This is an extended Argentinian article written in SPANISH in 1959 about the lumbar fat hernias (also named back mice) as a cause of low back pain and reflex lumbosciatic pain. The author presents a long bibliography of many articles from the 50s about these intriguing fatty nodules. He also refers to Steindler’s theories to explain the pain to the leg by a REFLEX pain, that’s why they called it reflex lumbosciatic pain.

He presents the results with 11 patients that were treated by repeated local anesthetic injection or surgical excision.

Tibaudin’s MAIN conclusions about the lumbar fatty hernias and low back pain:

• The entity EXISTS.
• The lumbar fatty hernias are a COMMON cause of reflex lumbosciatic pain.
• More common in women, especially with overweight.
• The physical examination is the clue to diagnose it.
• The anesthetic block test confirms the diagnosis. They called it Steindler’s test.
• Most patients recover with the conservative treatment, other need to undergo surgery.

Hernias grasas lumbares como causa de lumbociáticas reflejas

[Lumbar Fat Hernias as the Cause of Reflex Lumbosciaticas]

By Dr. Hector A. Tibaudin

 

Published in Argentina

Prensa Med Argent. 1959 Mar 27; 46: 773-82. Spanish. PubMed PMID: 13838290.

 

Tibaudin’s introduction about 3 types of pain

Dr. Tibaudin starts mentioning a classification of the “lumbagos and lumbosciaticas“ or “reflex lumbosciatic pain” following Steindler’s classification:

–Local pain: Local irritation of the terminal sensorial organs (examples: inflammatory processes and aponeurotic tears).

–Referred pain: This pain extends to the complete extend of the nerve, and it can be produced at any location in the nerve course, from the periphery to the spinal root. There may be obvious neurological signs -sensitive signs and reflexes- (the herniated disc is an example of it).

–Reflex pain: It is a combination of LOCAL pain and REFERRED pain. It is the most frequent group. Its characteristic feature is the presence of a trigger point, while pressed it reproduces the referred and local pain. There may NEVER be neurological signs (the fatty lumbar hernias are an example of it).

Short historical overview from Tibaudin about the fatty lumbar hernias (some old references):

Tibaudin refers to Scudamore, who in 1837 stated that the inflammation appeared in the fibrous tissue. In 1816, Balfour highlighted that there was the presence of palpable painful nodules. In 1904, Gowers proposed to use the term “FIBROSITIS” to designate this entity. Stockman studied it, but Copeman and Ackerman are the ones that clarify the nature of the nodules, and Herz confirmed it.

Copeman and Ackerman’s contribution

Copeman and Ackerman performed a thorough investigation dissecting over 40 cadavers. They described that under the skin and the cellular tissue appears a vascularized fascia formed by two sheets that COVER the whole back. In certain places, under this fascia there is a fatty pad, which they called “the basic fat pad” since it was present in very wasted bodies. The point with higher accumulation is around the iliac crest along the external border, especially where the two fascia sheets open to wrap the lumbar muscles.

Copeman and Ackerman noticed that in certain areas the fascia is weaker and vessels and nerves in a kind of foramina cross it. The fascia present in this foramina is a kind of prolongation sheet that worked as FASCIAL VALVES.

They also noticed that the SUBFASCIAL FAT could herniate through the foramina or to other weak holes, becoming a then fatty hernia.

This herniation could be suddenly produced after a physical effort because of a tissue tension or in the intercourse of an infectious disease while, apparently, the fatty tissue is edematous and it can be under tension (these hernias could become silent until something wakes up the pain).

Ackerman and Copeman found that the most common place of fatty herniation was the edge of the sacroespinalis muscles.

Dal Lago y Vera and Tibaudin found that the most common place is OVER THE ILIAC CREST.

Tibaudin explains Copeman and Ackerman’s three types of hernia:

-Pediculated hernia, sessile hernia or nonpediculated and foraminal hernia.

Tibaudin’s microscopic findings:

He says that the fatty hernias are composed MAINLY of the typical adipose tissue. Dal Lago reported that in several cases he found necrotic tissue and certain “lipophagic granulomas” (they considered that these were findings related to the certain degree of the strangulation of the fatty hernia through the pedicle with edema). In one of Tibaudin’s cases they also found this.

 

There was also a CAPSULE surrounding the nodules.

 

Pathogenic factors

Tibaudin refers to the extended work from Copeman and Ackerman about the correlation of the trigger points with the basic fat deposits and the presence of fatty hernias that seem to originate from these basic fat pads.

The pain would be related to the chronic irritation of the fatty nodule with edema and hiperhemia, also by strangulation of the pedicle.

The concurrent infections or toxic cases could produce pain in a fatty nodule previously asymptomatic.

Then, by friction it could irritate the POSTERIOR BRANCHES OF THE second, third and fourth LUMBAR NERVES (also named CLUNEAL nerves).

Tibaudin’s macroscopic findings:

• The hernias can be perfectly differentiated from the cellular subcutaneous tissue in most cases.
• They are sometimes more pinkish or more yellowish than the surrounding fat.
• It is clear that it presents with a fibrous CAPSULE.
• They can have the size of a pea up to 4 cm.

-With time the irritation and the edema could increase the size of the herniated hernia.

Following Steindler, then the painful impulses would travel to the spine through the dorsal branches that would transmit the electrical sign to the anterior branches, he named that the REFLEX PAIN.

Symptoms

Tibaudin specifies that the symptoms correspond to the third group of the “lumbosciatic classification” from Steindler, called REFLEX PAIN.

