General Anesthesia for Episacral Lipoma Removal - A Case of Chronic Back Pain

Case at a Glance

A 30-year-old male healthcare worker presented with 15 years of chronic unilateral lower back pain associated with an episacral lipoma, seeking surgical intervention after conservative management failed.

Patient's Story

The patient is a 30-year-old male nurse, 5'10" and 225 lbs, with no significant medical history. He developed chronic right-sided lower back pain at age 15, coinciding with the appearance of a palpable mass in his lower back region. The pain was described as a constant deep ache located approximately 1.5-2 inches from the spine at the level of the sacral dimple on the right side. The patient experienced extreme stiffness and soreness upon waking, pain with prolonged sitting and walking, and a sensation of muscle instability on the affected side. Notably, there was no radiation to the legs, numbness, or tingling. Over the years, he pursued physical therapy intermittently with temporary relief but no lasting improvement. Healthcare providers had previously attributed his symptoms to core weakness and recommended stretching exercises.

Initial Assessment

Initial evaluation at age 15 included lumbar and sacroiliac X-rays, which were negative. The patient was reassured that lipomas typically do not cause pain. However, as his symptoms persisted into his career as a nurse, he sought further evaluation. Recent sacroiliac joint X-rays remained negative. Ultrasound imaging confirmed the presence of a lipoma measuring 1.4 x 1.2 x 2.2 cm in the right lower back region.

The Diagnostic Journey

The patient's brother, a radiology resident, initially questioned the need for MRI given the absence of neurological symptoms, stating that significant arthritis or ankylosing spondylitis would be visible on X-ray. The radiologist who performed the ultrasound recommended surgical consultation if the lipoma was causing pain. The patient was initially skeptical that the lipoma could be the source of his chronic pain, as he had been told for years that lipomas are typically painless.

Final Diagnosis

Symptomatic episacral lipoma causing chronic mechanical back pain. The lipoma had remained stable in size over 15 years, ruling out malignant transformation.

Treatment Plan

The general surgeon recommended surgical excision of the lipoma under general anesthesia with local anesthetic supplementation. The surgeon explained that while not commonly described in textbooks, he had observed significant pain relief in many patients with similar presentations following lipoma removal. The procedure was planned to take approximately 2 hours from induction to emergence, performed in the prone position. The use of general anesthesia was justified by the depth of the lipoma, difficulty achieving adequate local anesthesia, the prone positioning requirements, and the need for airway security during the procedure.

Outcome and Follow-up

The case represents a clinical scenario where empirical surgical intervention was recommended based on the surgeon's experience with similar cases, despite limited literature support. The surgeon noted that his approach to symptomatic lipomas had evolved over his career, with increasing recognition of their potential to cause chronic pain. Post-operative follow-up data was not available at the time of this report.