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

A meta-analysis of deltoid ligament on ankle joint fracture combining deltoid ligament injury

Purpose

Ankle fracture combined with deltoid ligament (DL) injury results in decreased stability of ankle mortise, reduced contact surface between tibial and talus, increased local stress, and increased postoperative complications. The purpose of this meta-analysis was to evaluate the postoperative effects of repairing ligaments in ankle fractures with DL rupture.

Methods

According to the steps of the Cochrane systematic review, the related literatures from PubMed, Embase and the Cochrane Library Databases were retrieved as of September 1, 2021, and all relevant randomized controlled trials and retrospective studies were collected. The evaluation indicators include medial clear space (MCS), visual analogue scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), complications rate. Meta-analysis was conducted by RevMan® 5.3 provided by the Cochrane collaboration.

Results

A total of 388 patients (195 patients in the ligament repair group and 193 patients in the non-repair group) were included in 7 clinical trials. Meta-analysis data showed there were no statistically significant differences between the ligament repair group and non-repair group in final follow-up VAS, final AOFAS and postoperative MCS (P = 0.50, P = 0.04, P = 0.14, P = 0.14, respectively). Final follow-up MCS and complications rate in ligament repair group were smaller than those in the non-repair group and were statistically significant (P < 0.00001, P = 0.006, respectively).

Conclusion

Although there was no difference in in final follow-up VAS, final follow-up AOFAS and postoperative MCS between experimental group and control group, It's statistically significant in final follow-up MCS and complications rate. Ligament repair could reduce the width of MCS, restore ankle stability, reduce the incidence of complications and lead to a better prognosis.

Could Spinal Epidural Lipomatosis Be the Hallmark of Metabolic Syndrome on the Spine? A Literature Review with Emphasis on Etiology

Spinal epidural lipomatosis is defined by an excessive amount of epidural fat in the spinal canal, usually in the lumbosacral tract: a well-known cause of lumbar pain and spinal stenosis with a possible wide range of neurological symptoms. Recent research data reveal that, nowadays, obesity has become the main cause of spinal epidural lipomatosis. Moreover, this condition was recently recognized as a previously unknown manifestation of metabolic syndrome. Radiological studies (CT and MRI) are the only tools that are able to diagnose the disease non-invasively. Indeed, radiologists play a key role in disease recognition, with subsequent possible implications on patients' systemic health assessments. Despite its clinical importance, the condition is still underreported and neglected. The current literature review summarizes all the main etiologies of spinal epidural lipomatosis, particularly regarding its linkage with metabolic syndrome. An overview of disease characteristics from diagnosis to treatment strategies is also provided.

MRI Features and Clinical Significance of Spinal Epidural Lipomatosis: All You Should Know

Spinal epidural lipomatosis (SEL) is defined as the abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. SEL can be asymptomatic or can cause a wide range of symptoms, the most common of which is neurogenic claudication. Several other neurological manifestations may also occur, above all myelopathy and radicular symptoms. The spinal level most frequently involved in patients with SEL is the lumbar one, followed by the thoracic one. Imaging plays a key role in disease assessment. MRI is considered the most effective and sensitive modality for diagnosing and staging SEL. Anyway, also CT scan can diagnose SEL. The diagnosis may be incidental (in mild-moderate disease) or may be taken into account in cases with neurological symptoms (in moderate-severe disease). There are some recognized risk factors for SEL, the most common of which are exogenous steroid use and obesity. Recent studies have found an association between SEL and obesity, hyperlipidemia and liver fat deposition. As a matter of fact, SEL can be considered the spinal hallmark of metabolic syndrome. Risk factors control represents the initial treatment strategy in patients with SEL (e.g. weight loss, steroid therapy suspension). Surgical decompression may be required when conservative treatment fails or when the patient develops acute/severe neurological symptoms.