Nunziata stated that 94% of these lumbosciaticas would be the cause of these “fibrositic lesions”.

Tibaudin says that the patients present different ONSET of symptoms:

-ACUTE LOW BACK pain just after an effort that can resolve spontaneously, which presents recurrences or persisting incapaciting pain.

-“INSIDIOUS start” LOW BACK PAIN

Location: generally bilateral with radiation to one or both thighs.

Even if the patients got better spontaneously, pressure on the fatty nodule can produce pain.

They never accompanied any neurological sign.

Tibaudin explains that pressure on the painful nodules sometimes elicits RADIATING PAIN as the one that the patient refers.

He also explained that they found many similar nodules exploring a group of people that presented lumbar fatty nodules that were not painful at all.

The size can be from a pea to a walnut without having clear relation with pain and size.

Dal Lago and Vera also found many other concomitant findings – miositis and panniculitis-, which Tibaudin did not have the opportunity to find.

The most common location of the nodules was above the sacroiliac joints over the iliac crest.

Most of their cases were women 9/11 and with overweight.

They performed an anesthetic test: solution of 1% of novocaine. They considered it positive when the local and radiating pain disappeared.

Radiology tests are usually with no pathological signs.

Prognostic

Usually if nothing is done, the patients undergo periods of pain and periods of remission of the pain. But sometimes the pain can really limit their lives.

With the treatment they performed, they ensured that around 80% of patients presented good outcome.

Medical treatment

-Treatment of the concomitant infections that can irritate the fatty hernias

-Treat the obesity

-Thermotherapy

–INTRANODULE injection of 10 to 20 cc of 1% novocaine solution with an intramuscular needle caliber 50-8. Injecting on pressure. Nunziata also agrees that this technique works so it makes the nodule pop. It also will stop the REFLEX pain. They repeated the procedure 10 times with thermotherapy and some hiperextension mobility.

Tibaudin explains Copeman’s technique of MULTIPLE PUNCTURE of the nodule. Nevertheless, Tibaudin prefers a single injection with pressure.

-Massage therapy: This could be tested at the beginning of the process while there aren’t inflammatory adhesions.

-Definitely, they see that the physical therapy reduces the edema and inflammation.

Surgical treatment: Tibaudin’s surgical technique

-Ventral decubitus

-Marking the nodule

-Antisepsis

-Anesthesia (1% novocaine + adrenaline)

-Horizontal incision or oblique until the superficial fascia.

-Then they excised the nodule. If there is a pedicle, they ligate it. If the nodule is not really visible, they just mark a cylinder and excised that fat all the way to the deep fascia.

-They suture the cellular tissue with one or two planes and then the skin.

-They leave a drainage for 48 hours. Sutures out at 7th day.

-They start mobility around 15 days.

Tibaudin’s medical cases

 They present a table with the results.

 

 -Case 1: A 42 year-old woman. They treat her left sacroiliac painful nodule with an infiltration after 15 days of left lumbosciatalgic pain.

–Case 2: A 44 year-old- woman. Low back pain for 30 years. Now also bilateral gluteal pain. It got worst with movement. Left very painful nodule. They excised a fatty nodule of the size of a MANDARIN on the left (they couldn’t find a foramina in the deep fascia) and one of 4 cm on the right (they saw a vascular pedicle with a foramina).

-Case 3: A 24-year-old woman. Past history of right lumbar pain that radiated to the posterior thigh while pregnant. Again new episode. They found a lumbar right painful nodule over the iliac crest. The pain got better after local anesthetic injection.

-Case 4: A 46-year-old woman. Right low back pain that radiates to leg. She did treatment with vitamin B1 without good results. They palpated a fatty nodule around the superior region of the right gluteal region. After 8 infiltrations they decided to operate since the pain comes after the effect of the injection is gone. But contact with patient was then gone.

–Case 5: A 38-year-old woman. Two years of right lumbar pain that radiates to leg. They palpated a fatty painful nodule over the right iliac crest. Infiltrations work but they decided to operate. The fatty hernia was removed and it presented a HARDER CONSISTENCY than the surrounded fatty tissue.

–Case 6: A 22–year-old woman. Gluteal right pain after a trauma one and a half year before. They found a painful nodule in the superior right gluteal zone. The injections with novocaine calm the pain for a while. They decided to operate her. They cannot localize a proper mass, so they excise the fatty tissue in a part. For a while she was feeling cramps, later she got asymptomatic.

-Case 7: A 33-year-old woman. It all started 2 years before as she woke up with 38ºC of temperature. The temperature disappeared but the pain stayed. At the end they operated her with good results.

-Case 8: A 35-year-old woman. Seven years before she presented an ACUTE PAIN after she crouched. The pain was radiating to the abdomen. They found a painful fatty nodule on the right gluteal zone. They operated her with good results.

-Case 9: A 32-year-old man. After a trauma he presents several fatty painful nodules in the left superior area. They got better after anesthetic injections. He got better after operation.

-Case 10: A 47-year-old man. Painful nodules over the right iliac crest. They performed an excision of the fatty tissue considering the fatty hernia was within, since they couldn’t localize it easily.

–Case 11: A 35-year-old man. Good outcome with just infiltrations.

Published in September 2018 By Marta Cañis Parera   

References

-TIBAUDIN HA. [Lumbar Fat Hernias as the Cause of Reflex Lumbo-sciaticas]. Prensa Med Argent. 1959 Mar 27; 46: 773-82. Spanish. PubMed PMID: 13838290.