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Tardivo V, Scudieri C, Bruzzo M, Lupidi F. Acute neurologic decline in a patient with spinal stenosis: blame it on the epidural fat. Br J Neurosurg 2024; 38:765-770. [PMID: 34319197 DOI: 10.1080/02688697.2021.1958149] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 05/15/2021] [Accepted: 06/30/2021] [Indexed: 10/25/2022]
Abstract
Spinal epidural lipomatosis [SEL] is defined as an excessive accumulation of extradural normal adipose tissue. This condition may be idiopathic or acquired. Surgical decompression is considered the gold standard treatment in patients presenting with progressive neurologic deficit. We report a case of a 69-year-old male patient presented with neurogenic claudication and lower left limb radiculopathy. The magnetic resonance imaging (MRI) revealed a L5-S1 epidural compression sustained by a large epidural plaque whose signal was consistent with adipose tissue. A conservative approach, including weight loss attempt, revealed unsuccessful and the patient presented some months after the diagnosis at the emergency department with acute onset bilateral drop foot, more severe on the right side and urinary disturbances. Microsurgical decompression via L5 laminectomy and partial L4 laminectomy and fatty plaque debulking was performed. The post operative course was uneventful and at the two months post operative follow up the patient reported a significative improvement of the pre operative neurological signs and symptoms and of pain control. SEL deserves attention as an identifiable cause of radiculopathies, typically attributed to spinal stenosis, with a higher incidence than previously reported. Moreover cases of acute onset of cauda equina like syndrome were reported in patent affected by SEL, probably related to a local venous engorgement with stasis and edema. Therefore it should be considered as a possible diagnosis not only in patients complaining of stenosis-type symptoms but also in cases of acute neurological decline with cauda equina like syndrome, especially when provided with a "benign" imaging reading.
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Affiliation(s)
- Valentina Tardivo
- Neurosurgery Unit San Carlo Borromeo Hospital, Milan, Italy
- Neurosurgery Unit, EO Ospedali Galliera, Genova, Italy
| | - Claudia Scudieri
- Neurosurgery Unit, EO Ospedali Galliera, Genova, Italy
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Mattia Bruzzo
- Neurosurgery Unit San Carlo Borromeo Hospital, Milan, Italy
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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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Salna Iv J, Lee J, Maddock E, Espinosa J, Lucerna A. A case of spinal epidural lipomatosis presenting as a stroke mimic. Am J Emerg Med 2023:S0735-6757(23)00355-8. [PMID: 37451969 DOI: 10.1016/j.ajem.2023.07.009] [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: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
Here we present the case of a patient with right upper extremity and right lower extremity weakness of a three-day duration, which triggered a stroke evaluation. Ultimately, the diagnosis of spinal epidural lipomatosis (SEL) was made. Non-stroke diagnoses that present with stroke-like symptoms are referred to in the medical literature as stroke mimics. Such cases present with neurological deficits that imitate acute ischemic stroke. The frequency of such presentations occurs in up to 30% of initially suspected stroke. This case illustrates that SEL can present as a stroke mimic. To our knowledge, this is the first description of a presentation in the medical literature of SEL as a stroke mimic.
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Affiliation(s)
- Jonas Salna Iv
- Department of Emergency Medicine, Jefferson Health NJ, Stratford, NJ, USA; Department of Critical Care, Jefferson Health NJ, Stratford, NJ, USA
| | - James Lee
- Department of Emergency Medicine, Jefferson Health NJ, Stratford, NJ, USA
| | - Eric Maddock
- Department of Emergency Medicine, Jefferson Health NJ, Stratford, NJ, USA
| | - James Espinosa
- Department of Emergency Medicine, Jefferson Health NJ, Stratford, NJ, USA.