Rapid Development of Spinal Epidural Lipomatosis after Treatment of Metastatic Castration-Resistant Prostate Cancer with Second-Generation Androgen Receptor Antagonists

BACKGROUND

Previous studies have described the association of spinal epidural lipomatosis with several conditions including chronic steroid therapy, Cushing's syndrome, obesity, Paget disease, and hypothyroidism. We present a report of rapid development of spinal epidural lipomatosis after treatment with second-generation anti-androgen therapy, a new strategy for treatment of metastatic castration-resistant prostate cancer that has been increasingly employed in the past few years. A comprehensive discussion of the underlying molecular networks involving androgen receptor blockage and adipocyte differentiation, as well as the clinical implications of such a phenomenon, are provided.

CASE DESCRIPTION

We describe the clinical and radiological evolution of a 58-year-old male patient with metastatic prostate cancer, who developed new onset of rapidly progressing lumbosacral epidural lipomatosis with significant compression of the nerve roots of the cauda equina a few months after initiation of treatment with second-generation androgen receptor antagonists.

CONCLUSIONS

The underlying pathophysiology of adipose tissue growth following the administration of anti-androgen therapy is discussed, with emphasis on both the canonical Wnt/β-catenin pathway as well as in the Wnt-independent pathway involving direct activation of downstream transcription factors from the T-cell factor family by the androgen receptor. As second-generation androgen receptor antagonists have been increasingly used for treatment of castration-resistant stage metastatic prostate cancer, new onset of symptomatic epidural lipomatosis should be considered as a possible differential diagnosis, especially because the urinary symptoms of cauda equina compression may be improperly attributed to the primary prostate neoplasm.

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.

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.

Spinal epidural lipomatosis - an easily ignored secondary intraspinal disorder in spinal kyphotic deformities

Background

A previous study reported a high prevalence of spinal epidural lipomatosis (SEL) in patients with Scheuermann kyphosis (SK) and suggested that it may play a role in the pathogenesis of this disease. According to our observation, however, SEL occurs in other spinal kyphotic deformities as well. The aim of this study was to test the hypothesis that SEL commonly occurs in patients with different types of kyphotic deformities as a secondary intraspinal disorder.

Methods

MR images of 16 patients with congenital kyphosis (CK), 40 patients with SK, 13 patients with tuberculotic kyphosis (TK), and 69 age- and sex-matched controls were retrospectively evaluated. The body mass index (BMI), kyphosis Cobb angle, and sagittal diameters of spinal epidural fat (EF) and the dural sac (DS) in the apical region (EF_A, DS_A) and non-kyphotic region (EF_N, DS_N) were measured. The EF ratios at the apical vertebral level (EFR_A) and in the non-kyphotic region (EFR_N) were calculated as EF / (EF + DS).

Results

EF_A and EFR_A were significantly higher among patients with CK, SK, and TK than among controls (P < 0.05). Seven CK patients (43.8%), 8 SK patients (20.0%), and 11 TK patients (84.6%) fulfilled the diagnostic criteria for SEL, while only 6.3, 2.5, and 0% of patients in the control groups did (P = 0.019, 0.014, and < 0.001, respectively). Spearman’s correlation analysis showed statistically significant correlations between the kyphosis Cobb angle and the amount of EF in all three patient groups.

Conclusions

SEL is a common secondary intraspinal disorder in different types of kyphotic deformities, and surgeons should pay increased attention to this intraspinal anomaly because excessive EF may compress the spinal cord and cause neurological deficits.

Scoliosis associated with idiopathic lumbosacral epidural lipomatosis

There are very few reports of spinal epidural lipomatosis (SEL) in association with scoliosis. A 49-year-old man presented with persistent back pain and right hip lump. The lumbar spine X-rays showed scoliosis (Lenke classification 5BN). Lumbar MRI demonstrated circumferential epidural fat deposit from L1 to lower S2 level. There was no obvious etiology of SEL except mild increased body mass index (BMI). The patient was managed with conservative treatment. After 6 months medication (limaprost and ginkgo), his symptoms were relieved.

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.].

