Spinal epidural lipomatosis: case reports, literature review and meta-analysis

A Novel Percutaneous Biportal Endoscopic Technique for Symptomatic Spinal Epidural Lipomatosis: Technical Note and Case Presentations

OBJECTIVE

To describe a minimally invasive decompression technique for symptomatic spinal epidural lipomatosis using percutaneous biportal endoscopic surgery.

METHODS

In this report, we describe the indirect decompressive effect that was gained by partial laminotomy and ligamentum flavectomy under biportal endoscopic view. Direct neural decompression was then performed by removal of proliferated fat. We described the technical process and compared pre- and postoperative radiating leg pain, life quality, and a radiologic grading system of neural compression.

RESULTS

This technique was performed successfully in 3 patients with idiopathic spinal epidural lipomatosis. Radiating pain was reduced, and functional disability and radiologic compression were improved. Postoperative instability and surgical complications related to the procedure were not observed.

CONCLUSIONS

Percutaneous spinal endoscopy is a minimally invasive muscle-preserving technique for spinal lipomatosis that achieves neural decompression directly by lipoma removal and indirectly by partial bone and ligament removal.

Spinal epidural lipomatosis following bilateral spinal decompression surgery

A 73-year-old man underwent bilateral spinal decompression of L4/5 for severe spinal canal stenosis, requiring minimal analgesia and providing immediate relief. Two days post-operatively, he presented with new onset bilateral leg pain and difficulty mobilising. MRI demonstrated spinal epidural lipomatosis (SEL), which was not present pre-operatively, at L5/S1. Further surgery was performed with decompression of L5/S1 through removal of epidural fat. At both 3 weeks and 5 months follow-up clinics, the patient was asymptomatic. To our knowledge, this is the first case of acute spinal epidural lipomatosis directly following spinal surgery. It is important to recognise SEL as a complication following spinal surgical intervention, due to the potential development of significant neurological consequences.

Volumetric evaluation of lumbar epidural fat distribution in epidural lipomatosis and back pain in patients who are obese: introducing a novel technique (Fat Finder algorithm)

OBJECTIVE

Spinal epidural lipomatosis (EL) represents an excessive deposition of unencapsulated adipose tissue in the spinal canal that can result in chronic back pain in patients who are obese with and without diabetes. We aim to calculate the total volumetric epidural fat on lumbar spine MRI in a predominately obese population and correlate total epidural fat to lower back pain (LBP) and body mass index (BMI).

RESEARCH DESIGN AND METHODS

We developed a program (Fat Finder) to quantify volumetric distribution of epidural fat throughout the lumbar spine. Eleven patients with LBP were imaged using two MRI protocols: parallel axial slices and conventional clinical protocol. The distribution of epidural fat per level was analyzed and normalized to the spinal canal size.

RESULTS

Our sample had an average age of 59.9 years and BMI of 31.57 kg/m². EL subgroup consisted of seven patients. The L2-L5 total fat volume was 3477.6 mm³ (1431.1-5595.9) in the EL group versus 1783.8 mm³ (815.0-2717.5) in the age-similar non-EL group. A higher percentage of fat volume in the canal was associated with higher LBP scores. The fat percentage was 32.2% among patients with EL versus 15.4% for age-similar non-EL with LBP score of 6.1 and 4.0, respectively.

CONCLUSIONS

The Fat Finder is a novel volumetric method to quantify epidural lumbar spinal fat. The epidural fat favors the lower spinal segment with direct proportionality between the fat volume and LBP score, independent of BMI.

Spinal epidural lipomatosis presenting to a U.S. Veterans Affairs pain and rehabilitation department: a report of two cases

Background

Spinal epidural lipomatosis is an uncommon source of neurogenic claudication. We present two cases of spinal epidural lipomatosis as it relates to diagnosis, management, and a possible association with common medical intervention.

Case presentation

Case 1: 63-year old male patient presented with neurogenic claudication symptoms, but without evidence of bony central canal stenosis on lumbar computed tomography. He entered a trial of spinal manipulation with transient beneficial gains after seven appointments, but no durable change in neurogenic claudication. An MRI was recommended at this point which revealed grade III spinal epidural lipomatosis at the L5/S1 level.Case 2: 51-year old male patient presented to a pain management physician with radicular symptoms for a series of lumbar epidural steroid injections. He completed a series of three lumbar epidural steroid injections with only short-term benefit. A repeat MRI demonstrated the presence of grade I (borderline grade II) spinal epidural lipomatosis.

