Left Lower Back Research Articles

A CASE OF LEFT SPINAL ERECTOR SPINAE COMPARTMENT SYNDROME AFTER RETROPERITONEOSCOPIC RIGHT NEPHRECTOMY FOR WHICH DECOMPRESSIVE FASCIOTOMY WAS EFFECTIVE

The patient was a male in his 60s who underwent a retroperitoneoscopic right nephrectomy for a diagnosis of right renal cell carcinoma (cT3aN0M0). During surgery, the patient was positioned in the left lateral recumbent, jackknife position. A blood test of the day after surgery showed an abnormally high CK level of 23,038 U/L. However, because his only symptom was mild pain in the left lower back, the patient was placed under follow-up observation. Two days postoperatively, the patient had worsening left lumbago, swelling, stiffness, and paresthesias in the left lumbar region. A simple CT scan showed internal hypo-absorption and increased volume of the left erector spinae muscle. With a diagnosis of left erector spinae compartment syndrome, the patient underwent an emergency decompressive fasciotomy by an orthopedic surgeon. The patient's postoperative course was uneventful with no sequelae, and he was discharged on postoperative day 22.In this case, the increased pressure on the lumbar region due to the cushion inserted into the lumbar flexion to reinforce the jackknife position was thought to have contributed significantly to the development of erector spinae compartment syndrome.Although erector spinae compartment syndrome is very rare after lateral recumbency surgery, taking thorough precautions is necessary, including the decompression of as much pressure as possible in the preoperative position and appropriate intraoperative blood pressure control, and to deal with it promptly, including fasciotomy in case of postoperative low back pain that coincides with the surface of the operating table.

DERMATOFIBROSARCOMA PROTRUBERANS- A RARE CASE REPORT

Dermatobrosarcoma protruberans (DFSP) is a rare mesenchymal sarcoma with low to intermediate grade malignant potential that typically involves the dermis with an incidence rate of 0.8 to 4.5 cases per million persons per year. Typical presentation is an asymptomatic, indolent, exophytic protruberant tumour with a high local recurrance rate seen on the trunk. We report a typical case of DFSP with local recurrence on the left lower back in a 32-year old female which was managed with wide local excision with margins free of tumour inltration conrmed by histopathology. This case is reported for its rarity

Syringocystadenoma Papilliferum at an Unusual Location: a Case Report

A case of 15year old female presented with lesion over back since childhood, with occasional bleeding and oozing from lesion without any associated systemic complaints. There were multiple verrucous coalescing papules forming plaque with overlying erosion present over left lower back- diagnosed provisionally as angiokeratoma circumscriptum and was biopsied. Histopathology revealed findings consistent with Syringocystadenoma papilliferum. Surgical excision was done and closed with rotation flap. Syringocystadenoma is benign cutaneous adnexal tumor presenting clinically with many morphologies such as warty papules, nodules, plaques with oozing of serous material. Lesion is usually seen in head and neck area in most cases however can also occur on extremities, buttocks, anogenital region. It is characterized by multiple invaginations from skin surface in association with hair follicles lined by cuboidal to columnar epithelium on luminal aspect and myoepithelial cells on outside. There is papillary architecture and dermal ductal component.

Perception of Tactile Distance on the Back.

The perceived distance between two touches is anisotropic on many parts of the body. Generally, tactile distances oriented across body width are perceived as larger than distances oriented along body length, though the magnitude of such biases differs substantially across the body. In this study, we investigated tactile distance perception on the back. Participants made verbal estimates of the perceived distance between pairs of touches oriented either across body width or along body length on (a) the left hand, (b) the left upper back, and (c) the left lower back. There were clear tactile distance anisotropies on the hand and upper back, with distances oriented across body width overestimated relative to those along body length/height, consistent with previous results. On the lower back, however, an anisotropy in exactly the opposite direction was found. These results provide further evidence that tactile distance anisotropies vary systematically across the body and suggest that the spatial representation of touch on the lower back may differ qualitatively from that on other regions of the body.

