- Email: [email protected]
Lumbar hernia in a case of posterior meningomyelocele
Lumbar Hernia in a Case of Posterior M e n i n g o m y e l o c e l e By Douglas G. Lowell and Philip C. Guzzetta
Washington, DC 9 A child with a superior lumbar hernia and a posterior menin0omyelocele is described in this report. Although congenital lumbar hernia may be associated with lumbocostal vertebral deficiency syndromes, we believe this patient's condition became obvious due to the repair of the meningomyelocele. This is the first case report of this combination of defects. 9 1986 by Grune & Stratton. Inc. INDEX WORDS: Posterior meningomyelocele; congenital lumbar hernia.
A
CHILD with superior lumbar hernia and meningomyelocele was recently treated at Children's Hospital National Medical Center (CHNMC). We believe that the lumbar hernia became evident because of the operative repair of the posterior meningomyelocele. CASE REPORT A newborn female infant was transferred to our hospital for surgical repair of a posterior meningomyelocele at the L 2 to L4 level. The patient was a product of a normal pregnancy and vaginal delivery. The patient was alert and active. Her weight and length were greater than the 90th percentile, but her head circumference was in the 25th percentile. The anterior fontanelle was tense and craniofacial asymmetry was noted. Results of chest, abdominal, and cardiovascular examinations were normal. A maternal aunt had had a pilonidal cyst, but there were no other known congenital malformations in her family. A C A T scan taken after admission was consistent with hydrocephalus and probable Arnold-Chiari malformation. The posterior meningomyelocele was closed primarily, with muscle tissue being transposed medially within the lower back for soft tissue coverage after the meninges had been dissected free of skin and closed. A ventriculo-peritoneal shunt was placed. The shunt was revised 3 weeks after the initial surgery. Two days after the shunt revision, nurses noted a left-sided lumbar bulging mass that was accentuated by crying. Examination proved this to be a soft reducible mass below the 12th rib and immediately anterior to quadratus lumborum, ie, a superor lumbar triangle (Grynfelt-Lesshaft) hernia. At the time of surgical repair, a well-defined, 1.5 cm fascial defect was found at the level of the superior triangle (Fig 1). No latissimus dorsi muscle was observed, and the defect was closed by approximation of the fascia and the serratus posterior inferior muscles. The patient had an uneventful recovery; 6 months later, she displayed no evidence of a hernia.
Fig 1. Fascial defect in the superior lumbar triangle with retroparitoneal fat protruding through the defect.
superior lumbar triangle is normally covered by the latissimus dorsi muscle. A lumbar hernia may also occur in Petit's inferior lumbar triangle, which is bounded inferiorly by the iliac crest, anteriorly by the external oblique, and posteriorly by the latissimus dorsi. In 1870, Lesshaft determined from cadaver dissections that the superior lumbar triangle developed a defect more commonly than the inferior lumbar triangle because the superior lumbar triangle had a congenital weak point in its floor, where the 12th dorsal neurovascular bundle perforates the transversalis 2 fascia. We believe that the lumbar hernia in this patient represents a fascial defect that may have remained
DISCUSSION
Lumbar hernias are rarely seen in children t and may occur in two locations. A hernia within the superior lumbar triangle (Grynfelt-Lesshaft) is found between the inferior aspect of the 12th rib and elements of the serratus posterior along the superior margin, the internal oblique along the anterior margin, and the quadratus lumborum along the posterior margin. This Journal of Pediatric Surgery, Vol 21, No 10 (October), 1986: pp 913-914
From the Department of General Surgery, Rush-Presbyterian-St Luke's Medical Center, and the Department of Surgery, Children's Hospital National Medical Center, Child Health and Development, George Washington University, Washington, DC. Address reprint requests to Philip C. Guzzetta, MD, Department of Surgery, Children's Hospital National Medical Center, George Washington University, 901 23rd St NW, Washington DC 20037. 9 1986 by Grune & Stratton, Inc. 0022-3468/86/2110~9024503.00/0 .q13
914
LOWELL AND GUZZETTA
clinically inapparent; however, the operative correction of the posterior meningomyelocele, with its transposition of the covering latissimus dorsi medially, had allowed the underlying tissue to herniate through the defect. This explanation is supported by the fact that the hernia was first noticed only after repair of the meningomyelocele, and by the fact that acquired lumbar hernias outnumber congenital hernias by 10 to 1. 3 Previously published materials suggest an association between congenital lumbar hernias and lumbocostal vertebral deficiency syndromes, 4 possibly asso-
ciated with anoxic episodes during the eighth to ninth week of gestation as produced in animal studies, s These syndromes included hemivertebra, congenital absence of ribs, anterior meningomyelocele, and abdominal wall muscular hypoplasia. Posterior meningomyelocele is not included in the lumbocostal vertebral deficiency syndromes. We recommend operative repair before 12 months of age, as the hernial defect may enlarge with growth, making primary closure with surrounding tissue difficult. 6
REFERENCES
1. Swartz WT: Lumbar hernia, in Nyhus LM, Condon RE (eds): Hernia (ed 2). Philadelphia, Lippincott, 1978, pp 409-426 2. Lesshaft P: Die Lumalgegend in Anatomische chirurgischer Hinsicht. Arch Anat Physiol Wissensch Med 37:264-290, 1870 3. Lee CM, Matthers H: Congenital lumbar hernia. Arch Dis Child 32:42-45, 1957
4. Touloukian RJ: The lumbocostovertebralsyndrome: A single somatic defect. Surgery 71:174-181, 1978 5. Ingalls TM, Curley FJ, Prendle RA: Experimental production of congenital anomalies: Timing and degree of anoxia as a factor causing fetal deaths and congenital anomalies in the mouse. N Engl J Med 247:758-768, 1952 6. Talkukder BC: Congenital lumbar hernia. J Pediatr Surg 9:419-420, 1974
Washington, DC 9 A child with a superior lumbar hernia and a posterior menin0omyelocele is described in this report. Although congenital lumbar hernia may be associated with lumbocostal vertebral deficiency syndromes, we believe this patient's condition became obvious due to the repair of the meningomyelocele. This is the first case report of this combination of defects. 9 1986 by Grune & Stratton. Inc. INDEX WORDS: Posterior meningomyelocele; congenital lumbar hernia.