Conclusions

The first case illustrates a limitation of ruling out central canal stenosis with computed tomography for patients unable to undergo an MRI. The second case demonstrates a possible association between steroid injections and spinal epidural lipomatosis. An association of this kind has not been established; further research is needed to determine the significance.

Idiopathic Spinal Epidural Fat Accumulation Is Associated With Hyperlipidemia

STUDY DESIGN

Single-center retrospective analysis of consecutively collected data.

OBJECTIVE

To determine the clinical characteristics of idiopathic spinal epidural lipomatosis (SEL).

SUMMARY OF BACKGROUND DATA

SEL is associated with the overt accumulation of nonencapsulated adipose tissue in the epidural space, leading to spinal cord or nerve root compression. The etiology of this condition is currently not completely understood.

METHODS

Data of 166 male patients who underwent primary surgery for lumbar spinal canal stenosis (LSS) from May 2013 to February 2016 were retrospectively reviewed. Participants were divided into three groups based on the degree of epidural lipomatous lesion. Patient data of age at surgery, body mass index, prevalence of common noncommunicable diseases, blood tests, arteriosclerotic index, and preoperative clinical scores (assessed using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire) were evaluated. Multivariate analysis was performed to assess the potential associated factors for idiopathic SEL.

RESULTS

Patients with LSS with severe SEL had a significantly higher body mass index and elevated serum levels of total cholesterol and triglyceride compared with those without SEL. Analysis of preoperative clinical scores revealed that patients with SEL experienced pain more frequently and showed less walking ability than did those without SEL. Multivariate analysis revealed that hyperlipidemia was significantly associated with idiopathic SEL (odds ratio = 3.74, 95% confidence interval = 1.31-10.64).

CONCLUSION

Our data suggest that aberrant lipid metabolism is related to the pathogenesis of idiopathic SEL and that patients with LSS with idiopathic SEL have more severe pain than do those without SEL.

LEVEL OF EVIDENCE

3.

Management of idiopathic spinal epidural lipomatosis: a case report and review of the literature

BACKGROUND

Spinal epidural lipomatosis (SEL) is a rare pathologic growth of histologically normal unencapsulated adipose tissue in the epidural space. Although rare, SEL can compress the spinal cord or nerve roots causing myelopathy or radiculopathy. While SEL has been associated with long-term exposure to endogenous or exogenous steroids and obesity, idiopathic forms of SEL are much rarer.

CASE REPORT

In this report, we present the first case of SEL isolated to the cervical region compressing the spinal cord in a healthy, non-obese, preadolescent patient.

CONCLUSION

Idiopathic SEL in the pediatric population is a rare entity. This is the first case of epidural lipomatosis isolated to the cervical region in an adult or child patient. In refractory, symptomatic cases of idiopathic SEL, surgical decompression is often required.

Epidural angiolipoma: A rare cause of spinal cord compression

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Spinal epidural angiolipoma is a rare cause of progressive spinal cord compression.

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Magnetic resonance imaging is necessary for diagnosis.

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Total resection is the treatment of choice.

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Necessary precautions before and during surgery have to be taken (embolisation, transfusion).

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Prognosis after surgical management is excellent even at the stage of complete paraplegia.

Introduction

Angiolipomas are benign, slow growing lesions, almost always located subcutaneously in the trunc or limbs. They are composed of mature lipocytes admixed with abnormal blood vessels. Spinal epidural angiolipoma are rare accounting for approximately 0.14–1.2% of all spinal axis tumors and 2–3% of epidural spinal tumors.

Presentation of case

We report the case of a 65 years-old-woman, presenting with complete paraplegia installed since 7 months. Magnetic resonance imaging (MRI) showed an epidural dorsal fatty mass. The patient recovered immediately after surgery. The pathological examination concluded to an angiolipoma.

Discussion

Angiolipoma patients most commonly have long-lasting pain and then develop progressive neurological symptoms secondary to spinal cord compression. The mean duration of symptom progression at diagnosis is 1 year. MRI is the most reliable examination for the diagnosis of spinal angiolipoma. Total resection is the treatment of choice. No adjuvant treatment is indicated.

Since SAL are very haemorrhagic lesions, preoperative embolization is recommended.

