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Essential
Chiropractic Center
4910 Van Nuys Blvd. Suite 104, Sherman Oaks CA 91403 · (818) 501-8743
Serving the San Fernando Valley since 1988.
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4910 Van Nuys Blvd. Suite 104, Sherman Oaks CA 91403 · (818) 501-8743 Serving the San Fernando Valley since 1988.
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LOW BACK PAIN AND EPI-SACRAL LIPOMAS
A cause of low back pain and disability often overlooked by practitioners
who treat patients suffering from acute and chronic musculoskeletal complaints
is that of the epi-sacral lipoma. Although
usually thought to be a minor condition, it is capable of producing considerable
low back pain.
First described by Ries in 1937(l), episacral lipomas are small, tender,
"tumor-like" nodules occurring mainly over the sacroiliac region which
can cause disabling low back pain. The
term "lipoma" is descriptive only in that through direct palpation
over the region, the examiner is able to detect a subcutaneous mass similar to
the benign tumors; however, it is not a tumor but is actual subfascial fat which
has herniated through the overlying fascial layer.
Perhaps a better term is that of the lumbar fat herniation, as described
in 1944 by Copeman and Ackerman(2). In
their research, they reported 10 cases of severe and disabling low back pain in
which they identified the fatty tumors as the principle cause of the patient's
complaints. They subsequently
excised the herniation which produced striking relief of the pain.
In 1945, Hertz reported the cases of six women with excruciating low back
pain(3). All of the women had a
history of a traumatic strain prior to the occurrence of the pain, which was
sometimes accompanied with unilateral leg pain.
The low back pain in all six women was dramatically relieved by the
removal of a herniated fat tumor.
In a follow-up study by Copeman and Ackerman, 11 new cases were
described(4). In all patients, a
biopsy confirmed the presence of edematous fat lobules herniating through
deficiencies of the fibrous compartments. It
was felt that the pain was produced in the fibrofatty tissue and not in the
musculature itself. Hucherson and
Gandy reported in 1948 that of 32 patients who had undergone surgical removal of
the lipoma, only two patients failed to experience relief of pain(5).
Many other researchers have reported that in patients with backaches and
occurrence of the nodules, relief was obtained immediately by injection of a
local anesthetic and some by operation. At
times, dramatic relief was obtained and there was no recurrence of pain over
time(6,7,8,9). In a study by
Singewald(10), 1000 persons were evaluated for lipomas and 16% of those were
found to be present; however, only 10% had reported back pain.
Therefore, it is not an uncommon finding in the general population;
although, it is usually asymptomatic.
Fat herniations occur in predictable sites along the edge of the
sacrospinalis muscle just above the iliac crest, very close to the natural
"dimple" in the sacroiliac area(10).
In this area, through abnormal tension by trauma, or by inherent
weaknesses of the fascia, as well as through foramina for cutaneous nerves, the
underlying fat pad may herniate through the fibrous tissue between the
superficial and deep layers. Copeman
and Ackerman(4) mapped the basic fat pattern of the lumbar region from 14
cadaver studies with reference to the most common sites for the occurrence of
fat herniations (fig. l), these were felt to be extremely corresponding.
The researchers reported that during the dissection, it was not uncommon
to find that the fascia was not of uniform thickness as well as finding actual
deficiencies of the fascia where underlying fat tended to bulge through.
They were able to describe three basic types of herniations: pedunculated,
nonpedunculated and foraminal(fig. 2). The
nonpedunculated appears as a tense swollen nodule, which protrudes frequently
along the iliac crest. Pedunculated
hernias have the appearance of a strangulated polyp through the fascia connected
by a fibrous pedicle. In the
foraminal type, the fat herniates through the foramina containing the cutaneous
branches of the posterior rami of the first three lumbar nerves as they pierce
the deep fascia after leaving the body of the muscle.
A horizontal fold of membrane acts as a valve which prevents the
herniation from occurring during flexion of the back; however, a failure to
function normally may result in a herniation.
Of these three, the non-pedunculated appears to be the most common.
Biopsy of the specimens revealed that they were composed entirely of
normal adipose tissue with some edema present.