Spinal Cord Stimulation inpatient with Tethered Cord syndrome: A Case Report

Background: Neuromodulation techniques are an important part of the chronic refractory neuropathic pain treatment. Their effectiveness is insufficiently documented in patients with tethered cord syndrome. Case Description: We present the case of a 32-year-old woman with a history of myelomeningocele repair, followed by a detethering surgery complicated with cerebral fluid leakage. Her intractable pain in her left leg and low back was successfully treated with spinal cord stimulation. Pain intensity decreased from 8/10 to 1-2/10 on her visual analogue scale without regular analgesic intake and her quality of life improved significantly. Conclusions: A review of the literature documents only three case reports of similar efficacy of spinal cord stimulation in the treatment of pain in adult patients with tethered cord syndrome.

EXTENDED Palliative (compassionate) medicines for COVID-19

Background: Neuromodulation techniques are an important part of the chronic refractory neuropathic pain treatment. Their effectiveness is insufficiently documented in patients with tethered cord syndrome. Case Description: We present the case of a 32-year-old woman with a history of myelomeningocele repair, followed by a detethering surgery complicated with cerebral fluid leakage. Her intractable pain in her left leg and low back was successfully treated with spinal cord stimulation. Pain intensity decreased from 8/10 to 1-2/10 on her visual analogue scale without regular analgesic intake and her quality of life improved significantly. Conclusions: A review of the literature documents only three case reports of similar efficacy of spinal cord stimulation in the treatment of pain in adult patients with tethered cord syndrome.

Isolated giant plexiform neurofibroma of lower back: a rare case presentation

Plexiform neurofibroma is a rare benign tumor of the peripheral tissue cells that develops in the perineurium that is often considered pathognomonic of neurofibromatosis type 1 (NF1 or von Recklinghausen disease). They occur most frequently in the craniomaxillofacial region, rarely on back and extremities. They are extremely vascular and there is 15-20% potential for malignant transformation. A 35-year-old married female presented with painless swelling in left lower back that began at around 8 years of age. The swelling gradually increased in size. The patient reported embarrassment over the disfigurement caused by the mass. Her medical history was unremarkable and none of the relatives was known to be affected. Surgical resection of the swelling with primary closure was done. Histopathology findings were consistent with neurofibromatosis. Hereby reporting a rare case of isolated plexiform neurofibroma of lower back which was surgically cured as a perusal of rare entity. We also try to emphasize on the need of sprightful clinical diagnosis with multidisciplinary approach in the management of these type of tumors. Finally, we insist on the need of a long term clinical and radiological follow-up of these patients to assess post resection recurrence or malignant transformation.

Extensive Degeneration of Vertebral Body Leading to Baastrup's Disease: A Radiographic Review of an Image.

Baastrup’s disease, known colloquially as “kissing spine disease”, is a degenerative process, most commonly occurring in the lumbar spine, in which adjacent spinous processes closely approximate or even touch (Filippiadis et al. in Insights Imaging. 10.1007/s13244-014-0376-7, 2015). We present the case of an 86-year-old woman presenting with left low back, hip, and anterolateral thigh pain. Magnetic resonance imaging noted an approximation of the L2/3 spinous processes, with degeneration of the vertebral processes. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors. Informed consent for publication was obtained from the participant.

A Case Report of a Malignant Triton Tumor of the Left Retroperitoneum in a Young Female Without Neurofi bromatosis

The authors report the case of a 37-year-old with a malignant triton tumor in the retroperitoneum. She presented with generalized pain that was worse in her left lower back and radiated down the left thigh and subsequently with progressive bilateral weakness and numbness in both legs.

Low pressure voiding induced by a novel implantable pudendal nerve stimulator.