A
CHILD with superior lumbar hernia and meningomyelocele was recently treated at Children's Hospital National Medical Center (CHNMC). We believe that the lumbar hernia became evident because of the operative repair of the posterior meningomyelocele. CASE REPORT A newborn female infant was transferred to our hospital for surgical repair of a posterior meningomyelocele at the L 2 to L4 level. The patient was a product of a normal pregnancy and vaginal delivery. The patient was alert and active. Her weight and length were greater than the 90th percentile, but her head circumference was in the 25th percentile. The anterior fontanelle was tense and craniofacial asymmetry was noted. Results of chest, abdominal, and cardiovascular examinations were normal. A maternal aunt had had a pilonidal cyst, but there were no other known congenital malformations in her family. A C A T scan taken after admission was consistent with hydrocephalus and probable Arnold-Chiari malformation. The posterior meningomyelocele was closed primarily, with muscle tissue being transposed medially within the lower back for soft tissue coverage after the meninges had been dissected free of skin and closed. A ventriculo-peritoneal shunt was placed. The shunt was revised 3 weeks after the initial surgery. Two days after the shunt revision, nurses noted a left-sided lumbar bulging mass that was accentuated by crying. Examination proved this to be a soft reducible mass below the 12th rib and immediately anterior to quadratus lumborum, ie, a superor lumbar triangle (Grynfelt-Lesshaft) hernia. At the time of surgical repair, a well-defined, 1.5 cm fascial defect was found at the level of the superior triangle (Fig 1). No latissimus dorsi muscle was observed, and the defect was closed by approximation of the fascia and the serratus posterior inferior muscles. The patient had an uneventful recovery; 6 months later, she displayed no evidence of a hernia.
Fig 1. Fascial defect in the superior lumbar triangle with retroparitoneal fat protruding through the defect.
superior lumbar triangle is normally covered by the latissimus dorsi muscle. A lumbar hernia may also occur in Petit's inferior lumbar triangle, which is bounded inferiorly by the iliac crest, anteriorly by the external oblique, and posteriorly by the latissimus dorsi. In 1870, Lesshaft determined from cadaver dissections that the superior lumbar triangle developed a defect more commonly than the inferior lumbar triangle because the superior lumbar triangle had a congenital weak point in its floor, where the 12th dorsal neurovascular bundle perforates the transversalis 2 fascia. We believe that the lumbar hernia in this patient represents a fascial defect that may have remained
DISCUSSION
Lumbar hernias are rarely seen in children t and may occur in two locations. A hernia within the superior lumbar triangle (Grynfelt-Lesshaft) is found between the inferior aspect of the 12th rib and elements of the serratus posterior along the superior margin, the internal oblique along the anterior margin, and the quadratus lumborum along the posterior margin. This Journal of Pediatric Surgery, Vol 21, No 10 (October), 1986: pp 913-914
From the Department of General Surgery, Rush-Presbyterian-St Luke's Medical Center, and the Department of Surgery, Children's Hospital National Medical Center, Child Health and Development, George Washington University, Washington, DC. Address reprint requests to Philip C. Guzzetta, MD, Department of Surgery, Children's Hospital National Medical Center, George Washington University, 901 23rd St NW, Washington DC 20037. 9 1986 by Grune & Stratton, Inc. 0022-3468/86/2110~9024503.00/0 .q13
914
LOWELL AND GUZZETTA
clinically inapparent; however, the operative correction of the posterior meningomyelocele, with its transposition of the covering latissimus dorsi medially, had allowed the underlying tissue to herniate through the defect. This explanation is supported by the fact that the hernia was first noticed only after repair of the meningomyelocele, and by the fact that acquired lumbar hernias outnumber congenital hernias by 10 to 1. 3 Previously published materials suggest an association between congenital lumbar hernias and lumbocostal vertebral deficiency syndromes, 4 possibly asso-
ciated with anoxic episodes during the eighth to ninth week of gestation as produced in animal studies, s These syndromes included hemivertebra, congenital absence of ribs, anterior meningomyelocele, and abdominal wall muscular hypoplasia. Posterior meningomyelocele is not included in the lumbocostal vertebral deficiency syndromes. We recommend operative repair before 12 months of age, as the hernial defect may enlarge with growth, making primary closure with surrounding tissue difficult. 6
REFERENCES
1. Swartz WT: Lumbar hernia, in Nyhus LM, Condon RE (eds): Hernia (ed 2). Philadelphia, Lippincott, 1978, pp 409-426 2. Lesshaft P: Die Lumalgegend in Anatomische chirurgischer Hinsicht. Arch Anat Physiol Wissensch Med 37:264-290, 1870 3. Lee CM, Matthers H: Congenital lumbar hernia. Arch Dis Child 32:42-45, 1957
4. Touloukian RJ: The lumbocostovertebralsyndrome: A single somatic defect. Surgery 71:174-181, 1978 5. Ingalls TM, Curley FJ, Prendle RA: Experimental production of congenital anomalies: Timing and degree of anoxia as a factor causing fetal deaths and congenital anomalies in the mouse. N Engl J Med 247:758-768, 1952 6. Talkukder BC: Congenital lumbar hernia. J Pediatr Surg 9:419-420, 1974