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El Homsi M, Zadeh C, Charbel C, Alsheikh Deeb I, Gharzeddine K, Rebeiz K, Hourani R, Khoury N, Moukaddam H. Neurologic pathologies of the vertebral spine. Skeletal Radiol 2024; 53:419-436. [PMID: 37589755 DOI: 10.1007/s00256-023-04428-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/10/2023] [Accepted: 08/10/2023] [Indexed: 08/18/2023]
Abstract
At some institutions, musculoskeletal and general radiologists rather than neuroradiologists are responsible for reading magnetic resonance imaging (MRI) of the spine. However, neurological findings, especially intrathecal ones, can be challenging. Intrathecal neurological findings in the spine can be classified by location (epidural, intradural extramedullary, and intramedullary) or etiology (tumor, infection, inflammatory, congenital). In this paper, we provide a succinct review of the intrathecal neurological findings that can be seen on MRI of the spine, primarily by location and secondarily by etiology, in order that this may serve as a helpful guide for musculoskeletal and general radiologists when encountering intrathecal neurological pathologies.
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Affiliation(s)
- Maria El Homsi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Catherina Zadeh
- Department of Radiology, University of Iowa Hospital and Clinics, Iowa, IA, USA
| | - Charlotte Charbel
- Department of Radiology, Ichan School of Medicine at Mount Sinai, New York, NY, USA
| | - Ibrahim Alsheikh Deeb
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karem Gharzeddine
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karim Rebeiz
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roula Hourani
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nabil Khoury
- Department of Radiology, University of Iowa Hospital and Clinics, Iowa, IA, USA
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hicham Moukaddam
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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Liu Z, Wang Y, Ma X, Zhang L, Wang C. Role of epidural fat in the local milieu: what we know and what we don't. Connect Tissue Res 2024; 65:102-116. [PMID: 38493368 DOI: 10.1080/03008207.2024.2329871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/08/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Traditionally, the epidural fat (EF) is known as a physical buffer for the dural sac against the force and a lubricant facilitating the relative motion of the latter on the osseous spine. Along with the development of the studies on EF, controversies still exist on vital questions, such as the underlying mechanism of the spinal epidural lipomatosis. Meanwhile, the scattered and fragmented researches hinder the global insight into the seemingly dispensable tissue. METHODS Herein, we reviewed literature on the EF and its derivatives to elucidate the dynamic change and complex function of EF in the local milieu, especially at the pathophysiological conditions. We start with an introduction to EF and the current pathogenic landscape, emphasizing the interlink between the EF and adjacent structures. We generally categorize the major pathological changes of the EF into hypertrophy, atrophy, and inflammation. RESULTS AND CONCLUSIONS It is acknowledged that not only the EF (or its cellular components) may be influenced by various endogenic/exogenic and focal/systematic stimuli, but the adjacent structures can also in turn be affected by the EF, which may be a hidden pathogenic clue for specific spinal disease. Meanwhile, the unrevealed sections, which are also the directions the future research, are proposed according to the objective result and rational inference. Further effort should be taken to reveal the underlying mechanism and develop novel therapeutic pathways for the relevant diseases.
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Affiliation(s)
- Zhiming Liu
- Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yida Wang
- Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuexiao Ma
- Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lu Zhang
- Department of Medical Research Center, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chao Wang
- Department of Spine Surgery, the Affiliated Hospital of Qingdao University, Qingdao, China
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Alvarado AM, Masood Z, Woodrow S. Cervical syringomyelia with caudal thoracic epidural lipomatosis: case report and literature review. Int J Neurosci 2023; 133:1064-1070. [PMID: 35196943 DOI: 10.1080/00207454.2022.2045289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/17/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
Syringomyelia associated with epidural lipomatosis is a rare finding. Only three published cases of epidural lipomatosis associated with syringomyelia exist in the literature. We report the case of a 46-year-old woman who presented with progressive myelopathy over an 18-month period. Imaging revealed significant thoracic spinal cord compression secondary to epidural lipomatosis from T3 to T8 with cephalad cervical syringomyelia extending from C7 to T1. Imaging was unremarkable for Chiari malformation or a craniospinal space-occupying lesion. A T2 to T8 laminoplasty was performed, removing excessive epidural adipose tissue to decompress the thoracic spinal cord. Postoperatively, the patient reported symptom improvement with complete symptom resolution at 3 months. Follow-up imaging at 3-months demonstrated thoracic spinal cord decompression with mild syrinx reduction. At two-year follow-up the patient remained asymptomatic with unchanged imaging. Syringomyelia in the setting epidural lipomatosis is a rare finding.
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Affiliation(s)
| | - Zihan Masood
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sarah Woodrow
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, KS, USA
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Han F, Liu F, Chen H, Zhao H. Full-endoscopic Discectomy via interlaminar approach for a case with idiopathic spinal epidural lipomatosis. Asian J Surg 2023; 46:6081-6082. [PMID: 37775375 DOI: 10.1016/j.asjsur.2023.09.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023] Open
Affiliation(s)
- Fei Han
- Department of Spinal Surgery, Yichang Central People's Hospital, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China.
| | - Fengping Liu
- Department of Spinal Surgery, Yichang Central People's Hospital, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China.
| | - Haidan Chen
- Department of Spinal Surgery, Yichang Central People's Hospital, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China.
| | - Hongwei Zhao
- Department of Spinal Surgery, Yichang Central People's Hospital, China Three Gorges University, 183 Yiling Avenue, Yichang, 443003, China.
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Schmutzer-Sondergeld M, Zimmermann H, Trabold R, Liebig T, Schichor C, Siller S. Outcome of posterior decompression for spinal epidural lipomatosis. Acta Neurochir (Wien) 2023; 165:3479-3491. [PMID: 37743433 PMCID: PMC10624717 DOI: 10.1007/s00701-023-05814-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023]
Abstract
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.
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Affiliation(s)
| | - Hanna Zimmermann
- Department for Diagnostic and Interventional Neuroradiology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Raimund Trabold
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Liebig
- Department for Diagnostic and Interventional Neuroradiology, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Sebastian Siller
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Diltz ZR, West EJ, Colatruglio MR, Kirwan MJ, Konrade EN, Thompson KM. Perioperative Management of Comorbidities in Spine Surgery. Orthop Clin North Am 2023; 54:349-358. [PMID: 37271563 DOI: 10.1016/j.ocl.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The number of spinal operations performed in the United States has significantly increased in recent years. Along with these rising numbers, there has been a corresponding increase in the number of patient comorbidities. The focus of this article is to review comorbidities in Spine surgery patients and outline strategies to optimize patients and avoid complications.
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Affiliation(s)
- Zachary R Diltz
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Eric J West
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Matthew R Colatruglio
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Mateo J Kirwan
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Elliot N Konrade
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - Kirk M Thompson
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee Health Science Center, 1211 Union Avenue, Memphis, TN 38104, USA; Campbell Clinic Orthopedics, 1400 South Germantown Road, Germantown, TN 38138, USA.
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Rigsby RK, Barnes S, Sabaté J, Oyoyo U, Chowdhury S, Peters EM. Correlation of spinal epidural fat volume with body mass index: a longitudinal study. Clin Imaging 2023; 98:61-66. [PMID: 37004496 DOI: 10.1016/j.clinimag.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/05/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
Abstract
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.
