Abstract
While panniculectomy is traditionally considered a cosmetic surgery, there is growing interest in the potential role of panniculectomy for the treatment of low back pain. We present a case of a 69-year-old man with a history of over 10 years of significant low back pain with radiculopathy rated as 7 out of 10 and resistant to conservative measures as well as multiple spinal decompression surgeries. He had undergone bariatric surgery 14 years prior and maintained a stable body mass index. He presented with a large pannus desiring panniculectomy for aesthetic purposes. He underwent an uncomplicated panniculectomy. As an unintended benefit of his procedure on his 1-month post-op visit, he reported near resolution of his low back pain and radiculopathy. His reported pain had been reduced to 1–2 out of 10. More research needs to be done to assess the potential of panniculectomy as a treatment for low back pain in patients with massive weight loss.
Keywords: panniculectomy, abdominoplasty, low back pain, radiculopathy
Résumé
La panniculectomie est traditionnellement considérée comme étant une chirurgie cosmétique, mais il y a un intérêt croissant pour son rôle potentiel dans le traitement des lombalgies. Nous présentons le cas d’un homme de 69 ans ayant des antécédents de lombalgies significatives depuis 10 ans, avec radiculopathie cotée à 7/10 et résistante aux mesures conservatives ainsi qu’à plusieurs chirurgies de décompression médullaire. Il avait subi une chirurgie bariatrique 14 ans plus tôt et maintenait un IMC stable. Il s’est présenté avec un large pannicule adipeux abdominal et souhaitant une panniculectomie à des fins esthétiques. Une panniculectomie sans complications a été pratiquée. À sa visite postopératoire d’un mois, il a signalé un bénéfice non intentionnel qui était la quasi-disparition de sa lombalgie avec radiculopathie. Il a signalé que la cotation de la douleur était réduite à 1–2/10. Plus de recherches sont nécessaires pour évaluer le potentiel de la panniculectomie comme traitement des lombalgies chez des patients ayant eu une perte de poids majeure.
Mots clés: panniculectomie, lombalgie, radiculoplastie, abdominoplastie
Introduction
Historically panniculectomy has largely been considered a cosmetic surgery with a narrow scope of medical indications including intertrigo and other recurrent skin and soft tissue infections. They are often performed in the aftermath of weight loss from bariatric surgery. Interest in the use of panniculectomy as a treatment for back pain has grown, however, current research on the effect of panniculectomy on chronic low back pain is limited. Some recent small studies have shown that panniculectomy can lead to long-term improvements in low back pain and even sequela of stenosis such as urinary incontinence 1 particularly in patients who have failed conservative measures. Unfortunately, the majority of data on the effect of panniculectomy on low back pain is focused on the rectus plication portion of the procedure 2 in patients with rectus diastasis as a consequence of pregnancy. 3 As such, even less is known about the impact of the panniculectomy alone on low back pain.
Case Description
We present the case of a 69-year-old man with congestive heart failure, diabetes, coronary arterial disease, osteoarthritis, and a history of 10 years of low back pain with radiculopathy. Prior to his presentation, he had previously undergone several interventions and surgeries for his back pain including L2 kyphoplasty in 2017, caudal epidural steroid injection in 2019, anterior cervical discectomy and fusion 3–6 in 2020, L3 laminectomy in 2020, and c4–t2 fusion and c5–7 laminectomy for cervical stenosis in 2021 and multiple courses of physical and aqua therapy. Despite this, he continued to have significant low back pain, radiculopathy, and incontinence leading to multiple emergency room (ER) visits. Imaging completed in the ER demonstrated chronic L2–3 compression fractures and stable postsurgical changes.
The patient had undergone Roux-en-Y gastric bypass in 2009 with a weight loss of 220 lbs (50% of his total body weight) with a consequential significant pannus and ptosis, leading him to seek out a cosmetic panniculectomy. He had maintained his weight loss. After preoperative evaluation, he was considered an appropriate candidate for panniculectomy.
Operation
In 2023, the patient underwent panniculectomy with a horizontal ellipse incision. The umbilicus with the associated stalk was isolated and protected during the development of the flap and then delivered through an appropriately sized incision. Two 10F Jackson-Pratt (JP) drains were placed in the subcutaneous space and the skin was closed with 2–0 vicryl, 3–0 monocryl deep dermals, and 3–0 strata fix running subcuticular closure. The patient tolerated the procedure well without complications and was discharged home. His recovery was uncomplicated.
Follow up
On a 4-week post-op follow-up, he had returned to his baseline level of activity and function. Both JP drains were removed. The patient reported during this visit that he had experienced near-total resolution of his lower back pain and radiculopathy. He rated his pre-op pain as 7 out of 10 and reported that it now had been reduced to 1–2 out of 10.
Discussion
Other case reports have demonstrated significant improvements in back pain and spinal stenosis symptoms after panniculectomy including one woman reported to have had resolution of urinary incontinence after umbilical hernia repair, panniculectomy, and abdominal wall plication. 4 These reports have focused on the potential for improvement in low back pain for patients who have failed other more conservative measures. The patient we present failed to improve with conservative measures as well as multiple highly invasive surgeries including laminectomy, kyphoplasty, and several spinal fusions. While imaging is central to the diagnosis and treatment of low back pain, as of yet, there is no strong evidence to suggest that any imaging modality would be helpful in predicting improvement in chronic low back pain as a result of panniculectomy surgery.
Furthermore, research in this area has generally focused on abdominal wall plication specifically and its potential to improve back pain. For example, Oneal et al 2 presented 8 cases of women who had failed conservative management of back pain and demonstrated significant improvement in back pain after plication. They suggest a spine stabilizing effect through tightening the muscles of the lateral abdominal complex thereby either increasing intraabdominal pressure and the efficiency of abdominal muscles through repositioning. However, in this case, we demonstrate significant improvement in long-standing back pain with panniculectomy alone without rectus muscle plication. Adding to this, a recent study performed by Soteropulos 5 described the reduction of back pain in patients who underwent panniculectomy and found that whether or not rectus plication was performed had no impact on subsequent back pain reduction. We postulate that the excess weight of the pannus which applies leverage on the spine due to its distance from the central axis may play a more significant role in chronic back pain symptoms than previously thought. Removal of this leverage and shifting of the center of gravity closer to the spine by way of a panniculectomy procedure may improve back pain symptoms. Plastic surgeons should discuss with patients the possibility of improvement in low back pain when obtaining consent for this surgical procedure.
Conclusions
In conclusion, the patient described demonstrated a significant improvement in back pain and radiculopathy after panniculectomy alone. We suggest that the impact of the pannus itself on chronic low back pain may be underestimated and that panniculectomy, particularly in patients who have failed conservative measures, should continue to be examined for its potential in treating low back pain.
Footnotes
Ethical Approval and Informed Consent Statements: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Our institution does not require ethical approval for reporting individual cases or case series. Written informed consent was obtained directly from the patient presented for anonymized patient information to be published in this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Marc Skylsen https://orcid.org/0009-0001-7851-4314
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