Spinal cord compression by epidural lipomatosis in juvenile rheumatoid arthritis

Lipomatosis of spinal epidural space, peritoneum, and renal sinus: a rare complication of long-term steroid therapy in a child with nephrotic syndrome

Excessive visceral adipose tissue proliferation, resulting in diffuse lipomatosis, is a rare complication of long-term steroid therapy. A 10-year-old boy presented with severe radicular back pain with limitation of lower limb movements. He was diagnosed with steroid-resistant nephrotic syndrome and was on unregulated steroid therapy. Magnetic resonance imaging of the spine showed increased adipose tissue in the epidural space of the lumbo-sacral spine causing clumping of cauda equina nerve roots along with marked proliferation of fat in the renal sinus as well as peritoneum. He was started on pregabalin with tapering of steroids, following which there was a gradual decrease in pain and improvement of activity. Our patient had diffuse lipomatosis involving spinal epidural space, bilateral renal sinus, and peritoneum, secondary to steroid overuse. With the availability of advanced imaging techniques, the condition can be prevented by judicious and proper use of steroids with close follow-up for any untoward complications.

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.

Neonatal Epidural Lipomatosis: A Rare Case

A 7-day-old baby boy born by lower segment caesarean section as term appropriate for gestational age was admitted with the complaint of fever, lethargy, and refusal to feed. The baby was put on antibiotic treatment for sepsis and meningitis. On the 15th day of the treatment, he developed lower motor neuron paralysis of both lower limbs along with sensory deficit. He also had bladder and fecal incontinence. Magnetic resonance imaging of spine showed spinal epidural lipomatosis extending from T8 to L5 with maximum compression of theca at L3-L4 level.

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.

Juvenile chronic arthritis and the craniovertebral junction in the paediatric patient: review of the literature and management considerations

INTRODUCTION

Juvenile chronic arthritis (JCA) is a systemic disease of childhood affecting particularly joints. JCA is a heterogeneous group of inflammatory joint disorders with onset before the age of 16 years and is comprised of 7 subtype groups. The pathogenesis of JCA seen in the cervical spine is synovial inflammation, hyperaemia, and pannus formation at the occipitoatlantoaxial joints resulting in characteristic craniovertebral junction findings. Treatment of craniovertebral junction instability as a result of JCA is a challenge. The best treatment strategy may be difficult because of various radiological and clinical severities. A review of the literature and management considerations is presented.

REVIEW

No randomised controlled trial or systematic review on this subject has been published. Only experts' opinions, case reports, and case series have been described. Thirty-four studies have been reviewed in this study. Involvement of the cervical spine in patients with JCA can lead to pain and functional disability. The subtypes that usually affect the cervical spine are the polyarticular type and systemic onset type and rarely the pauciarticular type. The most common cervical spine changes related to JCA are as follows: (1) apophyseal joint ankylosis at C2-C3, (2) atlantoaxial subluxation, (3) atlantoaxial impaction, (4) atlantoaxial rotatory fixation, and (5) growth disturbances of the cervical spine. The incidence of severe subluxations has decreased in the last decade as result of antirheumatoid drugs and biologicals. However, neurological compromise still occurs in JCA patients necessitating surgical treatment.

CONCLUSION

Whenever the cervical spine is involved in rheumatoid arthritis patients without neurological deficits, conservative treatment is legitimate. Once patients develop neurological signs and symptoms, surgical treatment should be considered with particular focus to age, severity of the disease, and general health condition. Skilled anaesthesia is crucial and the surgical procedure should only be carried out in centres with experience in craniovertebral junction abnormalities.

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.

Epidural spinal tumor and periaortitis as rare complications of Wegener's granulomatosis

This case report describes findings in a 61-year-old woman who manifested scleritis, small pulmonary nodules, otitis media, periaortitis, and progressive epidural spinal tumor, associated with elevated serum myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) levels. She was clinically diagnosed with Wegener's granulomatosis, although vasculitis was not diagnosed due to the lack of typical histological findings. We discuss the differential diagnosis in this patient, and the association of MPO-ANCA with periaortitis or epidural spinal tumor.