To validate the functionality of an implantable pudendal nerve stimulator under development for Food and Drug Administration approval to restore bladder function after spinal cord injury. In nine cats under anesthesia, two tripolar cuff electrodes were implanted bilaterally on the pudendal nerves and one bipolar cuff electrode was implanted on the right pudendal nerve central to the tripolar cuff electrode. The pudendal nerve stimulator was implanted subcutaneously on the left lower back along the lumbosacral spine and connected to the cuff electrodes. In five cats, a double lumen catheter was inserted into the bladder through the urethra to infuse saline and measure bladder pressure and another catheter was inserted into the distal urethra to perfuse and measure the back pressure caused by urethral contraction. In four cats, a bladder catheter was inserted into the bladder dome and the urethra was left open so that voiding could occur without urethral outlet obstruction. The implantable pudendal nerve stimulator was controlled wirelessly and successfully provided the required stimulation waveforms to different cuff electrodes. Pudendal nerve stimulation (PNS) at 5 Hz increased bladder capacity to about 200% of control capacity. PNS at 20 to 30 Hz induced large (80-100 cmH2 O) bladder contractions under isovolumetric conditions. When combined with ipsilateral or bilateral pudendal nerve block induced by 6 to 10 kHz stimulation, PNS at 20 to 30 Hz elicited low pressure (<40 cmH 2 O) efficient (70%) voiding. The implantable stimulator generated the required stimulation waveforms and successfully induced low pressure efficient voiding in anesthetized cats.

Musculoskeletal pain symptoms in bagpipers: A pilot study

Musicians have musculoskeletal pain and overuse syndromes related to their instrument. Great Highland bagpipers (GHB) also have pain-related to use, but this has not been well documented because of their relatively rare instrument. Historically, bagpipers were used to direct troops on the battlefield. Bagpipers or their instruments were shot to prevent the ability to do this. Bagpipers are required to suspend part of the instrument on their shoulder, squeeze a bag under the same arm, and blow a wind instrument simultaneously. The literature shows only one previous study that documented the most common musculoskeletal complaint was of the left arm and low back, but did not study pain scales. An institutional review board approved, prospective, anonymous survey was sent to adult bagpipers that play in a GHB band. This pilot study was conducted to determine if they experience musculoskeletal pain or not. A larger scale international survey is planned since this pilot data is positive. Demographic data, pain location, severity (verbal numerical scale - VNS), duration, and McGill pain questionnaire were collected. Descriptive statistics computer program was applied. Ten surveys were collected in this pilot study. Ninety percent of bagpipers reported pain-related to playing the instrument (SE 0.1). The most severe pain was the ipsilateral (bagside) cheek (3.3/10), followed by ipsilateral shoulder, ipsilateral forearm, and contralateral cheek (2.4/10) on VNS. The average pain duration lasted 3.3 hours (± 2.3 SE) after playing the instrument. Pain was most commonly described as “aching” or “sore” on McGill questionnaire. This pilot data supports bagpipers experience musculoskeletal pain-related to playing their instrument. Future studies underway will conduct this survey internationally. This will be followed by detailed history, physical exam to determine exact sources of pain. It is hoped this research will help Physiatrists understand and treat musculoskeletal pain in bagpipers.

Temperature Probe Placement during Preterm Infant Resuscitation: A Randomised Trial

Background: Hypothermia on admission to intensive care is associated with poor outcomes in preterm infants. The neonatal resuscitation program recommends the use of servo-control thermoregulation during resuscitation. Very little evidence exists to guide optimal temperature probe placement in the delivery room. Objective: The aim of this work was to determine, in moderately preterm infants, if temperature probe placement in the dorsal, thoracic, or axillary area during delivery room resuscitation would result in differing temperatures on admission to the neonatal intensive care unit (NICU). Methods: A randomised trial with 3 arms was conducted. In total, 122 inborn preterm infants born between 280/7 and 356/7 weeks of gestational age were recruited. The infants were randomly assigned to thermal probe placement in the left lower back, left upper thorax, or left axilla immediately after birth. Temperature was servo-controlled using an infant resuscitation table set to 36.5°C. The primary outcome was axillary temperature at admission to the NICU before transfer to a closed isolette, recorded with a digital thermometer. The secondary outcomes assessed were temperature within the target range (36.5-37.5°C), hypothermia (<36.5°C), and hyperthermia (>37.5°C). Results: All 122 infants were available for outcome analysis. The groups were comparable for birthweight, gestational age, and sex. The mean admission temperature was comparable between the 3 probe positions (mean, 95% CI): dorsum (36.7°C, 36.6-36.8), thorax (36.8°C, 36.7-36.9), and axilla (36.7°C, 36.6-36.9), p = 0.43. The proportion of infants with admission temperatures in the target range was comparable (87.2, 81.4, and 72.5% respectively), p = 0.44. Conclusion: Dorsal, thoracic, or axillary temperature probe positioning during resuscitation yield similar admission temperatures in moderately preterm infants. Further studies are required in infants below 28 weeks of gestation to determine the best practice.

