1978 Faille

Notes on the article:

 Low back pain and lumbar fat herniation

Faille, R. J.

Am Surg. 1978 Jun; 44(6): 359-61.

PubMed PMID: 150243.

About the author

Ronald James Faille, M.D. from the Division of neurological Surgery, Madigan Army Medical Center, Tacoma, Washington.

Faille starts his article with a clear massage

“It is a most striking experience to hear a patient who has gone through the whole gambit of medical, gynecological and orthopedic treatments exclaim emphatically ‘That is the point!’, when his episacroiliac lipoma is touched by the examiner”.

Faille comments previous works

He mentions Ries’ work (1937), where low back nodules were called “episacroiliac lipomas“. And also Copeman and Ackerman’s, who removed the sacroiliac nodules in British soldiers and obtained dramatic relief. The nodule is supposed to be adipose tissue that has herniated through the lumbar fascia from subfascial fat.

He resumes the typical patient described by Singewald:

“The present complaints are of UNILATERAL LOW BACK PAIN with some radiation to the buttock or thigh, a FAIRLY LONG HISTORY OF SYMPTOMS with evaluations by many specialists, negative X-rays and myelogram, inability of chiropractors or osteopaths to afford relief, exacerbation of the pain with activity and certain postures, and the objective finding of a TENDER NODULE in the paraespinal area”

Considerations about these nodules

  • It is a common finding in the general population but it is usually asymptomatic.
  • Occasionally it can be the cause of unilateral low back pain that does not respond to the usual therapeutic modalities.
  • Local anesthetic infiltration is diagnostic and provides immediate and often permanent relief.
  • Surgical removal has been performed in refractory cases.

Initial interest and posterior lack of interest

Faille is aware that there was interest in this entity in the 50’s, as it is shown by the publication work of several authors –Ries, 1937; Herz, 1945; Copeman and Ackerman, 1947; Hittner, 1949; Hucherson, 1948; Bonner, 1954; Wollgast, 1961. But Faille states that little mention about it has been made in recent literature.

Consequences of the under-recognition of this entity

Faille warns that the failure to recognize this entity can result in unnecessary prolonged disability.

Faille presents 3 clinical cases

 Case 1 and 2 are treated with local infiltration

Case 1- A 52-year-old man with left-sided back pain. It had begun three months before and had progressed to incapacitation. Occasionally radiated toward the left hip. Aggravated by certain postures and coughing. He presented tender mobile nodule above the iliac crest. Infiltration with local anesthetic produced dramatic relief. The pain returned approximately five hours later but gradually resolved over the next several days. Follow-up over six months show no recurrence.

Case 2- A 30-year-old man, right low back pain radiated to leg for one month. For a week he was confined to bed. A small tender nodule was present above iliac crest. The local anesthetic infiltration gave him immediate dramatic relief. Eight hours later the pain returned much less severe. Six weeks later the pain recurred with its original intensity. Again the infiltration gave relief. Return of pain after six months.

 Faille uses percutaneous radiofrequency with success in case 3

 

Case 3- A 31-year-old man with severe back pain of several months duration after heavy lifting. Localized in the left iliac crest area. Occasionally radiated to buttock. He was injected in a trigger point that gave him few hours of relief on several occasions. Finally they performed a percutaneous radio-frequency heat lesion (using 50 Ma for 30 seconds each, with the needle position varied. Free from pain for one-year follow-up.

Faille comments about the adipose tissue in textbooks

Faille pays attention to the fact that the standard anatomy textbooks make NO mention of the adipose tissue beneath the fascial layers of the back.

However, Copeman and Ackerman dissected the backs of cadavers and found all to have some adipose tissue between the superficial and deep fascia as well as beneath the deep fascial layer along the lateral border of the erector spinae muscles.

During lumbar laminectomy, separating the fascial layers laterally for several centimeters can expose this adipose tissue.

The fat can herniate through fascial foramina or fascial defect forming a soft nodule. They resemble lipomas but pathological studies show normal fat.

Trauma and bed rest have been suggested as possible precipitating factors. But the neurophysiological mechanism for pain is uncertain. One possible explanation is the irritation of the lateral cutaneous branches of the dorsal rami from the lumbar nerves. This could explain the frequent radiation of the pain into the buttocks.

Faille suggests that radiofrequency heat lesion may be a simple alternative to treat these nodules apart from local infiltration and surgery, despite the fact that it is necessary to do further research.

Published in May 2018 By Marta Cañis Parera  ORCID iD icon

References

  • Faille R. J. Low back pain and lumbar fat herniation. Am Surg. 1978 Jun; 44(6): 359-61. PubMed PMID: 150243.
  • BONNER C. D., KASDON S. C. Herniation of fat through lumbodorsal fascia as a cause of low-back pain. N Engl J Med. 1954 Dec 30; 251(27): 1102-4. PubMed PMID: 13223963.
  • 1944 Copeman, W.S.C. and Ackerman, W. Fibrositis of the back (1944). Quart. J. Med. 13, 37
  • COPEMAN1 W. S., ACKERMAN W.L. 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.
  • HERZ. Herniation of fascial fat as a cause of low back pain with relief by surgery in six cases. JAMA.1945; 128 (13): 921–925. doi: 10.1001/ jama.1945.02860300011003
  • HITTNER V. J. Episacroiliac lipomas. Am J Surg. 1949 Sep; 78(3) :382. PubMed PMID: 18139061.
  • HUCHERSON D. C, GANDY J. R. Herniation of fascial fat; a cause of low back pain. Am J Surg. 1948 Nov; 76(5): 605-9. PubMed PMID: 18891320.
  • Reis E. Episacroiliac lipoma. Am J Obstet Gynecol1937; 34: 492-8.
  • Singewald M. L. Another cause of low back pain: lipomata in the sacroiliac region. Trans Am Clin Climatol Assoc. 1966; 77: 73-9. PubMed PMID: 4223124; PubMed Central PMCID: PMC2441105.
  • WOLLGAST G. F., AFEMAN C. E. Sacroiliac (episacral) lipomas. Arch Surg. 1961 Dec; 83:925-7. PubMed PMID: 14008087.