Symptomatic spinal epidural lipomatosis with severe obesity at a young age

Symptomatic spinal epidural lipomatosis is a rare disorder characterized by overgrowth of fat in the extradural space. Most patients have an underlying endocrine disorder, such as Cushing's syndrome, or have taken exogenous steroids chronically. Although less common, obesity alone is thought to be a cause of spinal epidural lipomatosis, representing <25% of reported cases. Patients rarely become symptomatic before middle age without chronic exogenous steroid use. The usual clinical manifestations are similar to degenerative lumbar stenosis with neurogenic claudication, resulting in decreased walking and standing endurance with variable neurological deficits.This article describes 2 unique cases of spinal epidural lipomatosis, both in young patients with underlying morbid obesity who presented with acute progressive leg weakness and urinary retention. The patients had no underlying endocrinopathy, nor any history of exogenous steroid use. They underwent emergency laminectomy and removal of epidural fat, and histopathological examination confirmed the diagnosis of epidural lipomatosis. Postoperatively, the patients demonstrated significant improvement.We conducted a review of the available English literature and compared the age distribution in each group. Based on our review, our 2 patients are considerably younger than those in past reports, especially in the patient group to which the steroid was not administered. In addition, few cases exist of spinal epidural lipomatosis with acute sphincter dysfunction and paraparesis. Our cases suggest that morbid obesity can lead to juvenile spinal epidural lipomatosis with acute neurological changes.

Corticosteroid-induced spinal epidural lipomatosis in the pediatric age group: report of a new case and updated analysis of the literature

Spinal epidural lipomatosis is a rare complication of chronic corticosteroid treatment. We report a new pediatric case and an analysis of this and 19 pediatric cases identified in the international literature. The youngest of these combined 20 patients was 5 years old when lipomatosis was diagnosed. Lipomatosis manifested after a mean of 1.3 (+/- 1.5) years (SD) (median, 0.8 years; range, 3 weeks - 6.5 years) of corticosteroid treatment. The corticosteroid dose at the time of presentation of the lipomatosis ranged widely, between 5 and 80 mg of prednisone/day. Back pain was the most common presenting symptom. Imaging revealed that lipomatosis almost always involved the thoracic spine, extending into the lumbosacral region in a subset of patients. Predominantly lumbosacral involvement was documented in only two cases. Although a neurological deficit at presentation was documented in about half of the cases, surgical decompression was not performed in the cases reported after 1996. Instead, reducing the corticosteroid dose (sometimes combined with dietary restriction to mobilize fat) sufficed to induce remission. In summary, pediatric spinal epidural lipomatosis remains a potentially serious untoward effect of corticosteroid treatment, which, if recognized in a timely manner, can have a good outcome with conservative treatment.

Thoracic spinal epidural lipomatosis associated with adolescent scoliosis

Although a variety of neural axis abnormalities in association with idiopathic scoliosis have been reported, there are no documented cases of spinal epidural lipomatosis (SEL) in a child with scoliosis. An otherwise healthy, neurologically intact 14-year-old girl presented with spinal deformity. Radiographs confirmed a left thoracic, right lumbar Lenke class 5CN scoliosis. Preoperative magnetic resonance imaging (MRI) demonstrated extensive SEL in the thoracic spine. She underwent posterior spinal fusion with segmental instrumentation using bony anchors that did not violate the spinal canal. Intraoperative spinal cord monitoring and postoperative clinical course were uneventful. SEL should be added to the list of potential abnormalities to be looked for in children with spinal deformities undergoing preoperative MRI of the neural axis.

Idiopathic spinal epidural lipomatosis

We report a rare case of paraparesis caused by thoracic spinal epidural lipomatosis in a female patient who did not have any recognized predisposing factor for this condition.

Neurological involvement in patients with rheumatic disease

Patients with multi-system rheumatic conditions may have disease affecting the central and peripheral nervous systems. Early assessment is often helpful in averting the development of serious complications, which in some conditions can be prevented by the prompt institution of treatment. We review the spectrum of neurological disease in patients with a rheumatological diagnosis. The wide variety of associated neurological complications is discussed in the context of specific rheumatic conditions, varying from spinal cord involvement in rheumatoid arthritis, to neuropsychiatric involvement in systemic lupus erythematosus and neurological sequelae in vasculitic disorders. We discuss diagnostic criteria and recommended management options (where available), and describe the role of new tools such as functional brain imaging in the diagnosis and monitoring of disease. We also discuss the potential for development of neurological complications from the use of anti-rheumatic drugs.

Epidural spinal lipomatosis with acute onset of paraplegia in an HIV-positive patient treated with corticosteroids and protease inhibitor: case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a case of HIV-related lipodystrophy with a rapid onset of symptoms from epidural lipomatosis in the wake of protease inhibitor and steroid treatment.

