Lumbar spinal epidural lipomatosis: A case report and review of the literature

Outcome of posterior decompression for spinal epidural lipomatosis

BACKGROUND

In contrast to osteoligamentous lumbar stenosis (LSS), outcome of surgical treatment for spinal epidural lipomatosis (SEL) is still not well defined. We present risk factors for SEL and clinical long-term outcome data after surgical treatment for patients with pure SEL and a mixed-type pathology with combined SEL and LSS (SEL+LSS) compared to patients with pure LSS.

METHODS

From our prospective institutional database, we identified all consecutive patients who were surgically treated for newly diagnosed SEL (n = 31) and SEL+LSS (n = 26) between 2018 and 2022. In addition, a matched control group of patients with pure LSS (n = 30) was compared. Microsurgical treatment aimed for posterior decompression of the spinal canal. Study endpoints were outcome data including clinical symptoms at presentation, MR-morphological analysis, evaluation of pain-free walking distance, pain perception by VAS-N/-R scales, and patient's satisfaction by determination of the Odom score.

RESULTS

Patients with osteoligamentous SEL were significantly more likely to suffer from obesity (body mass index (BMI) of 30.2 ± 5.5 kg/m2, p = 0.03), lumbar pain (p = 0.006), and to have received long-term steroid therapy (p = 0.01) compared to patients with SEL+LSS and LSS. In all three groups, posterior decompression of the spinal canal resulted in significant improvement of these symptoms. Patients with SEL had a significant increase in pain-free walking distance during the postoperative course, at discharge, and last follow-up (FU) (p < 0.0001), similar to patients with SEL+LSS and pure LSS. In addition, patients with pure SEL and SEL+LSS had a significant reduction in pain perception, represented by smaller values of VAS-N and -R postoperatively and at FU, similar to patients with pure LSS. In uni- and multivariate analysis, domination of lumbar pain and steroid long-term therapy were significant characteristic risk factors for SEL.

CONCLUSIONS

Surgical treatment of pure SEL and SEL+LSS allows significant improvement in pain-free walking distance and pain perception immediately postoperatively and in long-term FU, similar to patients with pure LSS.

[Clinical research progress of spinal epidural lipomatosis]

Objective

To review the clinical research progress of spinal epidural lipomatosis (SEL).

Methods

The clinical studies on SEL at home and abroad in recent years were extensively reviewed, and the pathogenesis, clinical and imaging manifestations, and treatment status of SEL were summarized and analyzed.

Results

SEL is a disease characterized by compression of the spinal cord and nerve roots due to abnormal accumulation of epidural adipose tissue in the spinal canal. Its prevalence and diagnosis rate are low and the pathogenesis is not fully understood. MRI is the most sensitive and specific diagnostic test for SEL. Surgical decompression and removal of excess adipose tissue are the only options for patients with acute SEL or those who have failed conservative management, and conservative management should be considered for other patients.

Conclusion

SEL is a rare disease and related research still needs to be improved. In the future, high-quality, multi-center and large-sample studies will be of great significance for evaluating the choice of treatment methods and effectiveness of SEL patients.

Postpartum Spinal Epidural Lipomatosis With Epidural Venous Engorgement

Spinal epidural lipomatosis (SEL) refers to a condition characterized by the abnormal growth of fatty tissue within the vertebral canal, situated outside the spinal canal itself. This expansion of fat can result in symptoms such as back pain and radiculopathy. The majority of cases remain without noticeable symptoms. However, when SEL does cause symptoms, it is frequently linked to using external steroids. The contributing factors to SEL include obesity and Cushing's syndrome. The presentation of SEL can mimic other spinal disorders such as epidural hematoma, spinal stenosis, and degenerative joint disease. Patients might present with gradually progressing and long-standing complaints of back pain, muscle weakness, numbness, loss of bladder or bowel control, lack of coordination, abnormal reflexes, and, in rare instances, paralysis. We are reporting a case involving a 34-year-old female with obesity, who experienced sudden weakness in her left lower extremity shortly after a recent uncomplicated vaginal delivery using epidural analgesia. A magnetic resonance imaging (MRI) of her thoracic (T) and lumbar spine revealed spinal cord compression secondary to extensive posterior epidural lipomatosis associated with epidural venous engorgement. The patient underwent an immediate laminectomy procedure at the T3, T5, T7, and T9 levels to alleviate the compression. Postoperatively, she underwent a course of physiotherapy and gradually regained her normal muscle strength. She was discharged in stable condition on the sixth day after the surgery.