Dysfunction of Nucleus Accumbens Is Associated With Psychiatric Problems in Patients With Chronic Low Back Pain: A Functional Magnetic Resonance Imaging Study.

A cross-sectional study. The aim of this study was to evaluate activity of the nucleus accumbens (NAc) in response to lumbar mechanical stimulation in patients with chronic low back pain (cLBP) using functional magnetic resonance imaging (fMRI). Although a modified activity of the NAc was characterized in cLBP patients, its pathological significance has yet to be determined. We hypothesized that NAc activation in response to pain might differ depending on the extent of psychiatric problems, which might be associated with the affective/motivational background of chronic pain. Twenty-one patients with cLBP (four men, 17 women) were recruited. Subjects were divided into two groups on the basis of scores on the patient version of the Brief Scale for Psychiatric problems in Orthopaedic Patients (BS-POP) scores: ≥17 (High Score, HiS group) and <17 (non-High Score, non-HiS group). Each subject was placed in the prone position on a 3-Tesla magnetic resonance imaging (MRI) scanner and stimulated by mechanical stimulation on the left lower back. Three blocks of 30-second pain stimulus calibrated at either 3 or 5 on an 11-grade numerical rating scale (NRS) were applied with intervening 30-second rest conditions during whole-brain echo-planar imaging. Functional images were analyzed using a multisubject general linear model with Bonferroni multiple comparisons. Subjects in the HiS group had more intense daily pain and lower quality of life than those in the non-HiS group (P < 0.05). Catastrophic thinking in relation to pain experience did not differ between the groups. Activation at the NAc was smaller in the HiS group than in the non-HiS group (P < 0.001). The presence of psychiatric problems was associated with attenuated activity of the NAc in cLBP patients. Dysfunction of the NAc might potentially be involved in the affective/motivational factors in the chronification of LBP. N/A.

Attenuation of cortical activity triggering descending pain inhibition in chronic low back pain patients: a functional magnetic resonance imaging study

A considerable portion of chronic low back pain (cLBP) patients lack anatomical abnormality, resist conventional therapeutic interventions, and their symptoms are often complicated with psychological and social factors. Such patients have been reported to show cerebral abnormalities both in anatomy and function by neuroimaging studies. Here we examined differences in cerebral reactivity to a simulated low back pain stimulus between cLBP patients and healthy controls by functional magnetic resonance imaging (fMRI), and their behavioral correlates from a psychophysical questionnaire. Eleven cLBP patients and 13 healthy subjects (HS) were enrolled in this study. After psychophysical evaluation on-going pain with McGill Pain Questionnaire Short Form (MPQ), they underwent whole-brain fMRI in a 3-Tesla MRI scanner while receiving three blocks of 30-s mechanical pain stimuli at the left low back with a 30-s rest in between, followed by a three-dimensional anatomical imaging. Functional images were analyzed with a multi-subject general linear model for blood oxygenation level-dependent (BOLD) signal changes associated with pain. Individual BOLD signal amplitudes at activated clusters were examined for correlation with psychophysical variables. Two in the cLBP and five data sets in the HS groups were excluded from analysis because of deficient or artifactual data or mismatch in age. The HS group showed LBP-related activation at the right insular cortex, right dorsolateral prefrontal cortex (DLPFC), left anterior cingulate cortex (ACC), and left precuneus; and deactivation in a large area over the parietal and occipital cortices, including the bilateral superior parietal cortex. On the other hand, the cLBP group did not show any significant activation at those cortical areas, but showed similar deactivation at the bilateral superior parietal cortex and part of the premotor area. An HS>cLBP contrast revealed significantly less activity at the ACC and DLPFC in the cLBP group, which was negatively correlated with higher MPQ scores. The cLBP patients showed attenuated reactivity to pain at the ACC and DLPFC, known cortical areas mediating affective component, and top-down modulation, of pain. The present results might be associated with possible dysfunction of the descending pain inhibitory system in patients with chronic low back pain, which might possibly play a role in chronification of pain.