SUMMARY OF BACKGROUND DATA

Symptomatic spinal epidural lipomatosis is considered to be a rare condition usually presenting with slowly progressive cord or nerve root compression. Only 2 cases of spinal lipomatosis in HIV-related lipodystrophy have been reported.

METHODS

We describe the case of a 41-year-old male with HIV who received protease inhibitor medication and had neurologic deficits rapidly develop.

RESULTS

The patient had complete paraplegia develop within 12 hours from admission following a 1-day history of unsteady gait and a 3-day history of leg numbness. After diagnosis of epidural lipomatosis on magnetic resonance imaging, the patient underwent decompressive thoraco-laminectomy. He recovered well and was able to walk by postoperative day 4.

CONCLUSION

It is important to maintain an awareness for the possible association between HIV lipodystrophy and symptomatic epidural lipomatosis.

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

BACKGROUND CONTEXT

Symptomatic spinal epidural lipomatosis (SEL), a rare cause of spinal cord compression, has most often been associated with exogenous steroid use.

PURPOSE

Identify four associations with SEL, correlate the associated groups with level of disease and compare treatment with outcome data in these groups.

STUDY DESIGN/SETTING

Case reports of three patients and analysis of 104 cases from the literature.

PATIENT SAMPLE

Three patients from the senior author's practice.

OUTCOME MEASURES

Not applicable.

METHODS

The authors report three new cases of SEL not associated with steroid use. They review all available English literature and present a table of all 104 reported cases.

RESULTS

The clinical course of three new patients is reported.

CONCLUSIONS

Associated conditions are exogenous steroid use, obesity, endogenous steroid excess, and some remain idiopathic. Although SEL is a rare condition, our review of the literature reveals many more reported cases than previously thought. With increased awareness of this condition and improved imaging techniques, further studies of this disease should be undertaken.

Spinal epidural lipomatosis in children with renal diseases receiving steroid therapy

Spinal epidural lipomatosis (SEL) in patients on steroid therapy may be explained by two hypotheses: (1) steroids induce SEL and (2) steroids cause the growth of a pre-existing SEL, especially in obese children. Steroid-induced SEL (SSEL) is rarely described in children, with only six cases reported elsewhere. However, we have already reported four nephrotic children with SSEL, including one child in another hospital, in addition to the six cases. We investigated the frequency of SSEL in 125 children with renal diseases treated with glucocorticoids in a single hospital over 16 years, and examined the risk factors in 62 patients with SSEL reported in the literature. When patients complained of symptoms at the early stage of SSEL, i.e., back pain or numbness, and patients were obese, we performed spinal magnetic resonance imaging (MRI). SSEL was detected in 5 of 125 children (4.0%). Of the 5 patients with SSEL, 3 had vertebral compression fractures, and all 5 patients were on methylprednisolone pulse therapy. Our study suggests that many more patients can be detected at the early stage of SSEL by performing spinal MRI for patients with early symptoms, obesity, and those who have received methylprednisolone pulse therapy.

Effectiveness of high trough levels of cyclosporine for 5 months in a case of steroid-dependent nephrotic syndrome with severe steroid toxicity

Glucocorticoid treatment for steroid-dependent nephrotic syndrome (NS) is associated with severe adverse effects, such as bone fractures and epidural lipomatosis. Furthermore, a high trough level of cyclosporine (CsA) over an extended period of time is known to induce CsA nephropathy. We present a girl with steroid-dependent NS and steroid-induced vertebral compression fractures and epidural lipomatosis who was treated with a high-dose of prednisolone after experiencing several relapses. A high CsA trough level (between 147 and 225 ng/mL) over a period of only 5 months was effective in improving the vertebral compression fractures, alleviating the epidural lipomatosis by enabling the discontinuation of prednisolone treatment. Thus, high trough levels of CsA over a short period of time may enable prednisolone to be discontinued in cases of steroid-dependent NS without causing any clinical, histological, serum and/or urinary CsA-related adverse effects.

Epidural lipomatosis secondary to indinavir in an HIV-positive patient

A human immunodeficiency virus-positive patient receiving indinavir therapy developed a slowly progressive paraparesis. Magnetic resonance imaging findings were consistent with epidural lipomatosis. On discontinuing indinavir, symptoms gradually remitted. Although indinavir, a protease inhibitor, is known to cause abnormal fat accumulation, to the best of our knowledge this is the first report of epidural lipomatosis.