Conclusion

We think that spinal cord compression caused by angiolipoma have very good functional prognosis, even if tardily diagnosed

Clinical and imaging characteristics in patients undergoing surgery for lumbar epidural lipomatosis

Background

Lumbar epidural lipomatosis (LEL) is characterized by abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. Such accumulation compresses the dural sac and nerve roots, and results in various neurological findings. However, the pathophysiology of LEL remains unclear. This study examined the associations between imaging and clinical findings in detail, and investigated the mechanisms underlying symptom onset by measuring intraoperative epidural pressures in LEL.

Methods

Sixteen patients (all men; mean age, 68.8 years) were enrolled between 2011 and 2015. Mean body mass index was 26.5 kg/m². Four cases were steroid-induced, and the remaining 12 cases were idiopathic. All patients presented with neurological deficits in the lower extremities. Cauda equina syndrome (CES) alone was seen in 8 patients, radiculopathy alone in 4, and both radiculopathy and CES (mixed CES) in 4. All patients subsequently underwent laminectomy with epidural lipomatosis resection and were followed-up for more than 1 year. We investigated the clinical course and imaging and measured epidural pressures during surgery.

Results

Subjective symptoms improved within 1 week after surgery. Mean Japanese Orthopaedic Association (JOA) score was 15.2 ± 2.8 before surgery, improving to 25.4 ± 2.5 at 1 year after surgery. On magnetic resonance imaging, all lipomatosis lesions included the L4–5 level. On preoperative computed tomography, saucerization of the laminae was not observed in radiculopathy cases, whereas saucerization of the posterior vertebral body was observed in all radiculopathy or mixed CES cases. Intraoperative epidural pressures were significantly higher than preoperative subarachnoid pressures. The results suggest that high epidural pressure resulting from the proliferation of adipose tissue leads to saucerization of the lumbar spine and subsequent symptoms.

Conclusions

Clinical courses were satisfactory after laminectomy. In LEL, epidural pressure increases and symptoms develop through the abnormal proliferation of adipose tissue. Higher epidural pressures induce saucerization of the laminae and/or posterior vertebral body. Furthermore, the direction of proliferative adipose tissue (i.e., site of saucerization) might be related to the types of neurological symptoms.

Incidence of spinal epidural lipomatosis in patients with spinal stenosis

Inroduction

Spinal Epidural Lipomatosis (SEL) is believed to be a rare disorder. The incidence and prevalence of clinically symptomatic SEL in patients with spinal stenosis has never been reported in the literature. Our study aims to determine the prevalence, incidence, and associated risk factors of SEL in patients with the diagnosis of spinal stenosis.

Methods

This is a retrospective study. We reviewed the charts of 831 patients with the diagnosis of spinal stenosis over a 30 month period. All patients had spinal MRIs. Grading of SEL was performed using the Borré method.

Results

52 patients (21 female and 31 male) had symptomatic moderate and severe SEL. We found a prevalence of 6.26% and an annual incidence of 2.5%. SEL was most commonly seen at L5-S1 level. 27% had received corticosteroids. All SEL patients were overweight and 79% were obese.

Conclusions

SEL is not uncommon in patients with spinal stenosis. SEL should be considered as a possible diagnosis in those with symptoms of spinal stenosis especially in those with associated risk factors.

The rising root sign: the magnetic resonance appearances of post-operative spinal subdural extra-arachnoid collections

We present a case series of symptomatic post-operative spinal subdural extra-arachnoid collections that displace the cauda equina roots anteriorly. This is described as the "rising root sign".

Spinal cord compression secondary to idiopathic thoracic epidural lipomatosis in an adolescent: A case report and review of literature

INTRODUCTION

Spinal epidural lipomatosis (SEL) is a rare condition that presents with progressive spinal cord or nerve root compression. It is commonly reported in patients receiving long-term exogenous steroid therapy or in patients with endogenous steroid overproduction. The occurrence of this condition as an idiopathic entity is rarely reported.

CASE PRESENTATION

The authors present the clinical course and outcome of a 16-year-old male student, who presented with progressive spastic paraparesis of a one-year duration caused by idiopathic spinal epidural lipomatosis. Magnetic resonance imaging (MRI) study of the thoracic spine revealed marked compression of the spinal cord from a large dorsally located extradural mass extending from the T-4 to T-12 vertebral bodies. The patient underwent posterior thoracic laminoplasty from the T4 to T10 vertebral levels. He experienced gradual neurological, and he was able to walk without assistant by the end of 3-month follow-up period from surgery.

CONCLUSION

Idiopathic SEL is very rare, since no predisposing factors can be identified, and should be included in the differential diagnosis when patients present with spinal neurological compromise. MRI is the imaging modality of choice, and decompressive laminectomy and debulking of the fatty lesion is the main treatment modality in patients with progressive course of the disease..

