Pediatr S~:rg Int (1992) 7:317-318 Pe t 'c Surgery

International © Springer-Verlag 1992

Case report

Congenital lumbar and sciatic herniae in an infant

P e t e r N~or r i s l , J a m e s B r u c e ~, N i c h o l a s Thiess2 , and Alan A. W o o d w a r d ~

1 Department of General Surgery, Royal Children's Hospital, Melbourne, Australia 2 Department of Paediatrics, Warnambool Base Hospital, Victoria, Australia

Accepted 14 June 1991

A b s t r a c t . L u m b a r h e r n i a is a rare occu r r ence in chi ldhood a n d i n f a n c y ; sciat ic h e r n i a t i o n is e v e n m o r e unusua l . The c l i n i ca l de ta i l s o f a n e o n a t e wi th a l u m b a r he rn ia who later was n o t e d to have a sciat ic h e r n i a is p resen ted , together w i th a r~:~view of the l i terature .

K e y we, r d s : C o n g e n i t a l . h e r n i a - L u m b a r he rn ia - Sciatic h e r n i a - - D i a g n o s i s

t r iangle is fo rmed by the 12th r ib super io r ly , e rec to r s p i n a e media l ly , and in te rna l ob l i que m u s c l e in fe f io r ly . The infe - rior l u m b a r t r iangle is bo rde red by l a t i s s i m u s dors i supe- riorly, external ob l ique la teral ly , and the i l e u m in fe f io f ly . L u m b a r he rn iae occur m o s t c o m m o n l y v ia the supe r io r t r iangle.

C a s e r e p o r t

A 3.07-kg Caucasian male infant was born vaginally at 40 weeks' gesta- tion following a normal pregnancy. At 2 h of age he was noted to have a mass, 8 x :5 cm in diameter, protruding from his fight lumbar region. The lesion wa~; lobulated and reducible. It was noted to increase on crying and transmitted bowel sounds. Ultrasound investigation of the mass revealed its upper ::omponent to be renal and the lower part to be intestinal. No other abnormalities were found at this time (Fig. 1).

Surge:y was performed at 3 months of age. Two hernia sacs were discovere:l, separated by a band of fascia; one contained intestine and the other kidi:ey. The latissimus dorsi muscle was found to be deficient (Fig. 2 a). 'Fhe hernia was repaired with non-absorbable suture, apposing external oblique muscle to lumbar fascia.

On th:., 10th postoperative day, another swelling was noted in the patient's i:ight buttock. A hernia was found protruding from the greater sciatic forarnen (Fig. 2b). Repair was performed at 5 months of age. At that time, a hernia was found with an infrapiriformis sac containing adherent large bowel. Piriforrnis muscle was present but gluteus maxi- mus was :~bnormal, as it did not have a sacral attachment. The sac was excised and the piriformis was sutured to the sacrospinous ligament and reinforcec by gluteus maximus. A muscle biopsy taken at that time was normal. There were no postoperative complications, with no recurrence of the herniae nor any further new herniation.

Discussion

A d u l t lu:aabar he rn i ae are desc r ibed occu r r i ng through the supe r io r o r in fe r io r l u m b a r t r iangles . T h e super ior lumbar

Offprint r:'quests to: A. Woodward, Department of General Surgery, Royal C~!ldren's Hospital, Flemington Road, Parkville Vic 3052, Australia Fig. 1. Photograph of patient demonstrating the lumbar hernia

318

ISSIMUS ORSI

INAL iUE

i ~GLUTEUS MAXIMUS

IUI PIRIFORMIS " " ~ . -

SACRO LIGAMENT GLUTEUS / /MI////////// MAX MUS

s A c R o r u s E R o u s / L GAMENr /

b

Fig. 2.a Anatomy of the lumbar hernia, b Anatomy of the sciatic hernia (A = greater sciatic foramen, B = lesser sciatic foramen)

In infancy, these herniae are always due to an abnormal- ity of the musculature; our case confirms this. Most sciatic herniae arise through the greater sciatic foramen and are classified as suprapiriformis or infrapiriformis, relative to the piriformis muscle. Less common is the variant of

hernia passing inferior to the sacrospinous ligament: the hernia of the lesser sciatic foramen.

The aetiology of these hemiae is not known, but evi- dence exists to suggest that the defects are part of a more extensive congenital abnormality. The association between congenital lumbar hernia and costal and vertebral abnor- malities was reported in 1948 [7]. In a review of the litera- ture, Touloukian proposed that all cases belonged to the "lumbocostovertebral syndrome", based on the premise that the pathology was secondary to a single somatic defect early in embryonic development [6]. The associated skeletal defects were hemivertebrae and hypoplastic ribs. Two cases of associated anterior meningomyelocoele have been reported [5], and abnormalities of the diaphragm and renal tract have also been recorded.

There have been 10 further cases of lumbar herniae reported more recently: 8 were associated with another abnormality; 2 with a posterior meningomyelocoele [5]; and 2 cases with maternal diabetes associated with lumbar herniae and absent tibia [4].

There are no reports of congenital sciatic hernia as part of a syndrome; Watson made no mention of any associated abnormali ty [7]. More recently, of the four cases with sciatic hernia reported, three have had other pathologies: one with meningomyelocoele with umbilical hernia and talipes; one with an imperforate anus and absent kidney; and the third with meningomyelocoele and absent kidney [1, 31.

The present case emphasises that thorough examination and fol low-up are essential in the management of children with unusual body wall defects.

References

1. Franken E, Smith E (1969) Sciatic hernia: report of three cases includ- ing two with bilateral ureteric involvement. Am J Roentgenol 107: 791-795

2. Hancock BK, Wiseman NE (1988) Incarcerated congenital lumbar hernia associated with the lumbocostovertebral syndrome. J Pediatr Surg 23:782-783

3. Lebowitz R (1973) Ureteral sciatic hernia. Pediatr Radiol 1: 178-182 4. Loftus B, O'Carrol T (1985) Lumbar herniation and tibial absence in

infants of diabetic mothers. Diabetic Med 2: 283- 285 5. Lowell D, Guzetta P (1986) Lumbar hernia in a case of posterior

meningomyelocele. J Pediatr Surg 21: 913- 914 6. Touloukian R 61972) The lumbocostovertebral syndrome: a single

somatic defect. Surgery 71: 174-181 7. Watson L (1948) Hernia: anatomy, etiology, symptoms, diagnosis,

differential diagnosis, prognosis and treatment. 3rd edn. cv Mosby, St Louis