307 lines
24 KiB
Markdown
307 lines
24 KiB
Markdown
---
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title: "Lumbar Hernia"
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docid: "0fa5904f-36a1-42db-8398-80b5e495f7ae"
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authors:
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- key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
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value: "Siva P. Raman, MD"
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breadcrumbs:
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-
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name: "Gastrointestinal"
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slug: "gastrointestinal"
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treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
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-
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name: "Peritoneum, Mesentery, and Abdominal Wall"
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slug: "peritoneum-mesentery-and-abdominal-"
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treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
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-
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name: "External Hernias"
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slug: "external-hernias"
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treeNodeId: "71ab3f79-4332-463c-9f60-d3dd2902d974"
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-
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name: "Lumbar Hernia"
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slug: "lumbar-hernia"
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treeNodeId: null
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category: "Gastrointestinal"
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documentVersionId: "04dd5f57-9301-4bf0-b6f2-42661575dc41"
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imageCount: 8
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lastUpdated: "03/13/25"
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pageDescription: "Lumbar Hernia"
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pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, External Hernias, Lumbar Hernia"
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pageTitle: "Lumbar Hernia | STATdx"
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enhancedTitle: "Lumbar Hernia"
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type: "DX"
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references: true
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ddx: true
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anatomy:
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- "{'authors': 'Atif Zaheer, MD, FSAR; Siva P. Raman, MD; Michael P. Federle, MD, FACR', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'category': 'Gastrointestinal', 'compareUrl': '/compare/document/6691f48d-ac34-477b-8ec1-b9dd731a14a8/related-anatomy/treeNode?subContext=Peritoneal Cavity', 'documentId': '6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'documentType': 'ANATOMY', 'documentUrl': '/document/peritoneal-cavity/6691f48d-ac34-477b-8ec1-b9dd731a14a8', 'enhancedTitle': 'Peritoneal Cavity', 'entryDate': '07/06/23', 'imageCount': 53, 'imageUrl': '/image/thumbnail/e305c4ce-1242-49fa-bc19-e0f5461cdafa?size=174&quality=85', 'inCompareCart': False, 'rank': 1, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Peritoneal Cavity'}"
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- "{'authors': 'Jade Wong-You-Cheong, MBChB, MRCP, FRCR, FSRU, FSAR', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/9c50ad6a-e96b-44a1-93d1-a4e7de5212c2', 'category': 'Ultrasound', 'compareUrl': '/compare/document/9c50ad6a-e96b-44a1-93d1-a4e7de5212c2/related-anatomy/treeNode?subContext=Peritoneal Spaces and Structures', 'documentId': '9c50ad6a-e96b-44a1-93d1-a4e7de5212c2', 'documentType': 'ANATOMY', 'documentUrl': '/document/peritoneal-spaces-and-structures/9c50ad6a-e96b-44a1-93d1-a4e7de5212c2', 'enhancedTitle': 'Peritoneal Spaces and Structures', 'entryDate': '06/01/21', 'imageCount': 19, 'imageUrl': '/image/thumbnail/2f75e19a-ac4a-4c80-b849-10223abf64f2?size=174&quality=85', 'inCompareCart': False, 'rank': 2, 'referenceCount': 2, 'showCompareButton': False, 'title': 'Peritoneal Spaces and Structures'}"
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- "{'authors': 'Eric Turner, MD; Mark E. Lockhart, MD, MPH; Daniel Childers, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/79a4117f-773a-40b3-bdb5-b0195f84e087', 'category': 'Ultrasound', 'compareUrl': '/compare/document/79a4117f-773a-40b3-bdb5-b0195f84e087/related-anatomy/treeNode?subContext=Mesenteric Vessels', 'documentId': '79a4117f-773a-40b3-bdb5-b0195f84e087', 'documentType': 'ANATOMY', 'documentUrl': '/document/mesenteric-vessels/79a4117f-773a-40b3-bdb5-b0195f84e087', 'enhancedTitle': 'Mesenteric Vessels', 'entryDate': '05/13/24', 'imageCount': 22, 'imageUrl': '/image/thumbnail/102e0a5e-f97c-46b9-9dc0-6193e796506d?size=174&quality=85', 'inCompareCart': False, 'rank': 3, 'referenceCount': 0, 'showCompareButton': False, 'title': 'Mesenteric Vessels'}"
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cases: 2
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breadcrumbs:
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- "Gastrointestinal"
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- "Diagnosis"
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- "Peritoneum, Mesentery, and Abdominal Wall"
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- "External Hernias"
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- "Lumbar Hernia"
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---
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# KEY FACTS
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- ## Terminology
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- Lumbar hernia: Protrusion of abdominal contents through defect in lumbar region
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- Can occur in either superior lumbar triangle of Grynfeltt-Lesshaft or inferior lumbar triangle of Petit
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- Superior lumbar triangle of Grynfeltt-Lesshaft defined by 12th rib superiorly, superior border of internal oblique inferiorly, and erector spinae medially
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- Inferior lumbar triangle of Petit defined by latissimus dorsi muscle medially, iliac crest inferiorly, and free border of external oblique muscle laterally
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- Overall, hernias are more common in superior triangle
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- ## Imaging