The prevalence of spinal epidural lipomatosis on magnetic resonance imaging

BACKGROUND

Spinal epidural lipomatosis (SEL) refers to an excessive accumulation of fat within the epidural space. It can be idiopathic or secondary, resulting in significant morbidity. The prevalence of SEL, including idiopathic and secondary SEL, and its respective risk factors are poorly defined.

PURPOSE

We sought to: (1) assess the prevalence of SEL among patients who underwent a dedicated magnetic resonance imaging (MRI) scan of the spine-including incidental SEL (ie, SEL without any spine-related symptoms), SEL with spine-related symptoms, and symptomatic SEL (ie, with symptoms specific for SEL); and (2) assess factors associated with overall SEL and subgroups. In addition, we assessed differences between SEL subgroups.

METHODS

We reviewed the records of 28,902 patients, aged 18 years and older with a spine MRI (2004 to 2015) at two tertiary care centers. We identified SEL cases by searching radiology reports for SEL, including synonyms and misspellings. Prevalence numbers were calculated as a percentage of the total number of patients. We used multivariate logistic regression analysis to identify factors associated with overall SEL and subgroups.

RESULTS

The prevalence of overall SEL was 2.5% (731 of 28,902): incidental SEL, 0.6% (168 of 28,902); SEL with symptoms, 1.8% (526 of 28,902); and symptomatic SEL, 0.1% (37 of 28,902). Factors associated with overall SEL in multivariate analysis were the following: older age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: 1.01-1.02, p<.001), higher modified Charlson comorbidity index (OR: 1.10, 95% CI: 1.07-1.13, p<.001), male sex (OR: 2.01, 95% CI: 1.71-2.37, p<.001), BMI>30 (OR: 2.59, 95% CI: 1.97-3.41, p<.001), Black/African American race (OR: 1.66, 95% CI: 1.24-2.23, p=.001), systemic corticosteroid use (OR: 2.59, 95% CI: 1.69-3.99, p<.001), and epidural corticosteroid injections (OR: 3.48, 95% CI: 2.82-4.30, p<.001).

CONCLUSIONS

We found that about 1 in 40 patients undergoing a spine MRI had SEL; 23% of whom with no symptoms, 72% with spine-related symptoms, and 5% with symptoms specific for SEL. Our data help identify patients who might warrant an increased index of suspicion for SEL.

A proposed link between spinal epidural lipomatosis, prostate cancer and androgen deprivation therapy

We present a patient with prostate cancer with vertebral metastases who developed spastic paraparesis secondary to spinal epidural lipomatosis (SEL) after receiving androgen deprivation therapy (ADT). We propose a link between ADT, metastatic prostate cancer and SEL.

Epidural lipomatosis with cauda equina syndrome in chronic alcoholic patient: A case report

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Case of epidural lipomatosis with cauda equina syndrome in chronic alcoholic patient is provided.

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Posterior decompression was applied and neurologic deficit was significantly recovered.

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MRI is the best imaging tool of choice. Short T1 inversion recovery (STIR) sequence may be useful for confirmation of diagnosis as lipid is hypointense in this sequence.

Introduction

Epidural lipomatosis of the lumbar spine is a rare condition, which is described as the accumulation of fat in the extradural territory.

Presentation of case

We report the case of a 60-year-old, non-obese, and chronic alcoholic man who was transferred to our spine department with cauda equina syndrome (CES) for 4 months. On magnetic resonance imaging (MRI), spinal epidural lipomatosis (SEL) was confirmed in the multilevel lumbar lesion. A decompression surgery was performed and the patient recovered significantly.

Discussion

The patient was not obese, had no abnormal liver laboratory test results, and no history of steroid injection or administration. The clinical signs at onset suggested bilateral lower cauda equina dysfunction, indicating a more diffuse involvement, consistent with lumbosacral epidural lipomatosis.

Conclusion

This case report is the first description of SEL in a non-obese, chronic alcoholic patient who was neither receiving steroids nor had any kind of endocrinopathy.

Unusual cause of lumbar canal stenosis in 8th decade of life - Spinal epidural lipomatosis

Spinal Epidural lipomatosis (SEL) is an uncommon condition, usually presents in young and middle aged patients, with male preponderance. Idiopathic SEL is rare, particularly in 8th decade of life. SEL should also be considered as a differential diagnosis in approach of elderly patient presenting with lumbar canal stenosis. Such a case of 77 year old man is presented here.