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Alonge EO, Guo C, Wang Y, Zhang H. The Mysterious Role of Epidural Fat Tissue in Spine Surgery: A Comprehensive Descriptive Literature Review. Clin Spine Surg 2023; 36:1-7. [PMID: 34966038 DOI: 10.1097/bsd.0000000000001290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Though both neurosurgeons and orthopedic spinal surgeons are keenly aware of the clinical importance of epidural fat (EF), surgical practice varies amongst individual surgeons and across both fields. Thus, an in-depth understanding of the anatomical structure and composition of EF is vital, as it will play a significant role in the therapeutic management and the surgical choice of treatment. OBJECTIVE We aim to extensively review the anatomical and biological properties of EF and further outline the surgical importance of EF management. STUDY METHODOLOGY (i) MEDLINE search 1966-July 2019. Keywords: Review of the Literature. Authorship, Meta-analysis, Descriptive/Narrative overview; (ii) CINAHL search from 1982 to May 2019. Keywords: Review of the Literature spinal epidural fat; Authorship; Meta-analysis; Descriptive/Narrative overview; (iii) Hand searches of the references of retrieved literature; (iv) Personal and college libraries were searched for texts on research methods and literature reviews; and (v) 200 articles were downloaded, 50 were excluded because of similarity of topics and also because of new update on the same topics. (vi) Discussions with experts in the field of reviews of the literature. DISCUSSION Though excessive or reductive amounts of EF usually exacerbates neurological symptoms and lead to various pathologic conditions such as spinal epidural lipomatosis, but there is no basic science, experimental, or clinical research that proves the role of EF in the aforementioned pathologic situations. CONCLUSION Anatomical illustration, biological function and properties of EF knowledge may lead to changes in the stages of the surgical approach to avoid postoperative complications. However, the role of EF is exclusively bound to a scientific hypothesis as one cannot be sure if an excessive or reductive amount in EF is entirely responsible for the pathologic findings, or just only an incidental finding.
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Affiliation(s)
- Emmanuel O Alonge
- Xiangya Hospital of Central South University, Changsha, Hunan Province, China
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D’Agostino V, Petrera MR, Tedesco G, Pipola V, Ponti F, Spinnato P. Could Spinal Epidural Lipomatosis Be the Hallmark of Metabolic Syndrome on the Spine? A Literature Review with Emphasis on Etiology. Diagnostics (Basel) 2023; 13:diagnostics13020322. [PMID: 36673132 PMCID: PMC9858169 DOI: 10.3390/diagnostics13020322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/22/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Valerio D’Agostino
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Miriana Rosaria Petrera
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Giuseppe Tedesco
- Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Valerio Pipola
- Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Federico Ponti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Correspondence: or
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Alomari S, Lubelski D, Khalifeh JM, Sacino AN, Theodore N, Witham T, Bydon A. Etiologies and Outcomes of Spinal Epidural Lipomatosis: Systematic Review of the Literature and Meta-Analysis of Reported Cases. Clin Spine Surg 2022; 35:383-387. [PMID: 35552292 DOI: 10.1097/bsd.0000000000001344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/09/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN This was a systematic review of the literature. OBJECTIVE The aim was to examine the contemporary demographics, etiological factors, treatment options and outcomes of spinal epidural lipomatosis (SEL) in adults. SUMMARY OF BACKGROUND DATA SEL is primarily seen in obese patients as well as those on steroid therapy. Much regarding the etiology and treatment outcomes of SEL is unknown. METHODS We reviewed Ovid MEDLINE, PubMed, SCOPUS, and Google Scholars databases from 1990 through August 2020 to identify cases of SEL. Data collected included patient characteristics, disease associations, level of pathology, treatment, and clinical outcomes. RESULTS Ninety articles (145 individual cases) were included in the analysis. The median age was 54 years and 79% were males. Obesity-associated SEL constituted the largest proportion (52%) of our cohort. 22% of SEL cases were related to steroid use, while 26% cases were considered to be idiopathic. Lumbosacral SEL was the most frequently reported level of disease (68.9%), followed by the thoracic level (26.2%). The mean age of cases who underwent surgical intervention was 55 years, as compared with 48 years in those who received conservative management ( P =0.03). 95% of patients reported some degree of symptomatic improvement regardless of the treatment modality. Logistic regression suggested a possible superior outcome associated with those undergoing surgical treatment. CONCLUSION In contrast to historical comparisons, contemporary articles support that obesity has become the major contributing factor for SEL. Logistic regression of the existing cases suggests that there may be a role for surgical intervention in select patients.
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Affiliation(s)
- Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Lim MJR, Zheng Y, Babla Singbal S, Makmur A, Yeo TT, Kumar N. Clinical and radiological characteristics of spinal epidural lipomatosis: A retrospective review of 90 consecutive patients. J Clin Orthop Trauma 2022; 32:101988. [PMID: 36035782 PMCID: PMC9413947 DOI: 10.1016/j.jcot.2022.101988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 06/07/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background The epidemiology and clinical characteristics of spinal epidural lipomatosis (SEL) have been well-reported in the literature. However, few studies investigated the concomitant spinal pathologies that were present in patients with SEL. Therefore, we aimed to summarize the clinical and radiological characteristics of patients with SEL diagnosed on spinal imaging. Methods Patients who were diagnosed with SEL on magnetic resonance imaging from January 2018 to October 2020 at our institution were included in the study. Clinical data was collected using a standardized data collection form. SEL was graded using a modified version of the Borré grading system. Factors associated with moderate or severe SEL were determined using multiple logistic regression. Results A total of 90 patients were included in the analysis. The mean (±SD) age was 59.3 (±17.1) years, and 62 patients (68.9%) were male. 61 patients (67.8%) had moderate or severe SEL. Most patients were overweight or obese (57 patients, 63.3%). The most common presenting symptoms was back pain (57 patients, 63.3%). SEL was diagnosed incidentally in 42 patients (46.7%). The lumbar spine was the most common site of SEL (35 patients, 38.9%). The most common concomitant spinal pathologies were disc bulge (83 patients, 92.2%) and flavum hypertrophy (60 patients, 66.7%). Moderate or severe SEL was associated with WHO Obesity Class, back pain or radicular leg pain at first presentation, and SEL that was worst at the lumbar or lumbosacral spinal level. Conclusions Moderate or severe SEL were independently associated with WHO Obesity Class, back pain, radicular leg pain, and SEL that was worst at the lumbar or lumbosacral spinal level. Future studies should prospectively evaluate whether weight loss therapy is warranted in patients with SEL.
