a mobile degree the size of an almond, cherry, walnut, small egg or mandarin, certain degree of mobility, elastic consistency, and referred pain on pressure. Sometimes findings ARE almost SYMMETRICAL on right and left side, and usually just one side is painful.

–On removal: the mass appears (bigger in size than it seemed on examination). The size of an egg or a small mandarin. Yellowish poli-lobulated mass with shiny effect. EASY to separate from the surrounding fatty tissue. There is a PEDICLE from the mass that crosses the deep lumbar aponeurosis that needs haemostasis to avoid bleeding and suture.

Nine observations

 -Observation I: Woman of 32 yrs. Left low back pain of 2 years that refers to other regions. There is a tumefaction in the sacroiliac region the size of a large walnut, lobulated surface, elastic consistency mobile. When pressed there is referred pain. Infiltration of novocaine abolishes the pain, which returns after 3 days. They do surgical incision: a poli-lobulated yellowish mass appears. The size of a small chicken egg. It was easy to isolate it from the surrounding tissue. It finishes with a PEDICLE that crosses the lumbar aponeurosis. They removed the mass, previously applying haemostasis of the pedicle. The mass of 5x5x4 cm and 25gr showed an ovoid shape, with roundish surface, smooth and shiny, of yellow colour and very elastic consistency. Cured for at least 3 years after surgery.

-Observation II: 38 year-old patient. She was prescribed a corset for a while. On examination, they found 2 tumefactions, the sizes of an almond and a walnut. Again they proceed to remove them. They found that, by cutting the pedicle, there was haemorrhage. Again the patient remained free of pain.

-Observation III: Woman, 40 years old. A case similar to the previous one.

–Observation IV: Sacroiliac right region. On palpation, it seemed the size of a cherry. On surgery, a poli-lobulated mass the size of a small mandarin appears. Also with a pedicle that crosses the deep aponeurosis.

–Observation V: 35 yrs old patient. Histology stain of Hemat-Eosin x200 shows numerous capillaries disposed in the INTERALVEOLARI SEPTA.

–Observation VI: 54 years old patient. Similar to previous ones.

–Observation VII: 54 years old patient. Novocaine injection relieves pain for 2 days.

–Observation VIII: 53 years old patient.

-Observation IX: 46 years old patient.

Common histological findings in the observed cases

-Little vessel enlargement: The neo-formations show the typical AREOLAR structure of adipose tissue. There is a connective reticular tissue. Sometimes there is a capsule. There are many capillaries of small and medium calibre, DILATED AND REPLETED.

Nocentini and Rosati’s personal observations:

-They found mostly woman in middle ages, many with bilateral masses.

-They mention the importance of the pedicle to explain the genesis of the neo-formation.

-They find it necessary to discriminate this entity (as a circumscribed hyperplasia) from the true lipoma.

-They regarded the hyperplasia to a metabolic-endocrine dysfunction.

-The small opening that crosses the pedicle of the deep lumbar fascia showed that there must be a posterior hyperplasia stimulus.

-They noticed that the pain radiates in a characteristic pattern to the leg.

-In one case, the mass was visible on inspection (Observation VIII).

-They think the pain is related to the compression of the mass to adjacent nerves.

-They also agree that the relief by injection is a diagnostic test.

-All the cases they reported cured by surgery.

 

Nocentini and Rosati’s final conclusions

-It shouldn’t be considered a rare pathology and it should be considered in any case of lumbar pain.

-It shows a pain pattern (burning) and a characteristic distribution that irradiates to the gluteal region as well as to other parts.

-Surgery cures it.

-Histologically, it is not a lipoma.

-It relates to a herniation through the fascia, and increases volume by neo-formation and oedema.

Published in April 2018 By Marta Cañis Parera

References:

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• COPEMAN WS, ACKERMAN WL. Fatty herniation in low back pain. Lancet. 1947 Aug 2;2(6466):188. PubMed PMID: 20255787.
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• R HERZ. HERNIATION OF FASCIAL FAT AS A CAUSE OF LOW BACK PAINWITH RELIEF BY SURGERY IN SIX CASES. JAMA. 1945;128(13):921–925
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• 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
• KATZ KH, BERK MS. Episacroiliac lipoma as a cause of low-back pain. N Engl J Med. 1950 Nov 30;243(22):851-2. PubMed PMID: 14780382.
• MAcDERMOT, J. H.: Sacro-iliac Lipomata. Bulletin of the Vancouver Medical Association,18: 185,1942
• MOES RJ. 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.
• Reis E. Episacroiliac lipoma. Am J Obstet Gynecol 1937;34:492-8.
• SICARD A, LORD G. [Episacroiliac lipomas and lumbo-sciatica]. Presse Med. 1952 Jul 26;60(50):1073-4. Undetermined Language. PubMed PMID: 13026891.