Potential Involvement of Obesity-Associated Chronic Inflammation in the Pathogenesis of Idiopathic Spinal Epidural Lipomatosis

STUDY DESIGN

Multicenter case-control study.

OBJECTIVE

To characterize the pathogenesis of idiopathic spinal epidural lipomatosis (SEL).

SUMMARY OF BACKGROUND DATA

SEL is often associated with the history of steroid use or endocrine disorders; however, the pathogenesis of idiopathic SEL remains poorly understood.

METHODS

Sixteen patients who underwent lumbar decompression surgery due to severe idiopathic SEL were included in the study (L group, 15 men and 1 woman; mean age, 71.5 yrs). Fifteen patients without SEL, who underwent decompression surgery for lumbar canal stenosis, were selected as controls (C group, 14 men and 1 woman; mean age, 70.3 yrs). The following parameters were analyzed in these two groups: body mass index (BMI), medical history, histology, the size of adipocytes in the epidural fat (EF) tissues, and the expression level of the transcripts for adiponectin, leptin, tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, and IL-8.

RESULTS

The mean BMI of the L group was significantly higher than that of the C group (29.1 vs. 25.2 kg/m, P = 0.006), and there was a significant correlation between BMI and the width of EF in both groups. The average adipocyte size in the EF was significantly larger in the L group than in the C group (2846.8 vs. 1699.0 μm, P = 0.017). Furthermore, the expression levels of the transcripts for TNF-α and IL-1β in the L group were significantly higher than those in the C group [2.59-fold increase (P = 0.023) and 2.60-fold increase (P = 0.015), respectively].

CONCLUSION

Our data suggest that the pathogenesis of idiopathic SEL is associated with obesity. In addition, the increased expression of two major inflammatory cytokines in the EF in the L group may indicate that SEL is causally related to chronic inflammation.

LEVEL OF EVIDENCE

3.

Patient-reported outcome of surgical treatment for lumbar spinal epidural lipomatosis

BACKGROUND CONTEXT

Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of fat tissue in the spinal canal that can have a compressive effect, leading to clinical symptoms. This condition has a distinct pathology from spinal stenosis associated with degeneration of the intervertebral discs, ligaments, and facet joints. Several different conservative and surgical treatment strategies have been proposed for SEL, but its treatment remains controversial. There is a lack of evidence documenting the success of surgical decompression in SEL, and no previous studies have reported the postoperative outcome from the patient's perspective.

PURPOSE

The aim of the present study was to evaluate patient-rated outcome after surgical decompression in SEL.

STUDY DESIGN

A retrospective analysis of prospectively collected data was carried out.

PATIENT SAMPLE

A total of 22 patients (19 males; age: 68.2±9.9 years) who had undergone spine surgery for SEL were identified from our local Spine Surgery Outcomes Database, which includes a total of 10,028 spine surgeries recorded between 2005 and 2012. Inclusion criteria were epidural lipomatosis confirmed by preoperative magnetic resonance imaging (MRI) scans and subsequent decompression surgery without spinal fusion.

OUTCOME MEASURES

The Core Outcome Measures Index (COMI) was used to assess patient-rated outcome. The COMI includes the domains pain (separate 0-10 scales for back and leg pain), back-specific function, symptom-specific well-being, general quality of life (QOL), work disability, and social disability.

METHODS

The questionnaires were completed preoperatively and at 3, 12, and 24 months postoperatively. Surgical data were retrieved from the patient charts and from our local Spine Surgery Outcomes Database, which we operate in connection with the International Spine Tango Registry. Differences between pre- and postoperative scores were analyzed using paired t tests and repeated measures analysis of variance.

RESULTS

At 3-months follow-up, the COMI score and scores for leg pain and back pain had improved significantly compared with their preoperative values (p<.005). The mean decrease in COMI score after 3 months was 2.6±2.4 (range: -1.3 to 6.5) points: from 7.5±1.7 (range: 3.5-10) to 4.9±2.5 (range: 0.5-9.6). A total of 11 patients (50%) had an improvement of the COMI of more than the minimal clinically important change (MCIC) score of 2.2 points. The mean decrease in leg pain after 3 months was 2.4±3.5 (-5 to 10) points. Overall, 17 patients (77.3%) reported a reduced leg pain, 12 (54.6%) of whom by at least the MCIC score of 2 points. The significant reductions from baseline in COMI and leg and back pain scores were retained up to 2 years postoperatively (p<.02). The general QOL item of the COMI improved significantly after surgery (p<.0001). Over 80% of the cohort rated their preoperative QOL as bad (n=13) or very bad (n=5), whereas 3 months after surgery, only 7 patients rated their QOL as bad, and one as very bad (36%).