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Affiliation(s)
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Salil Babla Singbal
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Health System, Singapore
| | - Naresh Kumar
- Department of Orthopedic Surgery, National University Health System, Singapore
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Manjila S, Fana M, Medani K, Kay MD, Manjila R, Bazil TG, Udayasankar U. Spinal Epidural Lipomatosis Causing Lumbar Canal Stenosis: A Pictorial Essay on Radiological Grading and the Role of Bariatric Surgery Versus Laminectomy. Cureus 2022; 14:e26492. [PMID: 35919217 PMCID: PMC9339211 DOI: 10.7759/cureus.26492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 12/01/2022] Open
Abstract
Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue in the spinal canal that can have a compressive effect on intraspinal neuroanatomical structures, leading to clinical symptoms. Several different conservative and surgical treatment strategies have been proposed but the treatment and outcomes remain controversial. There is a lack of severity-based evidence documenting the success of decompressive laminectomy in SEL and there are only anecdotal reports of clinico-radiological success with weight loss from bariatric surgery. This article demonstrates the resolution of SEL in two patients with bariatric surgery with the help of pre and postoperative MR imaging. The authors also highlight the classic “types” of spinal epidural lipomatosis with a surgically relevant grading system and elucidate the existence of concurrent extraspinal lipomatosis (i.e. mediastinal and intra-abdominal lipomatosis), drawing parallels with the natural history of SEL. The controversial question remains whether a symptomatic SEL patient needs a multilevel laminectomy for spinal decompression or bariatric surgery that can indirectly help the spinal condition. We propose that bariatric intervention could be better frontline management in patients with multifocal/multisystem lipomatosis (i.e., combined spinal and extraspinal) and spinal decompression would be ideal for those SEL patients with coexisting bony and/or ligamentous spinal canal or foraminal stenosis. This manuscript serves as a comprehensive and contemporary update on the radiological profile and two plausible treatment paths and will look toward further verification by a randomized clinical trial.
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Mugge L, Dang DD, Dang J, Leiphart J. Acute Spinal Cord Injury Due to Epidural Lipomatosis Without Osseous Injury. Cureus 2022; 14:e25212. [PMID: 35747013 PMCID: PMC9212898 DOI: 10.7759/cureus.25212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna (Italy)
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Mukhtar N, Alzahrani AS. Spinal epidural lipomatosis: a rare and frequently unrecognized complication of Cushing syndrome. Endocrine 2022; 76:218-223. [PMID: 35258785 DOI: 10.1007/s12020-022-03026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
Abstract
CONTEXT Spinal Epidural Lipomatosis (SEL) is a rare and frequently unrecognized complication of Cushing syndrome (CS). Only nine previous cases of SEL have been described in CS. Here, we present a case of severe SEL and review the literature. CASE REPORT A 29-year-old man who had severe CS secondary to an ACTH-secreting pituitary macroadenoma. He presented with progressive lower limb weakness over a 2-year period leading to complete paraplegia in the last 4 months. In addition, he had classic symptoms and signs of severe CS. His evaluation confirmed the diagnosis of CS with a 4-fold increase in his daily free urinary cortisol (1190 mg/day), a positive 1-mg dexamethasone suppression test (AM cortisol 729 nmol/l) and an elevated ACTH of 196 ng/dl (10-65). Magnetic resonance imaging (MRI) revealed a 20-mm pituitary adenoma and extensive fat accumulation in the spinal canal extending from C7 to S5 with significant spinal cord compression from T2-T10. The patient underwent an urgent spinal cord decompression surgery. He showed an immediate improvement and was able to walk with crutches 3 weeks later and independently 3 months later. About 13 days after the spinal surgery, he underwent a trans-sphenoidal surgery resulting in eucortisolemia. CONCLUSION SEL is a rare and serious complication of CS. It should be considered in any patient with CS, especially when there is neurological symptoms or disproportionate weakness of the lower limbs. Its management should be individualized but prompt surgical decompression should be considered even in patients with relatively long history of paraparesis.
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Affiliation(s)
- Noha Mukhtar
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Ali S Alzahrani
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia.
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Holder EK, Raju R, Dundas MA, Husu EN, McCormick ZL. Is there an association between lumbosacral epidural lipomatosis and lumbosacral epidural steroid injections? A comprehensive narrative literature review. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 9:100101. [PMID: 35243452 PMCID: PMC8857075 DOI: 10.1016/j.xnsj.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/29/2022]
Abstract
Background Exogenous systemic steroid exposure is a well-established risk factor for spinal epidural lipomatosis (SEL), however the association between lumbosacral epidural steroid injections (LESIs) and lumbosacral epidural lipomatosis (LEL) is generally regarded as poorly understood. Our objective was to investigate the rationale and the evidence implicating LESI(s) as a potential cause of LEL as well as the evidence related to use of LESI(s) as a potential pain relieving treatment option for radicular pain in the setting of LEL. Methods PubMed, Embase, Google Scholar, OVID were searched from inception until April 2021. Three investigators identified literature that provided original descriptive patient clinical data attributing the development/progression of LEL to LESI(s) or described the use of LESI(s) as a pain relieving modality for radicular pain in the setting of LEL. Results Fourteen publications were included for review. Overall, the current level of evidence is of low-quality. There are significant methodological gaps on this subject matter and many studies do not account for confounding variables independently associated with LEL. Conclusions This review has identified substantial limitations in the literature regarding that which is truly known regarding LESI(s) and LEL, as well as conservative management overall. To provide a well-rounded perspective, we synthesized literature as it pertains to: 1) current knowledge regarding SEL, notable associations and potential implications for corticosteroid exposure; 2) corticosteroid exposure and lipoatrophy; 3) current management recommendations for SEL and 4) areas for future focus. Although LESI(s) have been associated with LEL in the literature, presently due to a lack of rigorous, high-quality studies, the presence or absence of an independent causal relationship between LESI(s) and LEL cannot be stated with confidence.
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Affiliation(s)
- Eric K. Holder
- Yale University School of Medicine, Department of Orthopaedics and Rehabilitation: Section of Physiatry, New Haven, CT 06510, USA
- Corresponding author at: Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, P.O Box 208071, USA.
| | - Robin Raju
- Yale University School of Medicine, Department of Orthopaedics and Rehabilitation: Section of Physiatry, New Haven, CT 06510, USA
| | - Mark A. Dundas
- Yale University School of Medicine, Department of Orthopaedics and Rehabilitation: Section of Physiatry, New Haven, CT 06510, USA
| | - Emanuel N. Husu
- Baylor College of Medicine, H. Ben Taub Department of Physical Medicine and Rehabilitation, Houston, TX, USA
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, Department of Clinical Sciences, North Chicago, IL, USA
| | - Zachary L. McCormick
- University of Utah School of Medicine, Department of Physical Medicine and Rehabilitation, Salt Lake City, UT, USA
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Dinger TF, Eerikäinen MS, Michel A, Gembruch O, Darkwah Oppong M, Chihi M, Blau T, Uerschels AK, Pierscianek D, Deuschl C, Jabbarli R, Sure U, Wrede KH. A New Subform? Fast-Progressing, Severe Neurological Deterioration Caused by Spinal Epidural Lipomatosis. J Clin Med 2022; 11:jcm11020366. [PMID: 35054059 PMCID: PMC8781155 DOI: 10.3390/jcm11020366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 02/04/2023] Open
Abstract
Spinal epidural lipomatosis (SEL) is a rare condition caused by hypertrophic growth of epidural fat. The prevalence of SEL in the Western world is approximately 1 in 40 patients and is likely to increase due to current medical and socio-economic developments. Rarely, SEL can lead to rapid severe neurological deterioration. The pathophysiology, optimal treatment, and outcome of these patients remain unclear. This study aims to widen current knowledge about this “SEL subform” and to improve its clinical management. A systematic literature review according to the PRISMA guidelines using PubMed, Scopus, Web of Science, and Cochrane Library was used to identify publications before 7 November 2021 reporting on acute/rapidly progressing, severe SEL. The final analysis comprised 12 patients with acute, severe SEL. The majority of the patients were male (9/12) and multimorbid (10/12). SEL mainly affected the thoracic part of the spinal cord (11/12), extending a median number of 7 spinal levels (range: 4–19). Surgery was the only chosen therapy (11/12), except for one critically ill patient. Regarding the outcome, half of the patients regained independence (6/11; = modified McCormick Scale ≤ II). Acute, severe SEL is a rare condition, mainly affecting multimorbid patients. The prognosis is poor in nearly 50% of the patients, even with maximum therapy. Further research is needed to stratify patients for conservative or surgical treatment.