Decompression of idiopathic symptomatic epidural lipomatosis of the lumbar spine

Epidural lipomatosis has been implicated as a cause or contributor of symptomatic lumbar spinal stenosis. Symptomatic spinal epidural lipomatosis (SEL) of the lumbar spine is a rare disease, often associated with steroid overload. Idiopathic lipomatosis is even much less frequent. Signs and symptoms depend upon the level and degree of nerve root compression. Diagnosis is best based on MRI. Weight reduction can be curative, however, after failure of medical treatment or in severe cases surgical decompression should be performed. A 70-year-old man with both lower limb severe paresthesia and radicular symptoms unrelieved with conservative treatments such as medications and physical therapy was treated by surgical decompression. Obesity, endocrinopathic disease, and chronic steroid therapy were excluded. Interlaminar fenestration, lateral recess decompression and fat debulking were applied at all levels through the L2-S1. After surgery there was a gradual improvement in symptoms. We report a rare case of idiopathic SEL which has shown entire evolvement of lumbar spine with specific increase of radiological and clinical severity from L2-3 to L5-S1 in a non-obese patient.

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.

Decompression of idiopathic lumbar epidural lipomatosis: diagnostic magnetic resonance imaging evaluation and review of the literature

Object

Idiopathic symptomatic spinal epidural lipomatosis (SEL) is a rare condition, and few reports have discussed diagnostic imaging criteria. To evaluate factors relating to its clinical symptoms, correlations between clinical features and the presence of spinal epidural fat were investigated, and the literature concerning idiopathic SEL was reviewed.

Methods

Morphological gradings of epidural fat were evaluated in seven patients with idiopathic SEL by using magnetic resonance (MR) imaging. In addition, body mass index (BMI), the number of involved vertebral levels, grade, and preoperative Japanese Orthopaedic Association (JOA) score were analyzed. Surgery resulted in symptomatic relief, with a mean JOA score recovery rate of 67.4%. Grading of epidural fat tended to display a slight negative correlation with preoperative JOA score, whereas a strong significant positive correlation was found between the number of involved vertebral levels and BMI.

Conclusions

The number of involved vertebral levels and obesity are strongly correlated, whereas severity of dural compression is not always significantly associated with neurological complications. These results indicate that epidural fat of the lumbar spine contributes to neurological deficits. In addition, weight-reduction therapy appears to decrease the number of vertebral levels involved. Magnetic resonance imaging–based grading is helpful for the diagnosis and evaluation of idiopathic lumbar SEL. Moreover, symptoms and neurological findings are important for determining the surgical approach.

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.

Epidural Steroid Injections in the Treatment of Symptomatic Lumbar Spinal Stenosis Associated with Epidural Lipomatosis

Epidural lipomatosis has been implicated as a cause or contributor of symptomatic lumbar spinal stenosis. Although epidural steroid injections have been very successful for symptomatic treatment of spinal stenosis; their role in treatment of symptomatic stenosis secondary to epidural lipomatosis is unclear. A review literature (MEDLINE, PubMed) found no reports justifying the use of steroids. We present two patients with lumbar epidural lipomatosis causing or contributing to symptomatic spinal stenosis. Both patients presented with unilateral lower limb radicular symptoms unrelieved with conservative measures such as medications and physical therapy. They were treated with a single transforaminal epidural steroid injection at the symptomatic level. Both had 80-85% pain relief. These reports suggest a beneficial role of epidural steroid injections for patients with symptomatic lumbar spinal stenosis caused by or contributing to epidural lipomatosis.