CONCLUSIONS

The present study is the first to demonstrate that surgical decompression is associated with a statistically significant improvement in patient-rated outcome scores in patients with symptomatic SEL, with a clinically relevant change occurring in approximately half of them. Surgical decompression hence represents a reasonable treatment option for SEL, although the reason behind the less good response in some patients needs further investigation.

[Spinal epidural lipomatosis as a rare side effect in steroid-dependent Jo-1 antibody syndrome]

Spinal epidural lipomatosis (SEL) of the thoracic and lumbar spine is a rare entity, which leads to compression of the spinal canal. The exact pathogenesis is still unknown. It most commonly occurs in patients with long-term exogenous or endogenous glucocorticoid excess or morbid obesity but there are also idiopathic forms. The symptoms depend on the severity of the SEL and can manifest as clinically asymptomatic, non-specific back pain, radiculopathy up to spinal cord compression. The diagnosis is usually achieved by magnetic resonance imaging (MRI) of the affected spinal segments. The treatment varies between discontinuation of glucocorticoids, weight reduction up to multisegmental decompressive laminectomy. The following case report presents the findings of SEL in a patient with steroid-dependent Jo-1 antibody syndrome and provides a current literature review on this rare disease.

Idiopathic Spinal Epidural Lipomatosis in the Lumbar Spine

Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging-verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [Orthopedics. 2016; 39(3):163-168.].

Unusual Spinal Epidural Lipomatosis and Lumbosacral Instability

Introduction. Epidural lipomatosis is most frequently observed in patients on chronic steroid treatment. Only a few idiopathic epidural lipomatosis cases have been described. Material and Methods. 64-year-old male patient presented with low back pain and left leg pain. Later, the patient experienced neurogenic claudication and radicular pain in the left leg without urinary dysfunction. Plain radiography and magnetic resonance imaging demonstrated an abnormal fat tissue overgrowth in the epidural space with compression of the dural sac, degenerative disc disease at L4-L5 level, and instability at L5-S1. Endocrinopathic diseases and chronic steroid therapy were excluded. If conservative treatment failed, surgical treatment can be indicated. Results. After surgery, there was a gradual improvement in symptoms and signs, and six months later the patient returned to daily activities and was neurologically normal. Conclusion. In the absence of common causes of neurogenic claudication, epidural lipomatosis should be considered. The standard test for the diagnosis of epidural lipomatosis is magnetic resonance (MR). At first, conservative treatment must be considered; weight loss and the suspension of prior corticosteroid therapy are indicated. In the presence of neurological impairment, the operative treatment of wide surgical decompression must be performed soon after diagnosis.

Severity of presentation is associated with time to recovery in spinal epidural lipomatosis

We present a patient with prednisone-induced spinal epidural lipomatosis (SEL) and relatively acute neurologic deterioration followed by rapid recovery after surgical decompression. SEL is a rare disease characterized by hypertrophy of epidural fat, most commonly associated with exogenous steroid use. To our knowledge, an analysis of the dynamics of steroid dose related to time to onset has never been performed, or of patient presentation features with respect to patient outcome. We retrospectively reviewed the literature for English language series and case reports of SEL associated with prednisone use from 1975-2013. Data were compiled for 41 patients regarding the prescribed dose of prednisone and length of treatment, as well as the severity of symptoms on the Ranawat scale, time to onset, time to recovery, and degree of recovery of neurological symptoms. Fisher's exact test and analysis of variance were used for comparing proportions, and p values <0.05 were considered statistically significant. We found that the mean cumulative dose of prednisone trended towards an association with a lack of recovery (p=0.06) and may be related to rate of recovery. Prescribed prednisone dose varied inversely with the time before onset of neurological symptoms, but failed to reach statistical significance. Higher severity of presenting symptoms on the Ranawat scale were found to be associated with a higher likelihood of delayed recovery (p=0.035). Patients with symptoms lower on the Ranawat scale more frequently experienced complete neurologic recovery, though this did not reach significance. The acuity of neurological deterioration was not related to the time to recovery or ultimate degree of recovery. Severity of presentation on the Ranawat scale is associated with rate of recovery and may be related to degree of recovery in SEL patients. Cumulative dose of prednisone may be related to degree and rate of recovery. Prescribed dose of prednisone may be related to time to onset of neurological symptoms. Acuity of neurological deterioration is not related to rate or degree of recovery.