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Affiliation(s)
- Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
- Correspondence: ; Tel.: +49-201-723-1201
| | - Maija Susanna Eerikäinen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (M.S.E.); (C.D.)
| | - Anna Michel
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Tobias Blau
- Institute of Neuropathology, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany;
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (M.S.E.); (C.D.)
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
| | - Karsten Henning Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, University of Duisburg-Essen, 47057 Duisburg, Germany; (A.M.); (O.G.); (M.D.O.); (M.C.); (A.-K.U.); (D.P.); (R.J.); (U.S.); (K.H.W.)
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Spinnato P, D'Agostino V, Fiorenzo D, Barakat M, Vara G, Ponti F, Filonzi G, Crombé A, Tetta C, Miceli M. Underreporting of spinal epidural lipomatosis: A retrospective analysis of lumbosacral MRI examinations from different radiological settings. Diagn Interv Imaging 2022; 103:251-257. [DOI: 10.1016/j.diii.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/31/2021] [Accepted: 01/01/2022] [Indexed: 11/03/2022]
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19
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Neal MT, Patra DP, Lyons MK. Surgical management of thoracic myelopathy from long-segment epidural lipomatosis with skip hemilaminotomies: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21595. [PMID: 35855484 PMCID: PMC9281437 DOI: 10.3171/case21595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thoracic spinal epidural lipomatosis (SEL) involves the pathological overgrowth of histologically normal, unencapsulated adipose tissue that can compress the spinal cord and cause myelopathy. SEL has been associated with multiple medical conditions, including Scheuermann kyphosis (SK). Optimal treatment strategies for SEL, especially in the setting of a sagittal spinal deformity, remain unclear. OBSERVATIONS In this report, the authors discussed surgical management of a patient with thoracic SEL and SK using skip hemilaminotomies for resection of the epidural adipose tissue. To the authors’ knowledge, only one other report described a similar surgical technique in a patient who did not have a spinal deformity. LESSONS When conservative efforts fail, thoracic SEL may require surgical treatment. Surgical planning must account for co-medical conditions such as SK. The described approach involving skip laminotomies, which minimizes spine destabilization, is a viable option to treat SEL spanning multiple spinal segments. Prognosis after surgical treatment varies and is impacted by multiple factors, including severity of preoperative neurological deficits.
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Affiliation(s)
| | - Devi P. Patra
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona
| | - Mark K. Lyons
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona
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Lumbar Epidural Lipomatosis is Increased in Patients With Morbid Obesity and Subsequently Decreases After Bariatric Surgery. World Neurosurg 2021; 158:e495-e500. [PMID: 34774806 DOI: 10.1016/j.wneu.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spinal epidural lipomatosis (SEL) is characterized by symptomatic neurogenic compression from adipose tissue in the spinal canal. The question arises whether patients with morbid obesity have higher volumes of epidural adipose tissue (EAT) in their lumbar spinal canal compared with patients with a normal weight, and to what extent this decreases after bariatric surgery. METHODS In this explorative study the lumbar EAT volume was assessed in 25 patients with morbid obesity (body mass index [BMI] >40) using available lumbar magnetic resonance imaging (MRI) prior to their bariatric surgery. An age- and sex-matched control group (n = 25) of patients with a normal weight (BMI 20-25) was used for comparison. Participants from the obesity group underwent a postoperative control MRI. RESULTS The mean volume of EAT per MRI slice of the group of patients with obesity was significantly higher than for the group of patients with normal weight (mean: 83.3 ± 30.7 mm3 vs. mean 56.5 ± 25 mm3; P < 0.001). Fifteen participants with obesity (15 of 25) agreed to undergo a follow-up MRI. There was a significant decrease in EAT volume per MRI slice for these 15 participants (mean 82 ± 25.5 mm3 vs. 46 ± 20.0 mm3; P < 0.001) over time up to 3.6 (range: 1.2-6.0) years after bariatric surgery. CONCLUSIONS Patients with obesity have significantly larger volumes of EAT in comparison with patients with normal weight. After bariatric surgery, a significant weight loss coincided with a significant volumetric reduction of this adipose tissue in the spinal canal. Future prospective studies in patients with symptomatic SEL may elucidate whether decreases in EAT volume influence concurrent neurogenic claudication symptoms.
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21
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Walker PB, Sark C, Brennan G, Smith T, Sherman WF, Kaye AD. Spinal Epidural Lipomatosis: A Comprehensive Review. Orthop Rev (Pavia) 2021; 13:25571. [PMID: 34745483 DOI: 10.52965/001c.25571] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/03/2021] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
| | - Cain Sark
- Louisiana State University Health Science Center Shreveport
| | - Gioe Brennan
- Louisiana State University Health Science Center Shreveport
| | - Taylor Smith
- Louisiana State University Health Science Center Shreveport
| | | | - Alan D Kaye
- Louisiana State University Health Science Center Shreveport
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22
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High prevalence of clinical and biological features of metabolic syndrome in patients with epidural lipomatosis: A single-center, retrospective study. Joint Bone Spine 2021; 89:105271. [PMID: 34536624 DOI: 10.1016/j.jbspin.2021.105271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/01/2021] [Indexed: 11/21/2022]
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Spinnato P, Barakat M, Lotrecchiano L, Giusti D, Filonzi G, Spinelli D, Pipola V, Moio A, Tetta C, Ponti F. MRI Features and Clinical Significance of Spinal Epidural Lipomatosis: All You Should Know. Curr Med Imaging 2021; 18:208-215. [PMID: 34429050 DOI: 10.2174/1573405617666210824111305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/25/2021] [Accepted: 03/12/2021] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Massimo Barakat
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Ludovica Lotrecchiano
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Davide Giusti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | | | - Daniele Spinelli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Valerio Pipola
- Department of Oncologic and Degenerative Spine Surgery, IRCCS, Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Antonio Moio
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Cecilia Tetta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
| | - Federico Ponti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna. Italy
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Abstract
PURPOSE OF REVIEW This article highlights both common structural causes of myelopathy, such as spondylotic disease, and infrequent but treatable causes, such as syringomyelia, spinal cord herniation, arachnoid cyst, arachnoid band and web, epidural lipomatosis, Hirayama disease, and arachnoiditis. RECENT FINDINGS Neuroimaging improvements and availability have uncovered many structural abnormalities in the spines and spinal cords of patients who were asymptomatic or minimally symptomatic. Recent published clinical series have improved our knowledge of the natural history of structural abnormalities and the risks of intervention versus conservative management. SUMMARY Myelopathy from a suspected structural cause is a common reason for neurologic consultation. Correlation between the history, examination, and imaging are especially important to determine whether intervention is necessary or conservative management is the best option.