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- Disruption of thoracolumbar fascia at insertion of aponeurosis of internal oblique and transverse abdominal muscles
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- Hernia may contain extraperitoneal fat, colon, kidney, or intraperitoneal structures (small bowel, ascites)
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- Most commonly involved are colon and small bowel
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- ## Top Differential Diagnoses
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- Abdominal wall neoplasms
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- Abdominal wall hematoma
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- Abdominal wall lipoma
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- ## Pathology
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- 80% of lumbar hernias are acquired
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- Can be spontaneous (especially in older patients and patients with excessive weight loss) or secondary to trauma, infection, or previous surgery in flank
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- Most commonly occurs following flank incision for renal surgery or iliac crest bone harvesting
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- < 20% of lumbar hernias are congenital and often associated with other congenital abnormalities
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- ## Clinical Issues
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- Very difficult to detect (and often missed) on physical examination and more likely to be diagnosed on CT
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- Risk of incarceration and strangulation higher than originally believed (approaching 30%)
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- Incarceration more common with traumatic lumbar hernias
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- Treatment: Early surgical repair because repair becomes technically more difficult as hernia enlarges
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# TERMINOLOGY
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- ## Definitions
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- Lumbar hernia: Protrusion of abdominal contents through defect in lumbar region
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- Lumbar region: Area bounded by 12th rib superiorly, iliac crest inferiorly, erector spinae muscles medially, and free border of external oblique muscle laterally
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- Superior lumbar triangle of Grynfeltt-Lesshaft
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- Defined by 12th rib superiorly, superior border of internal oblique inferiorly, and erector spinae muscles medially
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- Transversus abdominis muscle lies deep in floor; latissimus dorsi muscle serves as roof of this space
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- Inferior lumbar triangle of Petit
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- Defined by latissimus dorsi muscle medially, iliac crest inferiorly, and free border of external oblique muscle laterally
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- Thoracolumbar fascia lies in floor of this triangle
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Disruption of fascia and muscles in lumbar region with protrusion of abdominal contents
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- ### Location
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- Superior and inferior lumbar triangles
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- Primary type more common in superior lumbar triangle, more common on left side
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- Secondary type more common in inferior lumbar triangle
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- Traumatic lumbar hernias more common in inferior triangle because of deceleration forces during motor vehicle accidents at junction of lap belt and shoulder belt
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- Overall, hernias more common in superior triangle because it is larger than inferior triangle
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- ### Morphology
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- Disruption of thoracolumbar fascia at insertion of aponeurosis of internal oblique and transverse abdominal muscles
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- Hernia may contain extraperitoneal fat, colon, kidney, or intraperitoneal structures (small bowel, ascites)
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- Most commonly involved structures are colon (41%) and small bowel (32%)
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- Bowel wall thickening, infiltrated fat, and pain at site of hernia suggest strangulation and ischemia
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- ## Imaging Recommendations
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- ### Best imaging tool
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- CECT
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- ### Protocol advice
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- Multiplanar reformations can help visualize nature and size of defect as well as aiding in preoperative planning
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# DIFFERENTIAL DIAGNOSIS
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- ## Abdominal Wall Neoplasms
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- Can be primary (e.g., sarcoma) or metastatic (e.g., melanoma)
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- While mass could theoretically be confused with hernia on physical exam, distinction should be obvious on imaging
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- ## Abdominal Wall Hematoma
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- Most often in setting of trauma or coagulopathy
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- Heterogeneous high-density collection should be easily distinguishable from hernia on cross-sectional imaging
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- ## Abdominal Wall Lipoma
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- Discrete fat-containing mass without evidence of fascial defect or protrusion of abdominal contents
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Congenital (< 20%)
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- Associated with variety of other congenital abnormalities, including musculoskeletal abnormalities (i.e., absent ribs, spinal dysraphism, hemivertebrae), urinary tract abnormalities (ureteropelvic junction obstruction, cloacal extrophy, etc.), diaphragmatic hernia, myelomeningocele, etc.
