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Lumbar Hernia - Causes, Symptoms, Diagnosis, and Treatment

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A lumbar hernia is the protrusion of organs through a defect in the abdominal wall; please read this article to learn about its causes, symptoms, and treatment.

Medically reviewed by

Dr. Ghulam Fareed

Published At December 2, 2022
Reviewed AtDecember 4, 2023

What Is a Lumbar Hernia?

A lumbar hernia is the protrusion of the abdominal contents through the lumbar triangles due to a defect in the lumbar muscles. Diagnosing it is often difficult due to its resemblance to lipoma, fibroma, abscess, and kidney tumors. They are more prevalent in individuals between the age of 50 to 70, and delayed diagnosis is the reason for increased morbidity in patients suffering from lumbar hernia.

What Are Lumber Triangles?

Lumbar triangles are costo-iliac spaces in the posterior abdominal wall. The abdomen is the body space between the chest and the pelvis; it has an outer abdominal wall that is made up of different layers and an inner abdominal cavity that contains abdominal organs like the stomach, intestine, liver, kidneys, etc.

The abdominal wall is divided into anterior (front) and posterior (back) walls, and it is made of layers like skin, connective tissue, muscles, and peritoneum (the innermost tissue that covers most of the abdominal organs). The muscles in the posterior abdominal wall overlap with lumbar muscles; during this overlapping, a couple of spaces are created, known as the costo-iliac space. These spaces allow the muscle to expand and contract while performing different movements.

There are two costo-iliac spaces on the posterior abdominal wall - right and left; each costo-iliac space can be further divided into two triangles- the superior triangle (also known as the Grynfeltt-Lesshaft triangle) present just below the 12th rib in the posterior abdominal wall and the inferior triangle (also known as the Petit triangle) is close to the iliac crest (the curvature of the hip bone).

What Are the Causes of Lumbar Hernia?

Lumbar hernia is rare and often occurs due to an underlying pathology; the different causes for lumbar hernia are-

  • Congenital- When a lumbar hernia occurs at birth, it is known as a congenital lumbar hernia. It can be due to a developmental defect in the posterior abdominal wall or the musculoskeletal system.

A couple of genetic abnormalities in which lumbar hernia is always present as one of the symptoms are Lumbo Costovertebral syndrome-a rare genetic condition involving ribs, abdominal wall, and vertebral bodies, and arthrogryposis- is a term used to describe multiple conditions causing multiple contractures.

A strong correlation has been observed between maternal diabetes and congenital lumbar hernia. In many patients, it is always associated with other birth defects that involve the spine, intestinal and retroperitoneal organs.

  • Acquired- An acquired lumbar hernia will occur when there is a sudden or gradual change in the overlying and underlying musculature, for example- in cases of sudden and extreme weight loss, extreme obesity, muscular atrophy due to sedentary lifestyle, strenuous physical activity, wound infection, etc.

In these patients, because of the extreme transformations, the space in the lumbar triangles is extended more than what is needed; this will orchestrate the abdominal organs to get themselves tangled in the extra space.

  • Traumatic- Any blunt trauma (a vehicular collision, road injury, extreme fighting, or fractures) that can increase intra-abdominal pressure and rupture the muscles of the abdominal wall. This will increase the chances of protrusion of the abdominal organs into the ruptured space causing a lumbar hernia.

Trauma will also have associated complications, including laceration of the colon, mesenteric tears, kidney injury, pancreatic injury, etc.

  • Iatrogenic- Occasionally, a lumbar hernia presents itself as post-op complications; a few surgeries that can eventually lead to a lumbar hernia are- hip arthroplasty, spinal fusion, surgical reconstruction of the breast (that uses latissimus dorsi flap), and open nephrectomies.

What Are the Contents of the Lumbar Hernia?

It depends on which side the hernia occurs; a lumbar hernia on the left side (the most frequent side and can be either of the triangles) is composed of any of the contents in the left costo-iliac space, for example- the left half of the pancreas, the left adrenal gland, left edge of the liver, left fallopian tube, left half of the large intestine, left kidney, left ovary, spleen, and stomach.