Unusual presentation of spinal lipomatosis

Spinal epidural lipomatosis (SEL) is a rare condition characterized by overgrowth of normal adipose tissue in the extradural space within the spinal canal that can lead to significant spinal cord compression. It is most commonly reported in patients receiving chronic glucocorticoid therapy. Other causes can include obesity and hypercortisolism. Occasionally, idiopathic SEL will occur in patients with no known risk factors, but cases are more generally reported in obesity and males. We present the case of a 35 year-old non-obese woman found to have rapidly progressive SEL that was not associated with any of the common causes of the disorder.

Multiple epidural steroid injections and body mass index linked with occurrence of epidural lipomatosis: a case series

Background

Epidural lipomatosis (EL) is an increase of adipose tissue, normally occurring in the epidural space, sufficient to distort the thecal sac and compress neural elements. There is a lack of knowledge of risk factors, impact on patient’s symptoms, and its possible association with epidural steroid injections.

Methods

History, physical examination, patient chart, and MRI were analyzed from 856 outpatients referred for epidural steroid injections. Seventy patients with signs of EL on MRI comprised the study group. Thirty-four randomly selected patients comprised the control group. The severity of EL was determined by the MRI assessment. The impact of EL was determined by the patient’s history and physical examination. Logistic regression was used to correlate the probability of developing EL with BMI and epidural steroid injections.

Results

EL was centered at L5 and S1 segments. The average BMI for patients with EL was significantly greater than that of control group (36.0 ± 0.9 vs. 29.2 ± 0.9, p <0.01). The probability of developing EL with increasing BMI was linear up to the BMI of 35 after which it plateaued. Triglycerides were significantly higher for the EL group as compared to controls (250 ± 30 vs. 186 ± 21 mg/dL p < 0.01). The odds of having EL were 60% after two epidural steroid injections, 90% after three epidural steroid injections and approached 100% with further injections, independent of BMI. Other risk factors considered included alcohol abuse, use of protease inhibitors, levels of stress, hypothyroidism and genetic predisposition. However there were insufficient quantities to determine statistical significance with a degree of confidence. The impact of EL on patient’s symptoms correlated with EL severity with Spearman correlation coefficient of 0.73 at p < 0.01 significance level.

Conclusions

The BMI and triglycerides levels were found to be significantly elevated for the EL group, pointing to an increased risk of EL occurrence in progressively more obese US population. The data also revealed a strong correlation between the number of subsequent epidural steroid injections and EL occurrence calling for caution with the use of corticosteroids.

Spinal epidural lipomatosis in korean

Spinal epidural lipomatosis (SEL) is a rare disorder, regarded in literature as a consequence of administration of exogenous steroids, associated with a variety of systemic diseases, endocrinopathies and the Cushing's syndrome. Occasionally, SEL may occur in patients not exposed to steroids or suffering from endocrinopathies, namely, idiopathic SEL. Thus far, case studies of SEL among Korean have been published rather sporadically. We reviewed the clinical features of SEL cases, among Koreans with journal review, including this report of three operated cases. According to this study, there were some differences between Korean and western cases. Koreans had higher incidences of idiopathic SEL, predominant involvement in the lumbar segments, very few thoracic involvement and lower MBI, as opposed to westerners.

Spinal epidural lipomatosis in lumbar magnetic resonance imaging scans

The goal of this study was to quantify the frequency of advanced spinal epidural lipomatosis (SEL) detected on lumbar magnetic resonance imaging (MRI) scans performed at the authors' hospital and to compare the frequency, cause, and progression of SEL in these cases with that reported in the literature. The total number of MRI examinations of the lumbar spine performed at this hospital over 45 months was 1498 (705 men and 793 women; mean age, 60.3 years). After the MRI data were reduced (T1- and T2-weighted sagittal and axial images) on the basis of the exclusion criteria, the anterior and posterior diameters of the dural sac and spinal canal were measured, as well as the thickness of the epidural fat. On the basis of these parameters, the severity of SEL was classified as grade 0 to grade III. Five cases of grade III SEL were diagnosed. The frequency of grade III SEL noted in this study was 0.33% (5/1498). Obesity (body mass index greater than 27.5) was noted in 3 cases, and the use of exogenous corticosteroids was noted in 3 cases. Exogenous steroid usage associated with advanced SEL in this study was greater than that reported in the literature. Most symptoms of SEL progress slowly, and early diagnosis allows for a dose reduction of the prescribed steroids. Thus, lumbar MRI examinations should be conducted aggressively in patients with exogenous steroid use and presenting with low back pain or buttock pain.