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- Maybe secondary to somatic mutation during embryogenesis, possibly also explaining high rates of concomitant musculoskeletal abnormalities in spine and abdominal wall
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- Exact incidence is somewhat unclear, but only a few cases actually reported in literature
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- Acquired (80%)
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- Primary (55%): Spontaneous, seen in older-age patients and patients with excessive weight loss
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- Entities that increase intraabdominal pressure may also predispose to development of lumbar hernias, such as pregnancy, obesity, ascites, etc. (similar to other hernias)
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- Abdominal wall weakness that develops with age, muscle atrophy, etc. can also play role
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- Secondary (25%): Due to trauma, infection, or previous surgery in flank
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- Most common prior surgeries to result in lumbar hernia include nephrectomy, abdominal aortic aneurysm repair, latissimus dorsi myocutaneous flap repair, and iliac crest bone harvesting
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- Acute traumatic lumbar hernias are very rare and usually occur after blunt abdominal trauma (especially with seat belt injury)
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- Can occur after infections that weaken abdominal wall at this site (hepatic abscess, pelvic bone infections, etc.)
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- Surgeries with highest risk of development of lumbar hernia
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- Iliac crest bone harvesting (5-10%)
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- Open nephrectomy or adrenalectomy
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Flank bulge, "dragging" sensation, back pain
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- Palpable mass in posterolateral abdominal wall that worsens with coughing, activity, or Valsalva maneuver
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- Very difficult to detect on physical examination (and often missed) and more likely to be diagnosed on CT
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- ## Demographics
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- ### Age
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- Most diagnosed patients between 60-70 years old
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- ### Sex
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- M > F (2:1)
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- ### Epidemiology
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- Primary type: More common in men and older patients
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- Secondary type: History of trauma, infection, or surgery in lumbar region
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- ## Natural History & Prognosis
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- While incarceration and strangulation have traditionally been thought to be uncommon because of large size of opening into hernia, more recent data suggests risk may be higher than previously thought (perhaps as high as 30%)
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- Incarceration more common with acute traumatic lumbar hernias
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- Acute posttraumatic lumbar hernias have strong association with other internal abdominal injuries
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- Erythema and increased pain may suggest strangulation
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- Strangulation is secondary to volvulus or constricted neck of hernia
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- ## Treatment
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- In absence of acute complications (such as obstruction, incarceration, etc.), elective surgery is advocated as soon as possible
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- Early surgery is advocated, because as hernia enlarges, repair becomes technically more difficult (and due to risk of incarceration)
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- While lumbar hernia repair has traditionally been performed with open technique, these repairs are now increasingly being done laparoscopically (without clear data showing advantage of one vs. other) and typically with use of mesh
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- Laparoscopic repair typically recommended in hernias < 5 cm in size, while approach for larger hernias more variable
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- Recurrence more likely for large hernias (> 15 cm in size) and in obese patients
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- In congenital hernias, repair is usually performed before 12 months of age (as surgery may become more technically difficult as hernia enlarges over time)
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# DIAGNOSTIC CHECKLIST