LAPAROSCOPIC REPAIR OF LUMBAR HERNIA (GRYNFELT): TECHNICAL DESCRIPTION

ABSTRACTBackground: Lumbar hernias are rare. Usually manifest with reducible volume increase in the post-lateral region of the abdomen and may occur in two specific anatomic defects: the triangles of Grynfelt (upper) and Petit (lower). Despite controversies with better repair, laparoscopic approach, following the same principle of the treatment of inguinal hernias, seems to present significant advantages compared to conventional/open surgeries. However, some technical and anatomical details of the region, non usual to general surgeons, are fundamental for proper repair. Aim: To present systematization of laparoscopic transabdominal technique for repair of lumbar hernias with emphasis on anatomical details. Method : Patient is placed in the lateral decubitus. Laparoscopic access to abdominal cavity is performed by open technique on the left flank, 1.5 cm incision, followed by introduction of 11 mm trocar for a 30º scope. Two other 5 mm trocars, in the left anterior axillary line, are inserted into the abdominal cavity. The peritoneum of the left paracolic gutter is incised from the 10th rib to the iliac crest. Peritoneum and retroperitoneal is dissected. Reduction of all hernia contents is performed to demonstrate the hernia and its size. A 10x10 cm polypropylene mesh is introduced into the retroperitoneal space and fixed with absorbable staples covering the defect with at least 3-4 cm overlap. Subsequently, is carried out the closure of the peritoneum of paracolic gutter. Results: This technique was used in one patient with painful increased volume in the left lower back and bulging on the left lumbar region. CT scan was performed and revealed left superior lumbar hernia. Operative time was 45 min and there were no complications and hospitalization time of 24 h. Conclusion: As in inguinal hernia repair, laparoscopic approach is safe and effective for the repair of lumbar hernias, especially if the anatomical details are adequately respected.

Analysis of the body pressure-related sensory changes in the static supine position for healthy science research: a randomized controlled pilot trial

The aim of this study was to analyze body pressurerelated sensory changes after being in a static supine position to the head, shoulder, right and left arms, low back, pelvic girdle, and right and left legs. To analyze body pressure, a Body Pressure Measurement System was used. Body pressure sensors were attached to existing mattresses and pressure was monitored beneath the ten subjects (five male and five female). The level of pain was evaluated using the pain scale before, at 1, 5, 10, and 15 min, and in total of the head, shoulder, right and left arms, low back, pelvic girdle, and right and left legs after being in the static supine position. Head pressure intensity was significantly higher than other body part measures, and the head had the highest pain score, almost showing a similar tendency. However, the low back was not too high in body intensity, while it had the second highest total pain score. As well, the low back and pelvic girdle showed a significant difference between the pain scores of males and females. The pain appeared after 10 min on all measuring parts. As well, as time progressed, the level of pain became more increased. These results suggest that when performing physical therapy and healthy science research, the properties of time, posture, and gender need to be carefully considered.