The right lumbar hernia contains contents of the right costo-iliac space, for example- the appendix, right half of the small intestine, liver, right kidney, right ovary, gallbladder, etc.

What Are the Symptoms of a Lumbar Hernia?

A physical examination will reveal a mass on the posterior or the lateral side of the abdomen; in asymptomatic patients, when the mass is pressed, it disappears, however in patients with an incarcerated lumbar hernia, the lump is hard and does not disappear on pressing, and the symptoms often mimic that of sciatica, they are-

  • Lower back pain that increases on coughing or straining.

  • Weakness and numbness in one leg.

  • Tenderness over the bulge.

  • Abdominal cramps.

If the hernia is strangulated (which happens when the surrounding muscle clamps down on the herniated lump, thereby cutting off the blood supply), the symptoms are-

  • Vomiting.

  • Abdominal distension.

  • Bowel obstruction.

  • Sudden pain that quickly intensifies.

Strangulation is a time-dependent risk leaving surgery as the only treatment option for a lumbar hernia.

How Is a Lumbar Hernia Treated?

The first line of treatment is surgery because the herniated contents will not place themselves in their anatomical positions with any other type of treatment. The treatment is often an emergency, leaving little time for an investigation like an ultrasound or a computed tomography (CT) scan. The surgery can be done in different approaches; they are-

  • Open Surgery- After anesthesia, the patient is placed in the lateral position, and an incision (flank incision) is made parallel to the 12th rib- if it is the hernia is located in the superior lumbar triangle or along the iliac crest- if the hernia is located in the inferior lumbar triangle.

The globular mass herniated through the triangle with a tapering pedicle will be observed; it is up to the surgeon (based on symptoms) either to excise or invert it. If it is a small hernia, the surgeon will darn the incision after inverting, but for a large hernia, a prosthetic mesh is placed on the muscle and sutured the incision.

  • Laparoscopic Surgery- The underlying procedure is similar to an open technique, but instead of one large incision, the surgeon will place several multiple incisions. A laparoscope (an optic-fiber instrument that transmits real-time video to a monitor in the operating room) is inserted through one of the incisions, providing a clear view of the underlying anatomy. After a thorough assessment, the surgeon will insert a special instrument through the accessory incisions and conduct the repair with or without a prosthetic mesh.

  • Retromuscular Lumbar Hernia Repair- It is a unique approach to prevent a recurrence, the prosthetic mesh is placed below the muscle with a five-centimeter overlap, and permanent suturing is done by suture anchors to the iliac crest.

What Are the Complications of Surgery for Lumbar Hernia?

Bleeding and infection were seen in most surgeries and are also possible in lumbar hernia surgery. Apart from these few, complications specific to lumbar hernia are-

  • Recurrence- This is the most common complication seen after any hernia repair, let alone a lumbar hernia. It can occur for many reasons, such as a surgical error, weakening of the sutures holding the abdominal muscles together, improper healing of the surgical wound, etc.

  • Mesh-Related Infections- This depends on the type of mesh used and the comorbidities affecting the individual. For example- patients with diabetes and obesity have a higher chance of developing mesh-related infection due to inherent immunodeficiency. Some of the symptoms of mesh-related infection are fever and inflammation; these can be treated with antibiotics.

  • Paresthesia- This refers to the burning and pricking sensation caused due to injury of the underlying nerve.

  • Urinary Retention- This happens due to an injury to the underlying ureter.

Conclusion:

Because lumbar hernia is rare, there is no gold standard for treating it. However, the principles for treating inguinal and abdominal hernias also apply to treating lumbar hernias. After confirming with investigations, surgery should be done in patients with increased volume in the dorsal region as an elective procedure to prevent incarceration, strangulation, and other life-threatening conditions.

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Dr. Ghulam Fareed
Dr. Ghulam Fareed

Medical Gastroenterology

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