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- ## Consider
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- Look for evidence of prior surgery
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- Nephrectomy or iliac crest bone harvest site (typically for spinal fusion)
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- ## Image Interpretation Pearls
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- Identify muscle and fascial planes to determine specific type of hernia
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36a0911b-5166-43a2-9324-bce342e97745
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## References
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# Selected References
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1. [Sabbagh ED et al: Management of a primary Grynfeltt's hernia. J Visc Surg. 161(4):273-4, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38604931%5Bpmid%5D)
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1. [van Steensel S et al: Pitfalls and clinical recommendations for the primary lumbar hernia based on a systematic review of the literature. Hernia. 23(1):107-17, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30315438%5Bpmid%5D)
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1. [Mellnick VM et al: Traumatic lumbar hernias: do patient or hernia characteristics predict bowel or mesenteric injury? Emerg Radiol. 21(3):239-43, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24402010%5Bpmid%5D)
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1. [Saboo SS et al: Traumatic lumbar hernia: can't afford to miss. Emerg Radiol. 21(3):325-7, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24424984%5Bpmid%5D)
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1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
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1. [Baker ME et al: Lumbar hernia: diagnosis by CT. AJR Am J Roentgenol. 148(3):565-7, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3492886%5Bpmid%5D)
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1. [Touloukian RJ: The lymbocostovertebral syndrome: a single somatic defect. Surgery. 71(2):174-81, 1972](http://www.ncbi.nlm.nih.gov/pubmed/?term=5057828%5Bpmid%5D)
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## Differential diagnosis
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### Abdominal Wall Mass
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DDX:d51e2268-67b6-4a60-9222-f5a86f61ddec
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### Defect in Abdominal Wall (Hernia)
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DDX:5af046fa-59ef-45b5-952b-acbcdee36196
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## Anatomy
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### Peritoneal Cavity
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Gastrointestinal/ANATOMY:6691f48d-ac34-477b-8ec1-b9dd731a14a8
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### Peritoneal Spaces and Structures
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Ultrasound/ANATOMY:9c50ad6a-e96b-44a1-93d1-a4e7de5212c2
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### Mesenteric Vessels
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Ultrasound/ANATOMY:79a4117f-773a-40b3-bdb5-b0195f84e087
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## Cases
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- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '58c96b57-63db-4ca0-a349-5a94904cd179', 'description': 'There is a defect in the thoracolumbar fascia on the right side (curved arrows, #2,3) through which retroperitoneal fat herniates (arrow, #1). The site of herniation is just cephalad to the insertion of the fascia on the iliac crest.', 'history': 'Bulge in right flank.', 'imagePoolId': '7eff1f2b-8a13-4c53-9687-4aff5336ee3c', 'name': 'Right lumbar hernia', 'teachingPoint': None, 'demographics': '65 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '9e260cfc-1da3-4653-be86-21e587c2b643', 'description': 'CT shows a defect (arrows, #1,2) in the left thoracolumbar fascia through which the descending colon (open arrow, #1) herniates dorsally. The thoracolumbar fascia should be a strong sheet of tissue that inserts on the iliac crest (curved arrow, #4).', 'history': 'Left flank pain and bulge.', 'imagePoolId': '722090c5-0cb2-4df7-8d2e-ec208c296008', 'name': 'Left hernia with herniated colon', 'teachingPoint': None, 'demographics': '78 Years old female'}], 'caseType': 'typical', 'name': 'TYPICAL'}