Cutaneous paragonimiasis due to triploid Paragonimus westermani presenting as a non-migratory subcutaneous nodule: a case report

IntroductionParagonimiasis is a food-borne infection caused by Paragonimus parasites. The lungs and pleura are the primary sites for the infection; however, ectopic infection can occur in other organs such as skin, liver and brain. It is difficult to make a diagnosis of ectopic paragonimiasis due to an ignorance of, and unfamiliarity with the disease. We report the case of a patient with subcutaneous paragonimiasis diagnosed by histopathological analysis and serological testing.Case presentationA 39-year-old Chinese immigrant woman presented with a subcutaneous nodule in her left lower back. The nodule was initially suspected of lipoma and she was followed up on without any treatment. However, it gradually indurated and the nodule was resected surgically. A magnetic resonance imaging scan revealed a polycystic lesion with inhomogeneous low or high intensity on T1- or T2-weighted images, respectively. The rim of the lesion was enhanced after contrast enhancement, but the inside did not show high-signal intensity. A histological analysis of the surgically resected specimen revealed variable-sized tubulo-cystic structures. The cyst wall showed a granulomatous change with scant eosinophilic infiltration. A number of parasite ova were observed in the necrotic tissue inside the cysts, and a parasite body with a presumed oral sucker and reproductive organ was also detected, suggesting a trematode infection. A subsequent serological examination showed a positive reaction of her serum to the Paragonimus westermani antigen. No abnormal findings were found on her chest computed tomography scan. The diagnosis of subcutaneous paragonimiasis caused by Paragonimus westermani was made.ConclusionsWe report a case presenting only as a non-migratory subcutaneous nodule without any pleuropulmonary lesion, which was initially suspected of lipoma but denied by magnetic resonance imaging scan results. The case was subsequently diagnosed as subcutaneous paragonimiasis from the results of histopathological analysis and serological testing.

Case Report: A case of antiphospholipid-antibody-associated reactive angioendotheliomatosis and panniculitis

Introduction:Reactive angioendotheliomatosis (RAE) is a benign vascular disorder with a varied clinical presentation that has been associated with a wide range of systemic illnesses. It is characterized histologically by intravascular and extravascular hyperplasia of endothelial cells and pericytes, and this entity only affects the skin. We present the rare case of a woman with both RAE and panniculitis associated with anticardiolipin antibodies in the setting of antiphospholipid syndrome (APLS).Case description:A female in her forties presented for a second opinion of lumps in her skin. The first lump was noted on her right thigh four years prior to presentation, and biopsy demonstrated longstanding septal and lobular panniculitis. Studies that followed this finding revealed a diagnosis of APLS, and the patient had been placed on 400 mg per day of hydroxychloroquine and a daily low-dose of aspirin. She presented with a new subcutaneous plaque on the left lower back, and biopsy of this lesion was suggestive of RAE. She had no history of significant thrombotic events and had never been treated with an anticoagulant. Work-up was negative for other connective tissue diseases that are known for producing subcutaneous nodular lesions.Discussion:RAE is very rare, with less than 50 cases reported in total; five of these in association with APLS. In the context of APLS, RAE is likely a result of the procoagulant state induced by the presence of antiphospholipid antibodies. This case of both RAE and panniculitis associated with anticardiolipin antibodies in the setting of APLS describes rare manifestations of APLS as isolated incidents in a relatively healthy patient.