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Martínez Santos JL, Saway B, Damon AC, Varma A. Multilevel Hemilaminotomy Windows for the Surgical Management of Spinal Epidural Lipomatosis Causing Syringomyelia: Technical Note and Literature Review. World Neurosurg 2021; 148:4-12. [PMID: 33412315 DOI: 10.1016/j.wneu.2020.12.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Spinal epidural lipomatosis (SEL) is the excessive accumulation of extradural adipose tissue. Severe cases could result in myelopathy, and very rarely, in syringomyelia formation. Surgery has been associated with high morbidity and mortality, and no proven long-term benefits. The objective was to provide a technical description of an efficient and cost-effective procedure for multilevel thoracic decompression without requiring spinal instrumentation. METHODS A technique of multilevel hemilaminotomy windows is described in a patient with severe thoracic SEL causing syringomyelia. A 3-dimensional spine model was created to illustrate the technique and working angles. We performed a literature review by searching PubMed, Ovid Embase, and Scopus electronic databases with the predetermined inclusion criteria of cases with spinal lipomatosis and a fluid cavity within the spinal cord. RESULTS The patient's deficit and syringomyelia resolved postoperatively. A review of the literature revealed only 3 cases of syringomyelia secondary to SEL. Syringomyelia expansion occurred in all cases leading to progressive neurologic decline, and surgery with removal of the excessive adipose tissue resolved the syringomyelia and improved the neurologic functioning in all cases. CONCLUSIONS This technique of multilevel alternating hemilaminotomy "windows" allows for safe and effective decompression and resection of the excessive adipose tissue with reduced operative time and without requiring spine instrumentation. The technique maintains the integrity of the posterior column, thus reducing the risk of postdecompression deformity. Careful bipolar electrocoagulation of internal vertebral veins and meticulous hemostasis is key for minimizing the intraoperative blood loss and avoiding postoperative hematoma formation.
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Affiliation(s)
- Jaime L Martínez Santos
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA; Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA.
| | - Brian Saway
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aaron C Damon
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Abhay Varma
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Mallard F, Buni M, Nolet PS, Emary P, Taylor JA, Moammer G. Lumbar spinal epidural lipomatosis: A case report and review of the literature. Int J Surg Case Rep 2021; 78:71-75. [PMID: 33310475 PMCID: PMC7736757 DOI: 10.1016/j.ijscr.2020.11.128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Lumbar spinal epidural lipomatosis (SEL) is a rare condition defined by an excessive deposition of adipose tissue in the lumbar spinal canal. The objective of this case report is to document a clinical case of SEL presenting within a multidisciplinary spine clinic and to compare our clinical findings and management with the available literature. CASE PRESENTATION A 51-year-old female presented at a spine clinic with low back pain, bilateral leg pain and difficulty walking. Magnetic resonance imaging of the lumbar spine showed evidence of severe central canal stenosis due to extensive epidural lipomatosis. She was initially advised to lose weight and undergo a 3-month course of physiotherapy. However, because of lack of improvement, she was scheduled for and underwent L4-S1 posterior spinal decompression and L4-L5 posterior spinal instrumented fusion. At 12-month follow-up, the patient reported no pain and retained the ability to walk regular distances without experiencing discomfort. DISCUSSION This case report describes the conservative and surgical management of a case of lumbar spinal stenosis due to SEL. The therapeutic approach of patients with this condition is not standardized. As such, a discussion of the literature with respect to the diagnosis, clinical presentation, epidemiology, imaging appearance, risk factors, etiology, and management of SEL is also presented.
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Affiliation(s)
- Fabrice Mallard
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Institut Franco-Européen de Chiropraxie, Toulouse, France.
| | - Manar Buni
- Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Paul S Nolet
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Peter Emary
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Private Practice, Cambridge, Ontario, Canada; D'Youville College, Department of Chiropractic, Buffalo, New York, USA
| | - John A Taylor
- D'Youville College, Department of Chiropractic, Buffalo, New York, USA
| | - Gemah Moammer
- McMaster University, Grand River Hospital, Kitchener, Ontario, Canada; Spine Surgery, Grand River Hospital Corporation, Kitchener Waterloo Site, Ontario, Canada; Spine Surgery, St Mary's General Hospital, Kitchener, Ontario, Canada.
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Okada E, Ishihara S, Azuma K, Michikawa T, Suzuki S, Tsuji O, Nori S, Nagoshi N, Yagi M, Takayama M, Tsuji T, Fujita N, Nakamura M, Matsumoto M, Watanabe K. Metabolic Syndrome is a Predisposing Factor for Diffuse Idiopathic Skeletal Hyperostosis. Neurospine 2020; 18:109-116. [PMID: 33211945 PMCID: PMC8021843 DOI: 10.14245/ns.2040350.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/20/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Diffuse idiopathic skeletal hyperostosis (DISH) causes spinal ankylosis, which can result in patients suffering specific spinal fractures that lead to a reduction in the activities of daily life in older patients. Currently, DISH is associated with diabetes mellitus and cardiovascular disease; however, the association between DISH and metabolic syndrome has not been established. The purpose of this study was to investigate a potential association between DISH and metabolic syndrome. METHODS We retrospectively reviewed clinical data from consecutive subjects undergoing the musculoskeletal health medical checkups, and enrolled 327 subjects (174 men and 153 women; mean, 63.4 ± 13.7-years). Subjects who had spinal ankylosis at least 4 contiguous vertebral bodies were classified as the DISH group (n = 39) while the others were part of the non-DISH group (n = 288). The definition of the metabolic syndrome comes from diagnostic criteria used by the Japanese Society for Internal Medicine. Age, sex, body max index (BMI), hematological evaluation, blood pressure, presence of metabolic syndrome, the visceral fat area on abdominal computed tomography, and spinal epidural lipomatosis (SEL) on magnetic resonance imaging were evaluated. RESULTS Compared to the non-DISH group, in the DISH group, mean age (DISH group, 74.3 years; non-DISH group, 1.9 years; p < 0.001), male prevalence were higher (DISH group, 82.1%; non-DISH group, 49.3%; p < 0.001), and BMI was greater (DISH group, 24.8; non-DISH group, 23.0; p = 0.006). the metabolic syndrome was more frequently observed in DISH group (28.9%) than in the non-DISH group (16.0%) (p = 0.045). The visceral fat area was significantly larger in the DISH group than in the non-DISH group (DISH group, 130.7 ± 58.2 cm2; Non-DISH group, 89.0 ± 48.1 cm2; p < 0.001). The prevalence of SEL was similar between the 2 groups (10.3% in the DISH group vs. 8.7% in the nonDISH group; p = 0.464). Poisson regression analysis revealed that the metabolic syndrome was significantly associated with DISH with odds ratio of 2.0 (95% confidence interval, 1.0-3.7; p = 0.004). CONCLUSION Metabolic syndrome was significantly associated with DISH. Our data showed metabolic syndrome is potentially related to DISH.
