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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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Alnabwani D, Ganta N, Babayev R, Patel V, Shah V, Cheriyath P. Chronic Steroid Use Causing Spinal Epidural Lipomatosis. Cureus 2022; 14:e21945. [PMID: 35273886 PMCID: PMC8901088 DOI: 10.7759/cureus.21945] [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: 02/05/2022] [Indexed: 11/18/2022] Open
Abstract
Chronic steroid use causes aberrant fat deposition in the epidural space, which may in rare cases result in spinal epidural lipomatosis (SEL). We discuss the case of a 79-year-old female who had been on steroids for a long time, initially for polymyalgia rheumatica (PMR), then for adrenal insufficiency. Her dose was raised with a few steroid stress doses to control the flare of adrenal insufficiency. The patient presented with complaints of intractable lumbosacral pain and was subsequently diagnosed with SEL and foraminal and spinal canal stenosis based on magnetic resonance imaging of the lumbar spine. She successfully underwent laminectomy.
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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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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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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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