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A 64 year man walked into the accident and emergency department with a 24 hour history of swelling in his right flank. Approximately two weeks before his presentation he had developed a painful rash over his right loin. There was no history of trauma. He denied any systemic upset and a review of his gastrointestinal and genitourinary systems was unremarkable. He did however give a history of chickenpox as a child. On examination he appeared well, was apyrexial, and haemodynamically stable. He had a prominent vesicular rash over his right loin in the distribution of T11-L1 (fig 1A). His abdomen was soft and non-tender with no organomegaly. He had an obvious swelling over his right flank, which became more prominent on standing. This measured approximately 20 cm by 10 cm (fig 1B). The swelling was easily reducible, and a marked cough impulse was demonstrable. A provisional diagnosis of a lumbar hernia secondary to herpes zoster infection was made. He was reassured and sent home with follow up. At clinic review 43 days after his initial presentation there was complete resolution of both the vesicular rash and lumbar hernia.
A lumbar hernia may occur spontaneously through one of two anatomical weak points in the lumbar region, the lumbar triangle of Petit or the superior quadrilateral lumbar space. They have also been reported secondary to operative procedures in the lumbar region, and as a result of paralysis of the lateral lumbar muscles after poliomyelitis or spina bifida.
The incidence of muscle paresis after herpes zoster infection is estimated at 1%–5%, although this may well be an underestimate. The resulting weakness usually develops in those muscles innervated by the affected cord segment that corresponds to the cutaneous manifestation.1 Symptoms of focal muscle paresis usually appear within two weeks of the appearance of the rash. Total or almost complete recovery is usual, although in 20% of cases a substantial disability remains.2 Upper and lower limb, diaphragmatic, and abdominal wall muscle paresis has been described,3 but in the English literature we could find no previous case reports of a lumbar hernia secondary to abdominal wall muscle weakness after herpes zoster infection.
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