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Affiliation(s)
- Eijiro Okada
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Shinichi Ishihara
- Keio Spine Research Group, Tokyo, Japan.,Department of Orthopaedic Surgery, Ota Memorial Hospital, Oshimasho, Ota City, Japan
| | - Koichiro Azuma
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takehiro Michikawa
- Department of Environmental and Occupational Health, Toho University, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Michiyo Takayama
- Center for Preventive Medicine, Keio University Hospital, Tokyo, Japan
| | - Takashi Tsuji
- Keio Spine Research Group, Tokyo, Japan.,Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Nobuyuki Fujita
- Keio Spine Research Group, Tokyo, Japan.,Department of Orthopaedic Surgery, Fujita Health University, Toyoake-shi, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.,Keio Spine Research Group, Tokyo, Japan
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Sasagasako T, Hanakita J, Takahashi T, Minami M, Kanematsu R, Tomita Y. Clinical Implications of the Epidural Fat Thickness in the Management of Lumbar Spinal Stenosis. World Neurosurg 2020; 146:e205-e213. [PMID: 33091643 DOI: 10.1016/j.wneu.2020.10.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Lumbar epidural lipomatosis is a rare condition defined as the excessive accumulation of epidural fat (EF). We herein investigated the indicators of the posterior compression factors, EF and yellow ligament, to identify the clinical features of lumbar epidural lipomatosis. METHODS Five hundred consecutive patients who underwent posterior lumbar decompression surgery for lumbar spinal stenosis (LSS) were retrospectively reviewed. The EF/SC-L index (the ratio of the anteroposterior length of the EF to that of the spinal canal [SC]) was evaluated at the spinal level that exhibited maximum dural tube compression. The participants were divided into 3 groups: grade I, EF/SC-L index ≤50%; grade II, EF/SC-L index 51%-74%; grade III, EF/SC-L index ≥75%. EF/SC-A (the ratio of the cross-sectional area of EF to that of SC) and YL/SC-A (the ratio of the cross-sectional area of yellow ligament [YL] to that of SC) were calculated. The clinical outcomes were assessed according to the Japan Orthopaedic Association scale for lumbar disease. RESULTS EF/SC-L exhibited a significantly positive correlation with EF/SC-A (r = 0.82, P < 0.001), and a negative correlation with YL/SC-A (r = -0.71, P < 0.001). The Japan Orthopaedic Association score recovery rate was 56.7 ± 22.6 in the case-matched control group, 34.5 ± 31.2 in the grade II group (P < 0.001), and 39.6 ± 24.9 in the grade III group (P = 0.032). CONCLUSIONS The EF/SC-L index is a simple and reliable indicator to quantitatively evaluate posterior compression in patients with LSS. As the accumulation of EF is associated with worse operative outcomes, the EF/SC-L index should be considered when planning lumbar decompression surgery for patients with LSS.
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Affiliation(s)
- Tomoki Sasagasako
- Department of Spinal Disorder Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan.
| | - Junya Hanakita
- Department of Spinal Disorder Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan
| | - Toshiyuki Takahashi
- Department of Spinal Disorder Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan
| | - Manabu Minami
- Department of Spinal Disorder Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan
| | - Ryo Kanematsu
- Department of Spinal Disorder Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan
| | - Yosuke Tomita
- Department of Spinal Disorder Center, Fujieda Heisei Memorial Hospital, Fujieda, Shizuoka, Japan
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Ahmad S, Best T, Lansdown A, Hayhurst C, Smeeton F, Davies S, Rees A. Spinal epidural lipomatosis: a rare association of Cushing's disease. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200111. [PMID: 33434165 PMCID: PMC7576635 DOI: 10.1530/edm-20-0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/29/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Excess cortisol is associated with hypertrophy and redistribution of adipose tissue leading to central obesity which is classically seen in Cushing's syndrome. Abnormal accumulation of fatty tissue in the spinal canal is most commonly associated with chronic steroid therapy and rarely reported with endogenous Cushing's syndrome. Herein, we describe a case of spinal epidural lipomatosis (SEL) associated with Cushing's disease. A 17-year-old man was referred with lower limb weakness, weight gain, multiple stretch marks, back pain and loss of height. He had clinical and biochemical features of Cushing's syndrome. MRI and Inferior Petrosal Sinus Sampling (IPSS) confirmed a pituitary adenoma as the source. On day 1 post trans-sphenoidal adenectomy he developed spastic paraparesis with a sensory deficit to the level of T5. MRI spine showed increased fat deposition in the spinal canal from T2 to T9 consistent with a diagnosis of SEL. He was managed conservatively and made a good recovery following restoration of eucortisolism and a period of rehabilitation. LEARNING POINTS SEL is a serious complication of glucocorticoid excess and should be considered in any patient presenting with new lower limb neurological symptoms associated with hypercortisolism. It is important to distinguish symptomatic SEL from cortisol-induced proximal myopathy by good history and clinical examination. MRI of the spine is the gold standard investigation for making a diagnosis of SEL. Restoration of eucortisolism can lead to resolution of fat accumulation and good neurological outcome.
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Affiliation(s)
- Sajjad Ahmad
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Andrew Lansdown
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Fiona Smeeton
- GIM/Diabetes & Endocrinology, Neville Hall Hospital, Abergavenny, UK
| | - Steve Davies
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Aled Rees
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
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30
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Two-year outcome comparison of decompression in 14 lipomatosis cases with 169 degenerative lumbar spinal stenosis cases: a Swiss prospective multicenter cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2243-2253. [PMID: 32409888 DOI: 10.1007/s00586-020-06449-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/09/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Spinal epidural lipomatosis (SEL) is defined as an abnormal and extensive accumulation of unencapsulated adipose tissue within the spinal epidural space. To date, there is a lack of high-level evidence studies reporting the outcome of surgical treatment of symptomatic SEL in patients with lumbar spinal stenosis (LSS). The aim was to compare clinical outcomes in patients with symptomatic LSS with and without SEL who underwent decompression surgery alone at the 12- and 24-month follow-up. METHODS One hundred and eighty-three patients met the inclusion criteria, of which 14 had mainly SEL on at least one level operated in addition to possible degenerative changes on other levels and 169 degenerative LSS only. The main outcomes were pain (Spinal Stenosis Measure (SSM) symptoms), disability (SSM function), and quality of life [EQ-5D-3L summary index (SI)] at 24-month follow-up, and minimal clinically important difference (MCID) in SSM symptoms, SSM function, and EQ-5D-3L SI. RESULTS The multiple regression linear models showed that SEL was associated with worse SSM symptoms (p = 0.045) and EQ-5D-3L SI scores (p = 0.026) at 24-month follow-up, but not with worse SSM function scores. Further, depression (in all models) was negatively associated with better clinical outcomes at 24-month follow-up. In the outcomes SSM symptoms and EQ-5D-3L SI, distinctly more patients in the classical LSS group reached MCID than in the SEL group (71.3% and 62.3% vs. 50.0% and 42.9%). CONCLUSIONS Our study demonstrated that decompression alone surgery was associated with significant improvement in disability in both groups at 2 years, but not in pain and quality of life in patients with SEL.