| | - Alan Lucerna
- Department of Emergency Medicine, Jefferson Health NJ, Stratford, NJ, USA
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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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Hadidi O, Hijazi H, Pajda R, Bayer T. Spinal epidural lipomatosis and focal posterior longitudinal ligament hypertrophy causing severe cauda equina crowding. BMJ Case Rep 2022; 15:e250112. [PMID: 36180104 PMCID: PMC9528478 DOI: 10.1136/bcr-2022-250112] [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] [Indexed: 11/04/2022] Open
Affiliation(s)
- Omar Hadidi
- Trauma & Orthopaedic Surgery, Midland Regional Hospital Tullamore, Tullamore, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Humayun Hijazi
- Trauma & Orthopaedics, Midland Regional Hospital Tullamore, Tullamore, Ireland
| | - Rafal Pajda
- Trauma & Orthopaedic Surgery, Midland Regional Hospital Tullamore, Tullamore, Ireland
| | - Thomas Bayer
- Trauma & Orthopaedics, Midland Regional Hospital Tullamore, Tullamore, Ireland
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Yu Y, Jiang Y, Xu F, Yuan L, Mao Y, Li C. Percutaneous full-endoscopic uniportal decompression for the treatment of symptomatic idiopathic lumbar spinal epidural lipomatosis: Technical note. Front Surg 2022; 9:894662. [PMID: 36147697 PMCID: PMC9485546 DOI: 10.3389/fsurg.2022.894662] [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] [Received: 03/12/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022] Open
Abstract
Background Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue within the spinal canal, compressing the dura sac and/or nerve roots. When conservative treatments fail and clinical symptoms progress quickly and seriously, surgical decompression should be considered. With the rapid development of endoscopic armamentaria and techniques, the pathological scope that can be treated by percutaneous endoscopic spine surgery is ever expanding. Objective In this paper, the authors describe a patient with lumbar spinal epidural lipomatosis who was treated with a percutaneous full-endoscopic uniportal decompression surgery successfully. This article aims to validate the feasibility of percutaneous full-endoscopic uniportal decompression for the treatment of symptomatic idiopathic spinal epidural lipomatosis via interlaminar approach. Methods We describe a case of a 69-year-old man with a 10-year history of low back pain, intermittent claudication, and bilateral leg neuropathic pain. He was diagnosed with lumbar epidural lipomatosis, which did not respond to conservative therapy. After a comprehensive evaluation, he underwent percutaneous endoscopic spine surgery to remove hyperplastic adipose tissue and decompress nerve roots and dura sac. Results The patient was treated with a percutaneous full-endoscopic uniportal decompression surgery successfully. After the procedure, his leg pain decreased and his walking capacity improved. There were no surgery-related complications, such as cerebrospinal fluid leakage, incision infection, etc. Conclusions The case with SEL was successfully treated with a percutaneous full-endoscopic uniportal surgery, which has the advantages of excellent presentation of anatomical structures, expanded field of vision, less surgical-related trauma, and bleeding. The key point of the procedure is to release and cut off the bands which divide the epidural space into small rooms filled with excess adipose tissue.
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Affiliation(s)
- Yong Yu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Correspondence: Yong Yu
| | - Ye Jiang
- Department of Neurosurgery, Minhang Hospital, Fudan University, Shanghai, China
| | - Fulin Xu
- Department of Neurosurgery, Minhang Hospital, Fudan University, Shanghai, China
| | - Lutao Yuan
- Department of Neurosurgery, Minhang Hospital, Fudan University, Shanghai, China
| | - Yuhang Mao
- Department of Neurosurgery, Minhang Hospital, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
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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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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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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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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: 19] [Impact Index Per Article: 6.3] [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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Zhang B, Yuan H, Hu L, Saad M. Obesity is a risk factor for epidural lipomatosis: a meta-analysis. J Orthop Surg (Hong Kong) 2021; 29:23094990211027391. [PMID: 34323151 DOI: 10.1177/23094990211027391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The purpose of this meta-analysis was to summarize the evidence of associations between obesity factors and spinal epidural lipomatosis (SEL) and to evaluate the strength and validity of these associations. METHODS Electronic databases such as Wiley Online Library, PubMed, Embase, Cochrane Library were searched and manual retrieval of references, the time limit was from the establishment of the database to May 2020. Methodological quality evaluations of the included studies were assessed using the bias risk assessment tool recommended by the Cochrane Guidelines. The RevMan 5.3 software was used for meta-analysis. RESULTS Finally, seven studies were included for meta-analysis, all of which were observational studies with mixed bias risk. These studies involved 807 patients, with an average age of 64 to 73.6 years, and 59.4 percent of the participants were male. The sample sizes for the included studies ranged from 28 to 288. The results of meta-analysis showed that high body mass index (BMI) was one of the factors affecting SEL (P < 0.01, MD 1.37, 95% CI [0.81, 1.92]). All reviews had a high risk of bias, and the most common source of bias was that there was no strict unified case diagnosis standard between researches, and some studies (four items) did not clearly describe the confounders that they controlled. CONCLUSIONS We suggest that physicians should consider high BMI as a factor leading to SEL, and to control body weight actively should be considered as the preferred treatment strategy before surgical intervention is conducted.