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- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '11d6423f-b807-4a3a-9507-234d36d68eb7', 'description': 'A series of axial (#1-6) and coronal (#7-15) contrast-enhanced CT sections show avulsion of the muscular and tendinous insertions of the abdominal wall muscles from the left iliac wing and thoracolumbar fascia (arrows, #4-5, 8-13), especially along the more dorsal surfaces. More anteriorly, the musculotendinous insertions are intact (open arrows, #6, 14-15). The herniated abdominal fat is covered only by the latissimus dorsi muscle (curved arrows, #3-4). Also noted is infiltration of the fat adjacent to the descending colon (curved arrows, #1-2). \n\nComment: At surgery, a serosal tear of the descending colon was confirmed.', 'history': 'Patient injured in high-speed motor vehicle crash.', 'imagePoolId': '847c0a5b-0b04-43e1-a1b1-77018adfbc41', 'name': 'Traumatic lumbar hernia', 'teachingPoint': None, 'demographics': '46 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '2e3903c4-0c1c-4fe3-acee-5c6c3db7fa74', 'description': 'A series of axial nonenhanced CT sections (#1-5) show surgical absence of the left kidney with protrusion of abdominal fat through the site of the incision. The hernia is covered mostly by the thin latissimus dorsi muscle (arrows, #1-4). The defect, a variant of a lumbar hernia, is through the aponeuroses of the abdominal oblique and transverse muscles.', 'history': 'Bulge in flank some months after open nephrectomy.', 'imagePoolId': 'bf7bec4c-e54a-4371-add2-ed1ff53c85ba', 'name': 'Following nephrectomy for renal cancer', 'teachingPoint': None, 'demographics': '60 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd07fd737-202f-4c9a-80de-41e588b75a13', 'description': 'A series of axial contrast-enhanced CT sections (#1-11) show 2 separate protrusions of fat. The more cephalic of these (curved arrows, #1-2) is a herniation of abdominal fat into the thorax through a posteromedial defect in the diaphragm, called a Bochdalek hernia. The more caudal of these is a herniation of abdominal fat through a defect in the aponeuroses of the transverse abdominal and oblique muscles at their insertion into the thoracolumbar fascia. This is called a lumbar hernia. The herniated fat is covered by the latissimus dorsi muscle (arrows, #4-9). The fascial defect (open arrows) is seen best on sections #9-10. Caudal to this defect, the aponeuroses are intact but very thin bilaterally (curved arrows, #11), predisposing this patient to a lumbar hernia on the left side as well.\n\nComment: Lumbar hernias may allow herniation of retroperitoneal contests, such as fat, kidneys, or colon, or intraperitoneal contents, such as ascites or small intestine.', 'history': 'Patient with a nontender bulge in right flank.', 'imagePoolId': 'e3b26b1e-effc-450c-ad03-16422f747036', 'name': 'Lumbar and Bochdalek hernia', 'teachingPoint': None, 'demographics': '72 Years old female'}], 'caseType': 'variant', 'name': 'VARIANT'}
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## Images
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### Selected Images
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*Axial CECT demonstrates a classic right-sided lumbar hernia with herniation of retroperitoneal fat and a portion of the right kidney covered only by the thinned latissimus dorsi muscle <img src='img/arrows/WS.png'/>.*
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*Axial CECT demonstrates a defect in the thoracolumbar fascia on the right side <img src='img/arrows/WS.png'/> through which retroperitoneal fat herniates. The site of herniation is just cephalad to the insertion of the fascia on the iliac crest, classic for a lumbar hernia.*
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*Axial NECT demonstrates a traumatic lumbar hernia in the setting of blunt trauma. The abdominal wall is disrupted in the left flank with herniated abdominal fat covered only by the latissimus dorsi muscle <img src='img/arrows/WC.png'/>.*
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*Coronal CECT demonstrates a large right-sided lumbar hernia containing a long segment of the colon <img src='img/arrows/WC.png'/> and a portion of the liver <img src='img/arrows/WS.png'/>.*
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### Additional Images
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*Axial NECT demonstrates a lumbar hernia <img src='img/arrows/WS.png'/> with extension of the right kidney <img src='img/arrows/WC.png'/> into the hernia sac.*
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*Axial CECT shows avulsion of the muscular and tendinous insertions of the abdominal wall muscles from the left iliac wing and thoracolumbar fascia with creation of a posttraumatic lumbar hernia <img src='img/arrows/WS.png'/>. Posttraumatic lumbar hernias are rare but much more likely to be associated with strangulation or incarceration.*
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*Coronal CECT shows avulsion <img src='img/arrows/WC.png'/> of the muscular and tendinous insertions of the abdominal wall muscles from the left iliac wing and thoracolumbar fascia with creation of a posttraumatic lumbar hernia. Posttraumatic lumbar hernias are rare but much more likely to be associated with strangulation or incarceration.*
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*Axial NECT shows surgical absence of the left kidney with protrusion <img src='img/arrows/WS.png'/> of abdominal fat through the site of the incision. The hernia is covered mostly by the thin latissimus dorsi muscle. The defect, a variant of a lumbar hernia, is through the aponeuroses of the abdominal oblique and transverse muscles.*
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