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Chin J, Kviatkovsky B, Lomiguen C. Osteopathic Considerations for Peripheral Neuropathy Due to Concomitant Diffuse Idiopathic Skeletal Hyperostosis Syndrome and Lumbar Epidural Lipomatosis: Case Report. Interact J Med Res 2019; 8:e14607. [PMID: 31746769 PMCID: PMC6914272 DOI: 10.2196/14607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/16/2019] [Accepted: 08/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background Diffuse idiopathic skeletal hyperostosis (DISH) syndrome and lumbar epidural lipomatosis are relatively asymptomatic neurological conditions, with findings often seen incidentally on radiological studies. Objective The aim of this paper is to present unique findings of concomitant, symptomatic DISH syndrome and lumbar epidural lipomatosis and to discuss the osteopathic diagnosis and treatment implications. Methods Concomitant, symptomatic variants are rare and present challenges to treatment and management, as seen with a 60-year-old African American woman who presented with worsening disequilibrium and new-onset bilateral fingertip numbness. Past medical history was significant for alcohol abuse disorder, hypertension, hyperlipidemia, and multiple episodes of self-resolving vertigo and lower extremity neuropathy. Results The patient was referred to the neurology department for stroke workup, which was negative. Osteopathic structural exam revealed thoracolumbar and sacral dysfunctions. Magnetic resonance imaging revealed findings consistent with thoracic DISH syndrome and lumbar epidural lipomatosis in the areas of somatic dysfunctions. Conclusions Due to minimal information on osteopathic manipulative treatment in rare neurological diseases, only gentle techniques of myofascial release, balanced ligamentous tension, and muscle energy were performed with resultant minimal improvement, thus highlighting the necessity for better guidelines and further research.
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Affiliation(s)
- Justin Chin
- Touro College of Osteopathic Medicine, New York, NY, United States
| | - Bina Kviatkovsky
- Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
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Abe T, Miyazaki M, Ishihara T, Kanezaki S, Notani N, Kataoka M, Tsumura H. Spinal epidural lipomatosis is associated with liver fat deposition and dysfunction. Clin Neurol Neurosurg 2019; 185:105480. [PMID: 31430628 DOI: 10.1016/j.clineuro.2019.105480] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE This study examined the association of spinal epidural lipomatosis (SEL) with liver fat deposition and any other liver dysfunction, except steroid involvement. PATIENTS AND METHODS We analyzed 102 patients (62 men and 40 women; mean age 73.3 years) who underwent spinal magnetic resonance imaging (MRI), computed tomography (CT), and myelography for the diagnosis of lumbar spinal canal stenosis between January 2014 and June 2018. Additional data collected included height, weight, body mass index, blood test results (C-reactive protein, albumin, total bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyltransferase [γ-GTP], total cholesterol, neutral fat, amylase, urea nitrogen, creatinine, estimated glomerular filtration rate, uric acid, platelets), the epidural fat-occupying ratio in each vertebra from L1/2 to L5/S1 on MRI, and liver CT values. RESULTS In 30 cases, the average occupying ratio of epidural fat was ≥40% (SEL), and in 45 cases, liver CT values were <40 HU (fatty liver). Correlation analysis between average occupying ratio of epidural fat and various measurements showed liver CT value (r = -0.574, P < 0.001), body weight (r = 0.304, P = 0.002), γ-GTP (r = 0.370, P = 0.01), and uric acid (r = 0.201, P = 0.04) to be independent explanatory factors. Multivariate analysis revealed that SEL was associated with liver CT value (odds ratio 0.774, 95% confidence interval [CI] 0.689-0.871) and body weight (odds ratio 1.063, 95% CI 1.016-1.135). CONCLUSION There was a strong correlation between epidural fat and liver fat deposits suggesting an association between SEL and systemic fat deposition.
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Affiliation(s)
- Tetsutaro Abe
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Masashi Miyazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan.
| | - Toshinobu Ishihara
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Shozo Kanezaki
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Naoki Notani
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Masashi Kataoka
- Physical Therapy Course of Study, Faculty of Welfare and Health Sciences, Oita University, Oita, Japan
| | - Hiroshi Tsumura
- Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, Oita, Japan
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Abstract
Obesity is a major public health issue in the United States, and rates of obesity continue to increase across the population. The association of obesity with degenerative spinal pathology underlies the observation that a substantial number of patients undergoing spine surgery are either overweight or obese. Obesity is a notable independent risk factor for both surgical and medical complications in the perioperative period and an important consideration in preoperative planning, intraoperative strategies, and postoperative management. Despite these increased risks, surgery in obese patients for a variety of degenerative conditions results in improvement in outcomes. Although obese patients may undergo gains that are absolutely lower than their nonobese counterparts, they still experience a positive treatment effect with surgery appropriate for their condition. An evidence-based approach to both preoperative and perioperative management of patients with obesity is not well established. The purpose of this article is to review the effect of obesity on the development, management, and outcomes of patients with spinal disorders and to provide data that may guide an evidence-based approach to care in this expanding patient population.
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Ishihara S, Fujita N, Azuma K, Michikawa T, Yagi M, Tsuji T, Takayama M, Matsumoto H, Nakamura M, Matsumoto M, Watanabe K. Spinal epidural lipomatosis is a previously unrecognized manifestation of metabolic syndrome. Spine J 2019; 19:493-500. [PMID: 30077045 DOI: 10.1016/j.spinee.2018.07.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 06/29/2018] [Accepted: 07/26/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural lipomatosis (SEL) is a condition in which excess lumbar epidural fat (EF) deposition often leads to compression of the cauda equina or nerve root. Although SEL is often observed in obese adults, no systematic research investigating the potential association between SEL and metabolic syndrome has been conducted. PURPOSE To elucidate potential association between SEL and metabolic syndrome. STUDY DESIGN An observational study used data of a medical checkup. PATIENT SAMPLE We retrospectively reviewed data from consecutive subjects undergoing medical checkups. A total of 324 subjects (174 men and 150 women) were enrolled in this study. OUTCOME MEASURES The correlation of EF accumulation with demographic data and metabolic-related factors was evaluated. METHODS The degree of EF accumulation was evaluated based on the axial views of lumbar magnetic resonance imaging. Visceral and subcutaneous fat areas were measured at the navel level using abdominal computed tomography. Metabolic syndrome was diagnosed according to the criteria of the Japanese Society of Internal Medicine. The correlation of SEL with metabolic syndrome and metabolic-related conditions was statistically evaluated. RESULTS The degree of EF accumulation demonstrated a significant correlation to body mass index, abdominal circumference, and visceral fat area. However, age, body fat percentage, and subcutaneous fat area showed no correlation with the degree of EF accumulation. Logistic regression analysis revealed that metabolic syndrome (odds ratio [OR]=3.8, 95% confidence interval [CI]=1.5-9.6) was significantly associated with SEL. Among the diagnostic criteria for metabolic syndrome, visceral fat area ≥100 cm2 (OR=4.8, 95% CI=1.5-15.3) and hypertension (OR=3.5, 95% CI=1.1-11.8) were observed to be independently associated with SEL. CONCLUSION This is the first study to demonstrate that metabolic syndrome is associated with SEL in a relatively large, unbiased population. Our data suggest that metabolic-related conditions are potentially related to EF deposition and that SEL could be a previously unrecognized manifestation of metabolic syndrome.