Lumbosacral epidural lipomatosis: MRI grading

Lumbosacral epidural lipomatosis (LEL) is characterized by excessive deposition of epidural fat (EF). The purpose of our retrospective study was to quantify normal and pathologic amounts of EF in order to develop a reproducible MRI grading of LEL. In this study of 2528 patients (1095 men and 1433 women; age range 18-84 years, mean age 47.3 years) we performed a retrospective analysis of MRI exams. We obtained four linear measurements at the axial plane parallel and tangent to the superior end plate of S1 vertebral body: antero-posterior diameter of dural sac (A-Pd DuS), A-Pd of EF, located ventrally and dorsally to the DuS, and A-Pd of the spinal canal (Spi C). We calculated (a) DuS/EF index and (b) EF/Spi C index. We developed the following MRI grading of LEL: normal, grade 0: DuS/EF index >or=1.5, EF/Spi C index <or=40%; LEL grade I: DuS/EF index 1.49-1, EF/Spi C index 41-50% (mild EF overgrowth); LEL grade II: DuS/EF index 0.99-0.34, EF/Spi C index 51-74% (moderate EF overgrowth); LEL grade III: DuS/EF index <or=0.33, EF/Spi C index >or=75% (severe EF overgrowth). The MRI exams were evaluated independently by three readers. Intra- and interobserver reliabilities were obtained by calculating Kappa statistics. The MRI grading showed the following distribution: grade 0, 2003 patients (79.2%); LEL grade I, 308 patients (12.2%); LEL grade II, 165 patients (6.5%); and LEL grade III, 52 patients (2.1%). The kappa coefficients for intra- and interobserver agreement in a four-grade classification system were substantial to excellent: intraobserver, kappa range 0.79 [95% confidence interval (CI), 0.65-0.93] to 0.82 (95% CI, 0.70-0.95); interobserver, kappa range 0.76 (95% CI, 0.62-0.91) to 0.85 (95% CI, 0.73-0.97). In LEL grade I, there were no symptomatic cases due to fat hypertrophy. LEL grade II was symptomatic in only 24 cases (14.5%). In LEL grade III, all cases were symptomatic. A subgroup of 22 patients (42.3%) showed other substantial spinal pathologies (e.g., disk herniation). By means of simple reproducible measurements and indexes MRI grading enables a distinction between mild, moderate, and severe EF hypertrophy. Kappa statistics indicate that LEL can be reliably classified into a four-grade system by experienced observers.

A case of idiopathic spinal epidural lipomatosis presented with radicular pain caused by compression with enlarged veins surrounding nerve roots

OBJECTIVE

To report a case of idiopathic spinal epidural lipomatosis (SEDL) presented with unique radicular pain most likely caused by enlarged veins surrounding nerve roots.

PATIENT

A 26-year-old male presented with radicular pain of the right T6-T7 area. He also showed Becker's nevus in the corresponding area. CT myelography and magnetic resonance imaging revealed epidural lipomatosis posterior to T4-T8 of the spinal cord. Surgical removal of adipose tissue and a hemilaminectomy of T4-T7 were performed and resulted in relief of the radicular pain.

CONCLUSIONS

Lipomatosis was histologically confirmed and surrounded by enlarged veins. These abnormally enlarged veins compressed the nerve roots and were thought to cause radicular pain. Also, Becker's nevus of this case seems to have some relationship with SEDL.

Do glucocorticoids cause spinal epidural lipomatosis? When endocrinology and spinal surgery meet

Here, we report pathogenetic aspects of spinal epidural lipomatosis (SEL) based on a literature review. SEL is a rare entity but can cause significant morbidity. Its symptoms can be identical to those of more common disorders such as vertebral and disc disease, and cord lesions (for example, transverse myelitis, multiple sclerosis and syringomyelia). Therefore, it often goes undiagnosed. In addition, SEL occurs in patients on glucocorticoid therapy, which can lead to myopathy, thereby mimicking the motor symptoms of SEL. Glucocorticoids seem to play a major role in the development of SEL, although idiopathic SEL has also been reported. The latter occurs almost exclusively in obese individuals who may have concurrent hypercortisolism. Once clinically suspected, SEL is best diagnosed by magnetic resonance imaging (MRI). Treatment of SEL is directed at reducing body weight in patients with idiopathic SEL, and at decreasing glucocorticoid excess in patients with endogenous or exogenous hypercortisolism. In severe cases, decompressive laminectomy might become necessary to alleviate the neurological symptoms caused by spinal cord compression.

Epidural lipomatosis with lumbar radiculopathy in one obese patient. Case report and review of the literature

Idiopathic epidural spinal lipomas are rare: only 13 cases have been described in the literature. We report a further case in an obese patient without known etiological factors. Diagnosis of epidural lipomatosis was performed by MRI. Weight reduction was obtained by conservative treatment, reserving surgery in case symptoms did not disappear. Of the 8 obese patients with idiopathic epidural spinal lipomatosis described in the literature, 3 were treated conservatively, with complete regression of symptoms in 2 cases, partial in the other one. In our patient, the radicular symptomatology disappeared once he had lost weight.