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Affiliation(s)
- Bi Zhang
- Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China.,Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Haifeng Yuan
- Department of Spine Orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China
| | - Lihong Hu
- Department of Spine Orthopedics, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China
| | - Muhammad Saad
- Ningxia Medical University, Yinchuan, Ningxia, People's Republic of China
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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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Han X, Xu D, Ren Z, Chen X, Li Z, Li S. Lumbar spinal stenosis combined with obesity-induced idiopathic spinal epidural lipomatosis treated with posterior lumbar fusion: case report. BMC Surg 2021; 21:215. [PMID: 33902529 PMCID: PMC8077912 DOI: 10.1186/s12893-021-01157-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 03/15/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Spinal epidural lipomatosis is a rare cause of lumbar spinal stenosis. While conservative therapy is applicable for most of cases, surgical intervention is necessary for severe ones. This is the first time we apply this modified technique to this disease. CASE PRESENTATION The case is a 53-year-old man. He is 175 cm tall and weighs 102 kg (body mass index 33.3 kg/cm2), presenting with low back pain and bilateral legs pain and numbness. Radiological examination showed severe lumbar spinal stenosis resulting from adipose hyperplasia, combined with hyperosteogeny and hypertrophy of ligaments, which are common etiological factors. Posterior decompression, internal fixation and a modified articular fusion technique was performed on this patient, and regular follow-up that up o 22 months showed outstanding clinical outcomes. CONCLUSIONS A suitable style of posterior lumbar fusion should be considered to especially severe case with lumbar spinal stenosis and idiopathic spinal epidural lipomatosis.
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Affiliation(s)
- Xiao Han
- Department of Orthopaedics, Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking UnionDongcheng District Shuaifuyuan No. 1, Beijing, 100730, China
| | - Derong Xu
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - ZhiNan Ren
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Chen
- Department of Orthopaedics, Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking UnionDongcheng District Shuaifuyuan No. 1, Beijing, 100730, China
| | - Zheng Li
- Department of Orthopaedics, Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking UnionDongcheng District Shuaifuyuan No. 1, Beijing, 100730, China.
| | - Shugang Li
- Department of Orthopaedics, Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking UnionDongcheng District Shuaifuyuan No. 1, Beijing, 100730, China.
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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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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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Youn MS, Woo YH, Shin JK. Rapid progression of spinal epidural lipomatosis after percutaneous endoscopic spine surgery mimicking disc herniation. Int J Surg Case Rep 2020; 73:1-4. [PMID: 32622184 PMCID: PMC7334442 DOI: 10.1016/j.ijscr.2020.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 01/01/2023] Open
Abstract
Spinal epidural lipomatosis can occur and progress rapidly after endoscopic spine surgery. As in our case, focally progressed SEL anterior to the dural sac could be misdiagnosed for disc herniation. SEL should be recognized as a rare complication of endoscopic spine surgery.
Introduction Spinal epidural lipomatosis (SEL) is well known but uncommon complication of endoscopic spine surgery. Here, we present a case of SEL that progressed focally and rapidly after endoscopic spinal surgery. Presentation of case A 67-year-old man presented with back and Lt. leg radiating pain. MRI of the lumbar spine demonstrated severe foraminal stenosis at Lt. L4/5/S1. He underwent endoscopic posterior foraminotomy at Lt. L4/5/S1. After surgery, his leg pain disappeared. A month after surgery, the patient developed Lt. leg pain again. MR images showed focally progressed epidural fat posterior to the L5 body. After removal of lipomatosis via endoscopic posterior decompression at L3/4/5, his symptoms improved. Discussion Mostly, the epidural fat accumulates insidiously, and distributes widely across several levels. And the increased accumulation of fat is predominantly posterior and posterolateral within the spinal canal. As in this case, focally progressed SEL anterior to the dural sac is rare. And focally progressed SEL can be misdiagnosed for disc herniation. Conclusion SEL should be recognized as a rare complication of endoscopic spine surgery.