Quantification of vibrations during mountain biking

Background:  During cross-country mountain biking, riders are subjected to vibrations due to the terrain, which must be damped before reaching the central nervous system.  Damping vibrations requires work, which may help to explain the decrease in economy for mountain biking as compared to road cycling (Titlestad et al., 2006 Journal of Sports Sciences, 24(2), 125-135).  Purpose: To describe the relationship between vibration mechanics and their interaction with terrain, bicycle and rider during a race pace effort on a cross country mountain bike track.  Methods: Participants (n=8) completed two separate laps on a cross country track using 26” and 29” wheels, at race speed. Power, cadence, speed, heart rate, and geographical position were sampled and logged every second for control purposes. Tri-axial accelerometers located at handlebar centre, lower left arm, lower left leg, seat post, lower back and medial forehead, recorded accelerations with a output rate 128 Hz to measure vibrations experienced during the whole lap and over terrain sections (uphill and downhill). Vibrations were quantified using a root mean square (RMS) and using Fourier analyses.  Results: RMS data showed greater total accelerations for 29” vs 26” wheels (p=0.0020), and a significant interaction of terrain and accelerometer location (p<.0001). While climbing, accelerations were generally low and concentrated at low movement frequencies. While descending, however, high RMS values were seen on the bicycle (handlebar and seat post) and the parts of the body near the interface with the bicycle (left arm and left leg), while lower accelerations at the lower back and head were not significantly different than the accelerations during climbing.  In addition, Fourier analyses showed that the accelerations occurred at a higher frequency when compared to uphill sections.  No differences between overall power output (p=0.3062) and heart rate (p=0.8423), yet overall time was greater for 26” compared to 29” wheels (p=0.0061). Discussion: The results show that mountain bikers are subjected to large accelerations, or vibrations, particularly during downhill sections.  These vibrations are damped before reaching the lower back and head, which requires metabolic work.  In addition, 29 inch wheels showed a clear performance advantage, going faster for the same average power, although resulting in greater vibrations for the riders.  Conclusion: This study demonstrates an additional non-propulsive, muscular challenge to riding during cross country mountain biking represented by a change in accelerations at the point of interface between bike-body compared to lower back and head.

A case of mucinous nevus clinically mimicking nevus lipomatosus superficialis.

Dear Editor: Mucinous is a very rare entity and can be classified as both a cutaneous mucinosis and a connective tissue nevus1. The term nevus was proposed because of its nevoid appearance and the characteristic pattern of mucin deposits in the papillary dermis1. We report the case of a mucinous diagnosed in a young Korean man. A previously healthy 24-year-old man visited our clinic because of confluent flesh-colored to brownish non-firm nodules on his left lower back, with a zosteriform distribution (Fig. 1). The skin lesions had been present since adolescence without any symptom; however, they slowly grew in size. He had no history of trauma, and the lesion was not treated before. He also denied any familial history. Biopsy was taken, with the first impression of lipomatosus superficialis (NLS) according to clinical features. Histologically, the findings consisted of a band-like deposit of mucin mainly in the superficial dermis, with papillomatosis, hyperkeratosis, and elongation of the rete ridge in the epidermis (Fig. 2A). The mucin deposited in the dermis stained positive with alcian blue at pH 2.5 (Fig. 2B). Finally, the lesion was confirmed as a mucinous (epidermal-connective tissue of proteoglycan [epidermal-CTNP]). For the treatment, a first-stage operation was done without any complication, and a second-stage operation is planned 4 months later. Most of the lesions were removed with the first-stage operation and no recurrence has occurred. Fig. 1 Confluent flesh-colored to brownish non-firm papules and nodules on the left lower back, with a zosteriform distribution. Fig. 2 (A) The band-like deposition of mucin was mainly observed in the superficial dermis, with papillomatosis, hyperkeratosis, and elongation of the rete ridge in the epidermis (H&E, ×40). (B) Mucin deposited in the papillary dermis stained ... Mucinous is a neoplastic hamartoma and a rare form of primary cutaneous mucinosis2. Mucinous clinically presents as grouped brownish papules and confluent plaques, usually with a unilateral, linear, zosteriform, or grouped distribution. It usually appears at birth or in early childhood and mainly occurs on the back2. Although most cases are sporadic, the possibility of familial association has been suggested2. The nevoid feature of mucinous needs to be clinically differentiated from epidermal or NLS. In mucinous nevus, the band-like deposit of mucin is limited mainly in the superficial dermis, like in our case3. However, recently, a case of mucinous with mature fat cells in the upper dermis similar to NLS has been reported, making the diagnosis more confusing3. Mucinous is divided into two histopathologic types: CTNP type and combined epidermal-CTNP type4. The difference between the two types lies in whether the epidermis is normal or shows hyperkeratosis and acanthosis, with elongation of the rete ridge indicating epidermal nevus4. After reviewing the histopathologic changes of the reported cases of mucinous nevus, Chi et al.4 found that approximately half of the mucinous cases were CTNP. Here, we report a rare case of mucinous nevus, the epidermal-CTNP type, presenting similar to NLS.