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Affiliation(s)
- Shinichi Ishihara
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan; Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW), Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan.
| | - Koichiro Azuma
- Institute for Integrated Sports Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Takehiro Michikawa
- Environmental Epidemiology Section, Centre for Health and Environmental Risk Research, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, Ibaraki 305-8506, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan
| | - Takashi Tsuji
- Department of Orthopaedic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Michiyo Takayama
- Center for Preventive Medicine, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hideo Matsumoto
- Institute for Integrated Sports Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku-ku, Tokyo 160-8582, Japan
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Mattei TA, Goulart CR, Rai SS, Rehman AA, Williams M, Mendel E. Rapid Development of Spinal Epidural Lipomatosis after Treatment of Metastatic Castration-Resistant Prostate Cancer with Second-Generation Androgen Receptor Antagonists. World Neurosurg 2019; 125:222-227. [PMID: 30763756 DOI: 10.1016/j.wneu.2019.01.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Tobias A Mattei
- Department of Neurological Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA.
| | - Carlos R Goulart
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Shawn S Rai
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Azeem A Rehman
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Michelle Williams
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ehud Mendel
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Greenish D, Watura K, Harding I. Spinal epidural lipomatosis following bilateral spinal decompression surgery. BMJ Case Rep 2019; 12:12/2/e226985. [PMID: 30772832 DOI: 10.1136/bcr-2018-226985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Davyd Greenish
- Medicine, Taunton and Somerset NHS Foundation Trust, Taunton, Somerset, UK
| | - Karen Watura
- Medicine, Taunton and Somerset NHS Foundation Trust, Taunton, Somerset, UK
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Bajracharya L, Paudel S. Spinal Epidural lipomatosis due to adrenal cortisol secreting adenoma in a 14 year old girl - a case report. EUROPEAN JOURNAL OF MEDICAL CASE REPORTS 2019:12-15. [DOI: org/10.24911/ejmcr/173-1537696292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
Background: Spinal epidural lipomatosis (SEL) is an excessive fat deposition within the epidural space of spinal canal leading to compression of nervous structures and neurological manifestations. Exogenous glucocorticoid administration is the major cause of symptomatic SEL. The reported patient had SEL related to endogenous Cushing syndrome which is among few reported cases in the literature.
Case presentation: A 14 year girl with features of Cushing syndrome had severe back pain and magnetic resonance imaging of spine showed SEL. Subsequently, computed tomography of abdomen showed right adrenal adenoma.The patient underwent adrenalectomy which improved her signs of hypercortisolism and SEL.
Conclusion: In view of severe neurological deficits and therapeutic consequences, SEL should be considered in all patients with Cushing syndrome who present with symptoms of spinal cord compression. Correction of underlying endocrinopathy is imperative in management of SEL.
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Park SK, Han JM, Lee K, Cho WJ, Oh JH, Choi YS. The Clinical Characteristics of Spinal Epidural Lipomatosis in the Lumbar Spine. Anesth Pain Med 2018; 8:e83069. [PMID: 30538942 PMCID: PMC6252047 DOI: 10.5812/aapm.83069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/24/2018] [Accepted: 10/09/2018] [Indexed: 11/20/2022] Open
Abstract
Background Spinal epidural lipomatosis (SEL) is a rare disease, defined as diffuse hypertrophy of unencapsulated adipose tissue causing spinal canal compression and progressive neurologic deficits. However, there are few studies on SEL in Korea. Objectives The purpose of this study was to describe the prevalence and clinical characteristics of SEL in Korea. Methods Of the 3702 symptomatic patients (1575 males and 2127 females) who underwent lumbar spine magnetic resonance imaging (MRI) at the age of 20 years or older from January 2014 to December 2016, 42 patients (27 males and 15 females) diagnosed with SEL were selected. Medical records and telephone counseling were used to document sex, age, height, weight, clinical symptoms, coexistent spinal disease, accompanying diseases, and alcoholism and smoking status. One radiologist classified the severity of epidural lipomatosis into three grades from I to III according to Borre et al. We obtained four linear measurements at the axial plane parallel based in the narrowest on MRI image. Results The incidence of SEL in the lumbar spine was 1.1%, which was 1.71% in men and 0.7% in women. The mean age was 69.4 ± 10.9 years and the mean body mass index (BMI) was 26.4 ± 3.5 kg/m2. The most common clinical symptoms were lower back pain and radiating leg pain (26 patients, 61.9%). The level of affected SEL was found to be most prevalent at L5 - S1 (21 patients, 50%). Concomitant diseases were hypertension (26 patients, 61.9%) and diabetes (12 patients, 28.5%). The most common SEL grade was type III (21 patients, 50%), followed by types II (17 patients, 40.4%) and I (4 patients, 9.5%). Conclusions Lumbar spine MRI at one hospital showed that the incidence of symptomatic SEL was 1.1%; SEL is common at the L5-S1 level and in male patients, and severity grade is often severe.
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Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National School of Medicine, Jeju, Korea
- Corresponding Author: Department of Anesthesiology and Pain Medicine, Jeju National School of Medicine, Aran 13gil 15, Jeju-si 63241, Jeju Special Self-Governing Province, Korea. Tel: +82-647172025, E-mail:
| | - Ji Min Han
- Jeju National School of Medicine, Jeju, Korea
| | - Keumo Lee
- Jeju National School of Medicine, Jeju, Korea
| | - Woo Jin Cho
- Department of Anesthesiology and Pain Medicine, Jeju National School of Medicine, Jeju, Korea
| | - Ji Hun Oh
- Department of Anesthesiology and Pain Medicine, Jeju National School of Medicine, Jeju, Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National School of Medicine, Jeju, Korea
- Corresponding Author: Department of Anesthesiology and Pain Medicine, Jeju National School of Medicine, Aran 13gil 15, Jeju-si 63241, Jeju Special Self-Governing Province, Korea. Tel: +82-647172025,
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Treatment results for lumbar epidural lipomatosis: Does fat matter? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:69-77. [DOI: 10.1007/s00586-018-5771-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/09/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
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Smith MK, Martin R, Robblee J, Shore EM. A Case of Epidural Lipomatosis in Pregnancy: Management during Labour and Caesarean Section. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1182-1185. [PMID: 30007801 DOI: 10.1016/j.jogc.2018.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/09/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal epidural lipomatosis (SEL) is a rare condition of adipose tissue accumulation in the epidural space. As a result of excess adipose tissue, neuraxial anaesthesia has been reported to behave unpredictably in patients with this condition. CASE A 36-year-old woman had worsening postural headaches during pregnancy. MRI revealed SEL involving the thecal sac between L3/L4 and L5/S1. She had induction of labour but ultimately required a CS for delivery. Her anaesthesia was managed with an epidural inserted at L3/4. She developed a high block with relative sacral sparing. CONCLUSION Although neuraxial anaesthesia was thought to be contraindicated in patients with SEL, it can be done safely. Care must be taken to provide slow epidural titration to avoid high sensory block in patients with this condition.
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Affiliation(s)
| | - Rachel Martin
- Department of Anaesthesia, St. Michael's Hospital, Toronto, ON; Department of Anaesthesia, University of Toronto, Toronto, ON
| | - Jennifer Robblee
- Department of Neurology, Toronto Western Hospital, Toronto, ON; Department of Neurology, University of Toronto, Toronto, ON
| | - Eliane M Shore
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.
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Abstract
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.
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TO THE EDITOR. Spine (Phila Pa 1976) 2017; 42:E1212. [PMID: 28767634 DOI: 10.1097/brs.0000000000002366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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