Correlation of spinal epidural fat volume with body mass index: a longitudinal study

PURPOSE

Spinal epidural lipomatosis is abnormal accumulation of normal fat in the epidural space with weight loss suggested as first-line therapy in select symptomatic patients. However, moderate to large longitudinal studies establishing concordant changes between body mass index and epidural fat are lacking. The purpose of this study was to longitudinally assess this relationship.

METHODS

We performed an ancillary study of the Habitual Diet and Avocado Trial. Baseline and six-month abdominal MRIs were analyzed for 98 overweight or obese but otherwise healthy subjects. Dorsal epidural fat volumes in the lumbar spine were measured and correlated with changes in body mass index, changes in visceral fat volume, and demographic information.

RESULTS

There was a linear relationship between body mass index changes and epidural fat volume changes with a one-point change in body mass index corresponding to a 45 mm³ change in dorsal epidural fat volume (p < 0.001, 95% CI 31.87 to 76.77) as well as between visceral fat volume changes and epidural fat volume changes (regression coefficient 0.51, p < 0.001, 95% CI 0.22 to 0.47). Age was inversely related with subjects older than 45.7 years tending to lose epidural fat (regression coefficient -0.22, p = 0.025, 95% CI -10.43 to -0.72).

CONCLUSION

Changes in spinal dorsal epidural fat volume parallel changes in body mass index and visceral fat, supporting weight loss as initial treatment for uncomplicated obesity-associated spinal epidural lipomatosis.

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.

Extensive Symptomatic Thoracolumbar Epidural Lipomatosis Treated With Minimally Invasive Hemilaminectomies: Technical Case Report

BACKGROUND AND IMPORTANCE

Spinal epidural lipomatosis is a rare condition commonly associated with chronic corticosteroid use and obesity that involves deposition of adipose tissue in the epidural space of the spinal canal. This accumulation of adipose tissue may cause compression of the spinal cord and/or nerve roots and result in compressive symptoms such as myelopathy or radiculopathy. Spinal involvement is usually confined to either the thoracic or lumbar spine but can infrequently affect both regions. Depending on pre-existing conditions, treatment options include weight loss and discontinuation of exogenous steroid use, both of which have been shown to be effective therapeutic methods. Surgical decompression may be useful for appropriately selected patients in whom conservative therapy has failed or who experience acute neurological deterioration, although this is rarely indicated.

CLINICAL PRESENTATION

In this study, we describe a patient receiving long-term corticosteroid therapy who presented with symptomatic epidural lipomatosis that involved the thoracic and lumbar spine. She was treated with decompression by continuous T3-L5 hemilaminectomies performed through 5 small incisions of alternating laterality. After surgery, the patient experienced clinical improvement and was able to return to her baseline.

CONCLUSION

We illustrate a successful spinal decompression of extensive epidural lipomatosis through a less-invasive surgical approach using several small incisions to accomplish uninterrupted hemilaminectomies. This alternative approach to a standard continuous incision can be considered in cases of extensive spinal epidural lipomatosis in patients with multiple medical comorbidities in whom wound healing is believed to be an issue and for whom minimizing blood loss is crucial.

Acute Spinal Cord Injury Due to Epidural Lipomatosis Without Osseous Injury

Spinal epidural lipomatosis (SEL) is a common pathology of the lumbar spine. While the natural history is not well understood, there is a strong association with metabolic syndrome and endocrine dysfunction. Clinical presentation typically involves slow, progressive onset of radicular and myelopathic symptoms. Treatment primarily consists of weight loss, while surgery is reserved for refractory cases or acute cauda equina syndrome. We present a case of acute spinal cord injury (SCI) after trauma with underlying SEL in the cervicothoracic spine. Additionally, a literature review using a MEDLINE search of the English literature through April 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify all documented cases of acute spinal cord injury with underlying SEL.