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Affiliation(s)
- Myung Soo Youn
- Department of Orthopaedic Surgery, Busan Keun Hospital, 494 Gayadae-ro, Jin-gu, Busan, 47324, South Korea
| | - Young Ha Woo
- Department of Orthopaedic Surgery, Busan Keun Hospital, 494 Gayadae-ro, Jin-gu, Busan, 47324, South Korea
| | - Jong Ki Shin
- Department of Orthopaedic Surgery, Dongeui Medical Center, 62 Yangjung-ro, Jin-gu, Busan, 47227, South Korea.
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Facet Arthrosis and Spinal Lipomatosis-Related Spinal Canal Stenosis. J Orthop Sports Phys Ther 2020; 50:345. [PMID: 32476581 DOI: 10.2519/jospt.2020.9059] [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] [Indexed: 02/07/2023]
Abstract
A 33-year-old man was referred to physical therapy by his primary care physician for low back pain that had been present for 7 months. The neurologic screen with mixed upper and lower motor neuron signs was of concern for spinal cord involvement. The primary care physician was contacted and magnetic resonance imaging ordered. Facet arthrosis and epidural lipomatosis were present, resulting in thoracic and lumbar spinal stenosis. J Orthop Sports Phys Ther 2020;50(6):345. doi:10.2519/jospt.2020.9059.
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Lotan I, Charlson RW, Fatterpekar GM, Shapiro M, Smith ML, William C, Kister I. Progressive myelopathy associated with spinal epidural lipomatosis in three non-obese patients with type 1 diabetes mellitus. J Neurol Sci 2020; 411:116688. [PMID: 31972349 DOI: 10.1016/j.jns.2020.116688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/07/2020] [Accepted: 01/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Spinal epidural lipomatosis (SEL) is a rare condition defined as pathological overgrowth of the normally present epidural fat within the spinal canal. SEL is associated with Cushing disease, obesity and chronic corticosteroid therapy. Diabetes mellitus type 1 (DM1) has not known to be a risk factor for SEL. The neurological symptoms of SEL are attributed mainly to mechanical compression on the spinal cord and the cauda equina. METHODS A retrospective chart review of patients evaluated at NYU Multiple Sclerosis Care Center identified three diabetic patients with progressive myelopathy associated with SEL. We report the clinical course, diagnostic workup and outcomes in these three patients with SEL-associated myelopathy. RESULTS Three patients (2 females and 1 male) had long-standing DM1 and developed progressive myelopathy in their early 40's. All were found to have thoracic SEL (extensive extradural T1, T2 hyperintense signal; biopsy confirmed in one case) with associated extensive abnormal cord signal in lower cervical/upper thoracic spinal cord. A comprehensive evaluation for metabolic, infectious, autoimmune and vascular causes of myelopathy that included serologies, cerebrospinal fluid analyses, and spinal angiography did not reveal an alternative cause for myelopathy. One of the patients underwent a surgical decompression of SEL with subsequent clinical and radiologic improvement. CONCLUSIONS Our case series suggest that patients with DM1 and myelopathy of unknown cause should be evaluated for SEL. Timely diagnosis and appropriate intervention may forestall progression of neurological disability and even result in neurologic improvement. SEL should be considered on the short list of diagnoses that cause potentially reversible progressive myelopathy.
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Affiliation(s)
- Itay Lotan
- Department of Neurology, Multiple Sclerosis Comprehensive Care Center, NYU Langone Medical Center, New York, NY, United States of America; Department of Neurology, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Robert W Charlson
- Department of Neurology, Multiple Sclerosis Comprehensive Care Center, NYU Langone Medical Center, New York, NY, United States of America
| | - Girish M Fatterpekar
- Department of Radiology, NYU Langone Medical Center, New York, NY, United States of America
| | - Maksim Shapiro
- Department of Radiology, Neurointerventional Radiology Section, NYU School of Medicine, New York, NY, United States of America
| | - Michael L Smith
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, United States of America
| | - Christopher William
- Department of Pathology, New York University School of Medicine, New York, NY, United States of America
| | - Ilya Kister
- Department of Neurology, Multiple Sclerosis Comprehensive Care Center, NYU Langone Medical Center, New York, NY, United States of America
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