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Congenital lumbar hernias: A case report
Congenital Lumbar Hernias: A Case Report By S. Karmani, T. Ember, and R. Davenport London, England
Congenital lumbar hernias are rare and associated with other malformations. There have been 42 cases reported to date. The authors report the first case in the literature of isolated bilateral congenital lumbar hernias.
J Pediatr Surg 37:921-922. Copyright 2002, Elsevier Science (USA). All rights reserved. INDEX WORDS: Congenital, lumbar hernia, -surgery.
CASE REPORT A full-term 3.1-kg Nigerian boy was delivered by spontaneous vaginal delivery to a healthy primiparous mother. Apgar score was 9 at 3 minutes. A full examination found bilateral lumbar hernias of the inferior lumbar triangle (Fig 1). The left was larger than the right; both were reducible with effort. No other abnormalities were noted on examination. Radiographs of the chest (AP and lateral) and lumbar spine were normal as was ultrasound scan of the renal tracts. The child remained well, eating and gaining weight. Surgical repair of the hernia was performed at 4 weeks under general anesthetia. On the left side an incision was made over the hernia. After reduction, it was repaired using 3-0 prolene; fascial apposition was not possible, so the suture was used to fashion a darn reinforcement. On the right side, the kidney was clearly prolapsing into the hernia; this was reduced, and primary fascial approximation with 3-0 prolene was possible. Recovery was uneventful, and the patient was discharged on day 3. Follow-up in out-patients at 1 month showed no evidence of recurrence. The patient is doing well.
DISCUSSION
Lumbar hernias in infants and children are very rare; 42 cases have been reported in the literature from 1802 through 1994. Of these 42 cases, 16 were congenital, and, of these, 12 were part of the lumbocostovertebral syndrome. The other 4 were associated with myelodysplastic disorders.1 This is the first report of isolated congenital bilateral hernias in the literature. There is a male preponderance for lumbar hernias (2:1). The lumbar region is bounded superiorly by the 12th rib, inferiorly by the iliac crest, posteriorly by the vertebral column and musculature, and anteriorly by the posterior border of the external oblique. There are 2 areas for potential herniation. First is the superior triangle of Grynfelt-Lesshaft. This is bounded by the inferior aspect of the 12th rib, the internal oblique, and the quadratus lumborum. Leeshaft discovered this after cadaveric studies in 1870. It is a congenital weakness created by the 12th neurovascular bundle as it perforates the transversalis fascia in the floor of the inferior triangle. The second site is the inferior triangle of Petit. It is a potential space between the origin of the external oblique, latissimus dorsi, and the iliac crest. Journal of Pediatric Surgery, Vol 37, No 6 (June), 2002: pp 921-922
Fig 1. Bilateral congenital lumbar hernias; the left is larger than the right.
Lumbar hernias can be congenital or acquired. The cause of congenital hernias remains a matter of debate. The most popular theory in the literature proposed by Touloukain2 is one of a somatic mutation in the third to fifth week of embryogenesis, possibly as a result of transient anoxia. This produces derangement of the lumbar muscles and aponeuroses predisposing to herniation. This theory accounts for the fact that 12 of the 16 reported congenital cases had associated musculoskeletal abnormalities of the vertebral bodies, ribs, and trunk musculature (Lumbo-costovertebral syndrome. It does not explain the selective involvement of the lumbar region. Acquired hernias in the region follow surgery, trauma, and infection of the perinephric region. Lafer1 reported the association with intrathoracic neuFrom the Department of Paediatric Surgery, King’s College School of Medicine and Dentistry, Denmark Hill, Camberwell, London, England. Address reprint requests to S. Karmani, FRCS, 2 Dafforne Rd, London SW17 8TZ, England. Copyright 2002, Elsevier Science (USA). All rights reserved. 0022-3468/02/3706-0024$35.00/0 doi:10.1053/jpsu.2002.32913 921
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roblastoma, postulating that a localized neuropraxia caused by the tumour may produce the hernia. Other defects reported have included meningomyelocele3; congenital sciatic hernia focal nodular hyperplasia of the liver, and absent right kidney.4 Because of these associations it is vital to screen for them with radiographs of the chest, lumbar spine, and renal tract ultrasound in all cases of congenital lumbar hernias. Treatment is indicated in the first year to prevent incarceration, although this is uncommon. Early repair also is advocated as the defect may enlarge with growth.
Conservative treatment has been advocated in lumbar hernias associated with neuroblastoma if the nerve damage resulting in the defect is transient.1 Surgical correction can be by simple closure of small fascial defects or require rotation free flaps or synthetic reinforcement with prosthetic mesh or dura. Placement of the mesh internal to the defect may ensure a better result.5 This is the first report in the literature of congenital isolated bilateral lumbar hernias. This condition may represent a different pathologic entity to previously described congenital lumbar hernias.
REFERENCES 1. Lafer DJ: Neuroblastoma and lumbar hernia: A Causal relationship? J Pediatr Surg 29:926-929, 1994 2. Touloukain RJ: The lumbocostovertebral syndrome: A single somatic defect Surgery 71:174-181, 1972 3. Lowell DG, Guzetta PC: Lumbar hernia in a case of posterior meningomyelocele. J Pediatr Surg 21:913-914, 1986
4. Al-Salem AH, Abu-Sriar H, Qaissaruddin S: Focal nodular hyperplasia of the liver with the lumbocostvertebral syndrome. J Pediatr Surg 31:1282-1284, 1986 5. Fulham SB: Lumbar hernia. Surgeon’s workshop. J R Coll Surg Edinb 30:315-317, 1985
Congenital lumbar hernias are rare and associated with other malformations. There have been 42 cases reported to date. The authors report the first case in the literature of isolated bilateral congenital lumbar hernias.