Acute neurologic complications in children with systemic cancer

Neurologic complications are common in children with cancer, but the literature dealing with this subject is sparse. Using a symptoms and signs approach, the most common causes for requesting a neurologic evaluation for this population are reviewed. The spectrum of neurologic symptoms in children with cancer differs from adults and requires the consulting neurologist to have a thorough knowledge of childhood cancer and its effects on the nervous system.

Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections: case report

OBJECTIVE AND IMPORTANCE

Spinal epidural lipomatosis, which causes symptomatic compression of neural elements, is a well known but uncommon complication of Cushing's syndrome. Spinal epidural lipomatosis has been reported frequently in association with chronic systemic corticosteroid therapy, but thus far only one case has been attributed to local epidural corticosteroid injections.

CLINICAL PRESENTATION

We report another case of symptomatic spinal epidural lipomatosis after epidural corticosteroid injections. This is the first such case documented by magnetic resonance imaging and confirmed with surgical exploration.

INTERVENTION

The patient's symptoms of neurogenic claudication resolved after lumbar laminectomy in the region of previous corticosteroid injections and the removal of epidural fat, which was compressing the thecal sac.

CONCLUSION

This case should alert clinicians that epidural lipomatosis, which causes symptomatic thecal sac compression, is a possible complication, not only of systemic glucocorticoid therapy, but also of local epidural corticosteroid injections.

Ninety-degree rotation of the thoracic spinal thecal sac. Case report

This 44-year-old man presented with a 4-year history of progressive spastic weakness of his legs. He was found to have epidural lipomatosis behind the thoracic spinal cord, and the nerve roots exited from the posterior and anterior midline planes of the dura, indicating a 90 degree rotation of the thoracic cord. Magnetic resonance images clearly demonstrated the segmental thoracic nerve roots exiting from the dorsal midline of the dura, a finding confirmed at surgery. The authors found only one previously published case of rotation of the spinal cord. Directed mechanical stress caused by deformation of the rotated spinal cord, rather than compression from adipose tissue, is proposed as the mechanism of the myelopathy. The extent, location, and thickness of the associated extradural adipose tissue is suggestive of epidural lipomatosis. The lipomatous tissue might have been an epiphenomenon and cord rotation an isolated congenital anomaly. Alternatively, asymmetrical growth of epidural fat may have exerted torque, rotating the thecal sac.

Spinal epidural lipomatosis. Case report and review of the literature

Spinal epidural lipomatosis (SEL) is a condition in which excess adipose tissue is deposited circumferentially about the spinal cord in the epidural space. It is most frequently seen in patients on chronic glucocorticosteroid therapy for a variety of medical problems. This is a case report of lumbar epidural lipomatosis in a bodybuilder with radiculopathy supposedly induced by anabolic steroid intake.

Idiopathic spinal epidural lipomatosis

OBJECTIVE

Spinal epidural lipomatosis (SEDL) is a rare disorder often associated with the administration of exogenous steroids or the elevation of endogenous steroids. Spinal epidural lipomatosis develops in some patients in the absence of elevated steroid levels. The limited information known about idiopathic SEDL comes predominantly from isolated case reports. We proposed to study our experience with idiopathic SEDL and to review the literature.

METHODS

We identified eight symptomatic patients with idiopathic SEDL treated at our institution, which is the largest series reported. All patients were male and obese by body mass index (> 27.5 kg/m2). The mean age of the patients was 35.4 years. Idiopathic SEDL was equally distributed between the thoracic and lumbar spine. Six patients underwent laminectomy and fat debulking with good postoperative results; two patients were treated with a weight loss diet, which resulted in the relief of symptoms after losing > 15 kg each.

RESULTS AND CONCLUSION

A review of our patients in conjunction with other reported cases reveals the following: 1) idiopathic SEDL occurs almost exclusively in the obese population; 2) idiopathic SEDL seems to occur with equal frequency between the thoracic and lumber spine; 3) a strong male predominance exists; 4) thoracic SEDL presents at an earlier age compared with lumbar SEDL; 5) surgical decompression remains the treatment of choice for the immediate relief of symptoms. Our experience suggests that idiopathic epidural lipomatosis may be a pathological entity that has been underdiagnosed.