In some cases, there was evidence of patches of fibrous tissue growing in
the fatty tissue and others with nerve tissue present; however, this has not
been a consistent finding. From a
clinical standpoint, the mechanism of pain is not fully understood; however,
pain appears to be the primary feature and this seems to be due to the expansion
of the fat herniation in the otherwise unyielding fibrous capsule, in that
removal of the lipoma alleviates the pain.
The pain pattern of the fat herniation originates in a focal region;
however, it may radiate in an ill-defined distribution and may be variable in
both intensity and duration (9). Upon palpation, the patient is usually able to
describe the exact point of extreme, or pinpoint, tenderness.
It is different from a trigger point, as described by Travell(13), in
that the examiner can palpate a definite mass rather than a taut band of
skeletal muscle. However, like a
myofascial trigger point, firm pressure may produce pain which radiates in a
general as well as a segmental distribution(11). Depending upon the severity of
the pain, there may be a restriction of the lumbar range of motion and that the
pain may increase with positioning(9). There may well be a significant degree of
paraspinal muscle spasming which may also be related to the referred pain as
well as the nature of the original incident(2). No specific structural
abnormality of the spine has been identified.
Nerve root traction tests are usually normal with a production of
primarily low back and sacral pain upon testing unless there is a concomitant
disc herniation(8). Reports of pain radiating down the side affected with the
lipoma are frequent; however, there is no uniformity of the radiation area(5).
Diagnosis is usually confirmed by the injection of local anesthetic, which
significantly alleviates the pain - at least temporarily(12).
The
posterior elements of the lumbar spine are all innervated by branches of the
lumbar dorsal rami as apart from conditions produced by the intervetebral disc,
referred pain or syndromes mediated by other nerves(14). Any structure
innervated by the lumbar dorsal rami is potentially capable of being a primary
source of mechanical pain including the zygapophyseal joints, ligaments, muscles
and their fascia. Of course;
included in these possible sources are: strains, disc disease, degenerative
arthritis, facet syndrome, spondylosis, spondylolisthesis and subluxations.
Psychogenic as well as iatrogenic disorders must be further ruled out.
It is reasonable to assume that, due to the nature of the pain, heat,
massage and manipulation would be the treatment of choice, with steroid
injections reserved for primarily diagnostic purposes, and surgery as last
resort. The typical patient as
described by Singewald, however, presents with unilateral low back pain, with
some radiation of pain to the buttock or thigh, and a fairly long history of
symptomatology. Furthermore, having
had evaluations by medical, chiropractic, acupuncture, gynecological, and other
health specialists, and with negative x-rays or other diagnostic studies, the
patient finds no relief from the traditional forms of
physiotherapy. No studies
from a purely chiropractic standpoint have been submitted as to whether or not
manipulation of the pelvis, sacrum or vertebrae provide any significant relief. Current case study: A 39 year old male was referred to the clinic for evaluation of a work-related injury to his low back region. His presenting complaints were of low back pain radiating to the left lower extremity. He had previously been seen by a chiropractor but had not responded to manipulation. Due to signs of neurotraction, a MRI was obtained which revealed multilevel disc bulges with obscuration of the left L5-Sl nerve root. Nerve conduction and EMG testing was then performed, which revealed chronic denervation of the left L5-Sl nerve root. He was referred to an orthopedic surgeon and subsequently underwent lumbar laminectomy and diskectomy. Following surgery, as well as a prolonged course of physical therapy and exercise rehabilitation including ultrasound, iontophoresis and EMS, the patient stated that, overall, his leg pain had resolved; however, he continued to experience low back pain which was aggravated by lying supine as well as flexion and bending. He rated that approximately 30% of his pain remained in his low back. When asked to point to the greatest area of pain, he pointed to the left episacral region with radiation to the hip. Palpation revealed a hard nodule of approximately 2-cm in diameter directly overlying the PSIS. Firm pressure reproduced complaints of low back pain. A second nodule was palpated on the opposite side, however this was asymptomatic. He was then prepped for injection of a mixture of Dexamethasone and Zylocaine. Upon injection, he experienced immediate relief of the low back pain which lasted for 2-3 hours. In addition, he was able to forward flex at the waist without difficulty. Subsequent injections also alleviated pain for 2-3 hours, but no permanent relief was obtained. Due to his post-surgical status, no forceful spinal manipulation was attempted.