Spinal angiolipoma: etiology, imaging findings, classification, treatment, and prognosis

PURPOSE

To summarise our experience treating patients with spinal angiolipomas (SAs) and to evaluate factors relating to its prognosis.

METHODS

We retrospectively reviewed the records of patients diagnosed with SAs who received surgical treatment from January 2001 to February 2013.

RESULTS

Twenty-one patients were described. We divide SAs into two types: "intraspinal" and "dumbbell-shaped". The former were further subclassified as "with lipomatosis" and "without lipomatosis". Overweight people are more likely to get the "with lipomatosis" type which needs different surgical strategy and/or a diet therapy to get better outcomes.

CONCLUSION

Diagnosis of SAs should be made with reference to clinical, radiological, and pathological findings. Application of different methods is needed to treat SAs.

Steroid-induced Spinal Epidural Lipomatosis after Suprasella Tumor Resection

Spinal epidural lipomatosis (SEL) is an abnormal localized accumulation of fat tissues in the epidural space. It is strongly related with steroid administration. The symptoms of SEL are various and range from back pain to paraplegia. In severe cases, decompressive laminectomy is the choice of treatment. A 32-year-old woman who had been under long-term steroid administration after suprasellar tumor resection was admitted for both leg radiating pain and weakness. She was diagnosed with SEL and had a decompressive laminectomy. During the operation, we found the nerve roots were compressed by epidural fat tissues and engorged vessels. After the operation, her radiating pain was relieved and motor weakness was improved.

Considering Symptomatic Spinal Epidural Lipomatosis in the Differential Diagnosis

Spinal epidural lipomatosis (SEL) is the abnormal accumulation of normal fat within the spinal canal. It is more frequent in those patients receiving chronic glucocorticoid therapy or in cases of endogenous hypercortisolism states. We report a case of SEL in a patient with metastatic prostate cancer with history of steroid treatment as part of his chemotherapy regimen, presenting with clinical manifestations of partial cord compression. Magnetic resonance imaging images of the lumbar spine revealed the presence of epidural tumor suspicious for metastatic disease. Operative findings were consistent with epidural lipomatosis. Spinal epidural lipomatosis is a rare condition that needs to be included in the differential diagnosis of patients with risk factors, presenting with symptomatic cord compression.

Subacute steroid-induced paraparesis: surgical treatment of a devastating "invisible" side effect

PURPOSE

To emphasize an underestimated side effect following long-term use of steroids.

METHODS

We report on surgical treatment of two patients with serious neurologic deficits caused by epidural spinal lipoma following long-term intake of cortisone.

RESULTS

Early decompression of the spinal cord by removal of epidural lipoma was the most effective treatment in these patients with progressive symptoms.

CONCLUSION

Diagnostic work-up of such patients should include early spinal MRI resulting in surgical intervention, if indicated. Decompression of the spinal cord eventually combined with fusion is necessary.

Idiopathic thoracic epidural lipomatosis with chest pain

Spinal epidural lipomatosis (SEL) is an overgrowth of the normally encapsulated adipose tissue in the epidural space around the spinal cord in the thoracic and lumbar spine causing compression of the neural components. Idiopathic SEL in non-obese patients is exceptional. Idiopathic SEL can result in thoracic myelopathy and lumbar radiculopathy. A thoracic radiculopathy due to idiopathic SEL has not been reported yet. We report a case of idiopathic SEL with intractable chest pain and paresthesia. We suggest that idiopathic SEL should be considered as a cause of chest pain.

Spinal epidural lipomatosis: An unusual cause of relapsing and remitting paraparesis

Epidural lipomatosis is a rare entity to cause spinal cord compression and neurological deficits. This is usually associated with excess of steroids in the body either because of endogenous source as in Cushings disease or exogenous intake as in some diseases like systemic lupus erythematosus, in some endocrinopathies or in morbid obesity. But in some cases no cause has been found. Such idiopathic cases of spinal epidural lipomatosis have also been reported. Here, we report a case of idiopathic spinal epidural lipomatosis with relapsing and remitting paraparesis which is quite unusual. Treatment depends upon neurological status of the patient. We operated the patient as he had significant neurological compromise and he improved significantly.