J Pediatr Surg 37:921-922. Copyright 2002, Elsevier Science (USA). All rights reserved. INDEX WORDS: Congenital, lumbar hernia, -surgery.
CASE REPORT A full-term 3.1-kg Nigerian boy was delivered by spontaneous vaginal delivery to a healthy primiparous mother. Apgar score was 9 at 3 minutes. A full examination found bilateral lumbar hernias of the inferior lumbar triangle (Fig 1). The left was larger than the right; both were reducible with effort. No other abnormalities were noted on examination. Radiographs of the chest (AP and lateral) and lumbar spine were normal as was ultrasound scan of the renal tracts. The child remained well, eating and gaining weight. Surgical repair of the hernia was performed at 4 weeks under general anesthetia. On the left side an incision was made over the hernia. After reduction, it was repaired using 3-0 prolene; fascial apposition was not possible, so the suture was used to fashion a darn reinforcement. On the right side, the kidney was clearly prolapsing into the hernia; this was reduced, and primary fascial approximation with 3-0 prolene was possible. Recovery was uneventful, and the patient was discharged on day 3. Follow-up in out-patients at 1 month showed no evidence of recurrence. The patient is doing well.
DISCUSSION
Lumbar hernias in infants and children are very rare; 42 cases have been reported in the literature from 1802 through 1994. Of these 42 cases, 16 were congenital, and, of these, 12 were part of the lumbocostovertebral syndrome. The other 4 were associated with myelodysplastic disorders.1 This is the first report of isolated congenital bilateral hernias in the literature. There is a male preponderance for lumbar hernias (2:1). The lumbar region is bounded superiorly by the 12th rib, inferiorly by the iliac crest, posteriorly by the vertebral column and musculature, and anteriorly by the posterior border of the external oblique. There are 2 areas for potential herniation. First is the superior triangle of Grynfelt-Lesshaft. This is bounded by the inferior aspect of the 12th rib, the internal oblique, and the quadratus lumborum. Leeshaft discovered this after cadaveric studies in 1870. It is a congenital weakness created by the 12th neurovascular bundle as it perforates the transversalis fascia in the floor of the inferior triangle. The second site is the inferior triangle of Petit. It is a potential space between the origin of the external oblique, latissimus dorsi, and the iliac crest. Journal of Pediatric Surgery, Vol 37, No 6 (June), 2002: pp 921-922
Fig 1. Bilateral congenital lumbar hernias; the left is larger than the right.
Lumbar hernias can be congenital or acquired. The cause of congenital hernias remains a matter of debate. The most popular theory in the literature proposed by Touloukain2 is one of a somatic mutation in the third to fifth week of embryogenesis, possibly as a result of transient anoxia. This produces derangement of the lumbar muscles and aponeuroses predisposing to herniation. This theory accounts for the fact that 12 of the 16 reported congenital cases had associated musculoskeletal abnormalities of the vertebral bodies, ribs, and trunk musculature (Lumbo-costovertebral syndrome. It does not explain the selective involvement of the lumbar region. Acquired hernias in the region follow surgery, trauma, and infection of the perinephric region. Lafer1 reported the association with intrathoracic neuFrom the Department of Paediatric Surgery, King’s College School of Medicine and Dentistry, Denmark Hill, Camberwell, London, England. Address reprint requests to S. Karmani, FRCS, 2 Dafforne Rd, London SW17 8TZ, England. Copyright 2002, Elsevier Science (USA). All rights reserved. 0022-3468/02/3706-0024$35.00/0 doi:10.1053/jpsu.2002.32913 921
922
KARMANI, EMBER, AND DAVENPORT
roblastoma, postulating that a localized neuropraxia caused by the tumour may produce the hernia. Other defects reported have included meningomyelocele3; congenital sciatic hernia focal nodular hyperplasia of the liver, and absent right kidney.4 Because of these associations it is vital to screen for them with radiographs of the chest, lumbar spine, and renal tract ultrasound in all cases of congenital lumbar hernias. Treatment is indicated in the first year to prevent incarceration, although this is uncommon. Early repair also is advocated as the defect may enlarge with growth.
Conservative treatment has been advocated in lumbar hernias associated with neuroblastoma if the nerve damage resulting in the defect is transient.1 Surgical correction can be by simple closure of small fascial defects or require rotation free flaps or synthetic reinforcement with prosthetic mesh or dura. Placement of the mesh internal to the defect may ensure a better result.5 This is the first report in the literature of congenital isolated bilateral lumbar hernias. This condition may represent a different pathologic entity to previously described congenital lumbar hernias.
REFERENCES 1. Lafer DJ: Neuroblastoma and lumbar hernia: A Causal relationship? J Pediatr Surg 29:926-929, 1994 2. Touloukain RJ: The lumbocostovertebral syndrome: A single somatic defect Surgery 71:174-181, 1972 3. Lowell DG, Guzetta PC: Lumbar hernia in a case of posterior meningomyelocele. J Pediatr Surg 21:913-914, 1986
4. Al-Salem AH, Abu-Sriar H, Qaissaruddin S: Focal nodular hyperplasia of the liver with the lumbocostvertebral syndrome. J Pediatr Surg 31:1282-1284, 1986 5. Fulham SB: Lumbar hernia. Surgeon’s workshop. J R Coll Surg Edinb 30:315-317, 1985