Although absent from most differential diagnoses, which have a tendency
to show a strong pre-occupation towards the discs and vertebrae, the episacral
lipoma is of a fairly common occurrence and the symptomatology are similar to
other conditions. As this case
shows, the episacral lipoma may account for a significant degree of pain in
those patients with mild disc bulges, even in those patients who require low
back surgery, and may account for the prolonged pain symptomatology following
surgery. It is apparent that
residual pain from the lipoma may be aggravated by prolonged bed rest and
certain movements. For
chiropractors, the epi-sacral lipoma may be significant in that of the general
population, are these patients those who complain of intractable low back and
have tried the gamut of conventional medical treatment only to miraculously
respond to manipulation? Or are these patients considered the chiropractic
failures in that manipulation will not repair a fascial tear or reduce a
herniated lipoma? Is it possible
that sacroiliac joint dysfunction, pelvic unleveling or vertebral subluxation is
somehow pre-disposing to the herniation, due to altered biomechanics, which may
add more tension to the fascia?
To date, research in the chiropractic profession is lacking and no
published studies have been recorded. According
to published medical studies, the treatment of choice is
injection and in severe cases, excision of the lipoma and repair of the
fascial wound. The cases and history
have been thoroughly duplicated many times from a medical standpoint.
The episacral lipoma is one syndrome which should be considered more
often in the work-up and differential diagnosis of acute and chronic low back
pain, especially in instances of work-related injuries owing to the traumatic
nature of the herniation. Furthermore,
it is one condition where chiropractors and medical doctors may have much to
gain to their patients for interreferrals. References1.
Ries, E.:
Episacroiliac lipoma. Amer. J. Obstet. Gynec., 1937, 34: 490
2.
Copeman, W.S.C.,
and Ackerman, W.L.: “Fibrositis” of the back, Quart. J. Med. 13: 37-51
(April – July) 1944. 3.
Herz, R.:
Herniation of fascial fat as a cause of low back Pain.
JAMA 128:921-925,
1945. 4.
Copeman, W.S.C., and W.L. Ackerman: Edema or herniations of fat lobules
as a cause of lumbar and gluteal "fibrositis." Arch.
Int. Med. 79:22, 1947. 5.
Hucherson, D.C., and Gandy, J.R.: Herniation of fascial fat.
Am. J. Surg. 76:605-609,
1948. 6.
Dittrich, R.J.: Coccygodynia as referred Pain.
Am. J. of Bone and Jt. Surg.
33-A:715-718, 1951. 7.
Bonner, C.D., and Kasdon, S.C.: Herniation of fat through lumbodorsal
fascia as a cause of low-back pain. New
Eng. J. of Med. 251:1102-1104, 1954. 8.
Dittrich, R.J.:
Soft tissue lesions as a cause of low back pain.
Am. J. of Surg. 91:80-85,
1956. 9.
Wollgast, G.F.,
and C.E. Afeman: Sacroiliac (episacral) lipomas.
Arch. Surg. 83:925-927, 1961. 10.
Sinqewald,
M.: Sacroiliac lipomata - an often-unrecognized cause of low back Pain.
Bull. Hopkins Hosp.
118:492-498, 1966. 11.
Pace,
J.B.: Episacroiliac lipoma. Am.
Fam. Phys. 6:70-73, 1972. 12.
Faille,
R.J., Low back pain and lumbar fat herniation.
Am. Surg. 44:359-361, 1978. 13.
Travell,
J.G. and D.G. Simons: Myofascial Dain and dysfunction (1985).
Williams & Wilkins, Baltimore, Md. 14.
Bogduk,
N.: Lumbar dorsal ramus syndromes. Chapter
38, Modern manual therapy of the vertebral column. (1986). Ed. By Grieve, G.P.,
Churchill Livingston, N.Y., N.Y. |
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