[Epidural lipomatosis: complication of long-term corticotherapy. Apropos of 2 cases]

Spinal epidural lipomatosis (SEL) is defined as the deposition of loose fat tissue in the epidural space. Two cases are reported which illustrate the main features of this uncommon disease. Most frequently SEL is revealed by neurologic manifestations such as an acute chronic spinal cord compression. Corticosteroid therapy and obesity are the main factors able to induce the disease. The common location of the SEL at the thoracic spine is explained by the physiologic abundance of fat and by the relative narrowness of the spinal canal at this level. An osteoporotic vertebral crush fracture which reduces the diameter of the canal frequently reveals the SEL. MRI confirms the diagnosis of SEL and shows the extent in the spinal canal. The treatment of SEL is difficult. The decrease or the stop of corticosteroid therapy has allowed the recovery in a few cases with chronic neurologic symptoms. The risks of a surgical procedure are important in these patients and the medical or surgical treatment should be discussed taking into account the clinical symptoms of SEL, its location and extent, and the risks of recurrence if corticosteroid therapy must go on.

Neurogenic claudication by epidural lipomatosis: a case report and review of literature

Epidural lipomatosis is most frequently seen in patients on chronic steroid treatment. Only twelve cases of idiopathic spinal epidural lipomatosis have been described. In this report we present an additional case of this condition in a middle-aged male presenting with neurogenic claudication.

Lumbar epidural lipomatosis: the "Y" sign of thecal sac compression

PURPOSE

We have identified a specific sign of lumbar thecal sac compression seen in patients with symptomatic lumbar epidural lipomatosis. Recognition of this sign will aid with proper diagnosis of this unusual disorder.

METHODS

Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) examinations of the lumbar spine performed in the evaluation of low back pain over a 24 mo period demonstrated nine patients with excessive fat in the epidural space. Myelography was performed on five of these patients. Detailed analysis of the shape and degree of thecal sac compression was made.

RESULTS

Eight of the nine patients with epidural lipomatosis demonstrated a characteristic type of thecal sac compression not seen with other spinal disorders. On cross sectional imaging, the thecal sac has a striking stellate appearance with three rays emanating from a central core. This produces a trifid shape resembling the letter "Y". In two patients scanned following subsequent surgical removal of the epidural fat, the thecal sac had resumed its normal configuration.

CONCLUSION

A seemingly specific and easily recognized type of compression of the thecal sac may occur with lumbar epidural lipomatosis. This creates a trifid appearance of the thecal sac; we have termed this the "Y" sign.

Idiopathic spinal extradural lipomatosis in a non-obese otherwise healthy man

Spinal extradural lipomatosis is rare and is usually associated with long-term steroid administration or obesity. It is most commonly thoracic in situation. We present a unique case of spinal extradural lipomatosis in a 20-year-old non-obese, clinically normal man. The role of MRI in investigation and the management options are discussed.

Idiopathic and glucocorticoid-induced spinal epidural lipomatosis

Pathological overgrowth of the epidural fat in the spine has been described and reported nearly exclusively in patients either with Cushing's syndrome or on chronic intake of glucocorticoids for a variety of clinical disorders. The authors report four patients with documented spinal lipomatosis (three pathologically and one radiologically). Only one of these patients received corticosteroids, and none had an underlying endocrinological abnormality. All four patients were adult males with a mean age at onset of symptoms of 43 years (range from 18 to 60 years). The symptoms ranged from simple neurogenic claudication and radicular pain to frank myelopathy. Myelography followed by computerized tomography were instrumental in the diagnosis of the first three patients; the fourth was diagnosed by magnetic resonance imaging. The thoracic spine was involved in two cases and the lumbosacral area in the other two. The different treatment modalities were tailored according to the symptomatology of the patients. These included weight reduction of an overweight patient with minimal neurological findings in one case and decompressive laminectomy and fat debulking to achieve adequate cord decompression in the remaining three cases. Two patients improved significantly, the condition of one stabilized, and the fourth required a second decompression at other spinal levels. The various modalities of treatment and their potential complications are discussed.

An unusual epidural, vascular spinal lipoma in a 3-year-old child: a case report and review of the literature

Epidural lipomas are usually benign tumors affecting the spinal cord. We report the unusual presentation of a cervicothoracic spinal lipoma associated with a cervical dysraphism in a young boy. Diagnostic options using magnetic resonance imaging and gadolinium-diethylenetriaminepentaacetic acid are discussed as a pathway to early diagnosis of these and other occult spinal lesions.