A 72-year-old obese male with insulin-dependent diabetes mellitus presented with subacute bilateral lower extremity weakness after a fall with a flank injury three days prior to evaluation. Within hours of admission, the patient acutely progressed to paraplegia and sensory loss below the T6 level consistent with an ASIA (American Spinal Injury Association) A spinal cord injury. No fracture or dislocation was identified on CT imaging. MRI of the thoracic spine revealed spinal cord compression secondary to extensive posterior epidural lipomatosis with resultant anterior displacement of the thecal sac. The patient underwent emergent T2-T9 laminectomy for decompression. Post-operatively, the patient regained sensation below the level of injury. A review of the literature reviewed no published articles on cases of complete spinal cord injury secondary to underlying SEL without associated fracture. Finally, we present the first report of an acute spinal cord injury in the setting of SEL without fracture. Our case demonstrates that SEL outside the lumbar spine confers increased risk for SCI following trauma. Patients with cervicothoracic SEL may require close neurological observation and timely surgical decompression.

Spinal Epidural Lipomatosis: A Comprehensive Review

Purpose of review

This is a comprehensive review regarding the epidemiology, diagnosis, and management of spinal epidural lipomatosis (SEL).

Recent Findings

SEL is a relatively rare condition that has gained scientific relevance over the past few decades. Recent findings include expanding treatment strategies to include minimally invasive surgical techniques.

Summary

SEL is caused by an excess of adipose tissue accumulation localized to the thoracic and lumbar regions of the spine. While the exact pathogenesis is not fully elucidated, the etiology of SEL can be broadly classified based on five commonly associated risk factors; exogenous steroid use, obesity, endogenous steroid hormonal disease, spine surgery, and idiopathic disease. Progression of SEL may lead to neurological deficits, myelopathy, radiculopathy, neurogenic claudication, loss of sensation, difficulty voiding, lower extremity weakness, and rarely cauda equina syndrome. Conservative management is largely patient-specific and aimed at mitigating symptoms that arise from shared risk factors. If more advanced treatment measures are necessary, minimally invasive surgery and open surgical techniques, have proven successful.

Lumbar laminotomy and replantation for the treatment of lumbar spinal epidural lipomatosis: A case report

RATIONALE

Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by excessive overgrowth of extradural fat within the lumbar spinal canal. Surgical decompression is commonly performed to treat symptomatic SELs. Fenestration or laminectomy with epidural fat debulking was a routine surgical procedure according to the literature, that may be causing postoperative lumbar instability. In the present study, we presented a brief report of lumbar SEL and introduced another surgical approach.

PATIENT CONCERNS

A 55-year-old man complained of severe low back pain and right leg radicular pain for a year, accompanied by neurogenic intermittent claudication. He received a variety of conservative treatments, including non-steroidal anti-inflammatory drugs, acupuncture, and physical therapy. However, his pain did not diminish. Finally, a posterior epidural mass in the dorsal spine extending from the L3 to L5 level, which caused dural sac compression was found on lumbar magnetic resonance imaging. This mass was homogeneously hyperintense in both T1W1 and T2W1 images, suggestive of epidural fat accumulation.

DIAGNOSES

Lumbar SEL.

INTERVENTIONS

The patient underwent lumbar laminectomy, epidural fat debulking, and spinous process-vertebral plate in situ replantations.

OUTCOMES

The patient presented with complete recovery of radiculopathy and low back pain after surgery. Postoperative magnetic resonance imaging showed that the increased adipose tissue disappeared, and the dural sac compression was relieved. A computed tomography scan revealed the lumbar lamina in situ. He was able to walk normally and remained relatively asymptomatic for 12 months after the operation at the last follow-up visit.

LESSONS

Lumbar laminotomy and replantation provide an ideal option to treat lumbar SEL because it can achieve sufficient and effective decompression, simultaneously reconstruct the anatomy of the spinal canal, and reduce the risk of iatrogenic lumbar instability.