Idiopathic spinal epidural lipomatosis

Progressive myelopathy associated with spinal epidural lipomatosis in three non-obese patients with type 1 diabetes mellitus

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.

Spinal cord compression secondary to idiopathic thoracic epidural lipomatosis in an adolescent: A case report and review of literature

INTRODUCTION

Spinal epidural lipomatosis (SEL) is a rare condition that presents with progressive spinal cord or nerve root compression. It is commonly reported in patients receiving long-term exogenous steroid therapy or in patients with endogenous steroid overproduction. The occurrence of this condition as an idiopathic entity is rarely reported.

CASE PRESENTATION

The authors present the clinical course and outcome of a 16-year-old male student, who presented with progressive spastic paraparesis of a one-year duration caused by idiopathic spinal epidural lipomatosis. Magnetic resonance imaging (MRI) study of the thoracic spine revealed marked compression of the spinal cord from a large dorsally located extradural mass extending from the T-4 to T-12 vertebral bodies. The patient underwent posterior thoracic laminoplasty from the T4 to T10 vertebral levels. He experienced gradual neurological, and he was able to walk without assistant by the end of 3-month follow-up period from surgery.

CONCLUSION

Idiopathic SEL is very rare, since no predisposing factors can be identified, and should be included in the differential diagnosis when patients present with spinal neurological compromise. MRI is the imaging modality of choice, and decompressive laminectomy and debulking of the fatty lesion is the main treatment modality in patients with progressive course of the disease..

Idiopathic thoracic epidural lipomatosis with chest pain

Spinal epidural lipomatosis (SEL) is an overgrowth of the normally encapsulated adipose tissue in the epidural space around the spinal cord in the thoracic and lumbar spine causing compression of the neural components. Idiopathic SEL in non-obese patients is exceptional. Idiopathic SEL can result in thoracic myelopathy and lumbar radiculopathy. A thoracic radiculopathy due to idiopathic SEL has not been reported yet. We report a case of idiopathic SEL with intractable chest pain and paresthesia. We suggest that idiopathic SEL should be considered as a cause of chest pain.

Nondysraphic cervical and thoracic intraspinal lipomas: a review

BACKGROUND

Intraspinal lipomas are commonly seen in the lumbosacral area. A cervical and thoracic location is very rarely encountered. Management of these lesions is still controversial.

METHOD

We report a series of 8 such patients, who were surgically managed at our institute.

FINDINGS

All the patients were adults (mean age-34 years). Subcutaneous lipomas were seen in two patients. None of the 8 patients were obese. Mean duration of symptoms was 484 days. The Nurick's grade at the time of presentation ranged from 3 to 5. All 8 patients underwent partial decompression. Only 1 patient required repeat surgery after 11 years. All the patients reported improvement or stabilization of symptoms at follow-up (mean 56.3 months). The Nurick's grading at the time of follow-up ranged from 1 to 4.

CONCLUSION

A cervical or thoracic location is extremely rare among intraspinal lipomas. Patients usually present with a long duration of symptoms. Complete excision is extremely difficult and likely to be detrimental. Partial decompression usually leads to good improvement.

Lumbar nerve root compression due to extradural, intraforaminal lipoma. An underdiagnosed entity?

Intraspinal extradural lipomas, not associated with spinal dysraphism, are rare lesions. True adult lipomas have to be distinguished from angiolipomas and from epidural lipomatosis. The authors report a unique case of a patient with unilateral lumbar nerve root compression caused by extradural, intraforaminal, true adult lipoma. A 62-year-old woman suffered severe left L-5 radiculopathy that progressively worsened during the 12 months prior to presentation. She did not experience improvement with conservative therapy. An MR imaging study of the lumbar spine revealed shifting of the left L-5 nerve root caused by a small extradural intrarecessal (that is, the beginning of the intravertebral foramen)/intraforaminal mass with MR imaging characteristics of fatty tissue. No other relevant intraspinal pathology could be identified. A left L4-5 fenestration was carried out. A small fatty intrarecessal/intraforaminal mass compressing severely the left L-5 root was identified and completely resected. The histological examination revealed a lipoma. The patient recovered completely and is fully mobile and symptom free 1 year after the operation. Intraspinal lipomas should be considered in cases of radiculopathy, especially in the absence of relevant degenerative or tumorous pathology and in the presence of nerve root shifting caused by fatty tissue.

Does abdominal obesity cause increase in the amount of epidural fat?

It is known that epidural fat does not alter in obese people. This study aims to find out a possible relationship with epidural fat and abdominal obesity. In this cross-sectional study, 63 patients who were referred to our clinic for lumbar magnetic resonance imaging (MRI) examination were evaluated. Patients with the history of steroid treatment, thyroid disease or Cushing disease were excluded. Waist circumferences (WC), body weight and height were measured and subsequently body-mass index (BMI) was calculated (kg/m(2)). On midsagittal T1-weighted images, anterior epidural fat (AEF), posterior epidural fat (PEF) and posterior subcutaneous fat (SCF) thicknesses were measured at the S1 level. The results were compared with age, gender, body weight, height, WC and BMI. There were 31 men and 32 women, age ranged 19-77 years (mean 49). The mean BMI was 29.25 kg/m(2) (20.7-52.7); the mean WC was 97.4 +/- 13.2 cm (72-122) in women and 97.6 +/- 9.8 cm (72-118) in men. Cutoff value of WC was considered as 88 cm for women and 95 cm for men. BMI > 27.5 was considered to be obese. No statistical difference with respect to epidural fat thickness between genders was determined in AEF and PEF (P = 0.237, P = 0.616). SCF was significantly thicker in women (P = 0.021). A very poor and negative correlation was found between age and PEF (r = 0.373, P = 0.003), and a very poor and positive correlation between weight and PEF was found (r = 396, P = 0.001). The thickness of the epidural fat was not differ between obese and nonobese people (p = 0.571 for AEF and p = 0.307 for PEF). The thickness of the epidural fat was not different in people whose WC was greater than normal values in both gender (p > 0.05). Epidural fat is not affected by age, gender, BMI and WC which means that epidural fatty layer. A clear correlation has not been found between epidural fat amount and obesity or abnormal fat distribution yet.

Paget disease of the spine manifested by thoracic and lumbar epidural lipomatosis: magnetic resonance imaging findings

OBJECTIVE

To describe the magnetic resonance imaging (MRI) findings of thoracic and lumbar epidural lipomatosis associated with Paget disease of the spine.

SUMMARY OF BACKGROUND DATA

A 60-year-old male presented with progressive weakness of both limbs and dorsalgia and subsequently developed paraparesis.

METHODS

MRI of the thoracic and lumbar spine were undertaken and urgent decompression laminectomy followed.

RESULTS

MRI of the thoracic spine disclosed abnormal tissue extending posteriorly in the epidural space displacing the spinal cord. The lesion had intermediate to high signal intensity on T1 weighted images and intermediate signal intensity on T2 weighted images. MRI of the lumbar spine revealed abnormal tissue in the extradural space with the same MRI characteristics as seen in the thoracic spine. There was also abnormal signal intensity of the thoracic and lumbar vertebrae at the same levels where the abnormal epidural tissue existed. Abundant infiltrated epidural adipose tissue was removed during urgent decompression laminectomy of the thoracic spine and pathology diagnosed epidural lipomatosis. Histology of the bony elements of the specimen was consistent with Paget disease. Postoperative MRI showed resolution of the epidural mass of the thoracic spine and the patient was discharged 6 weeks after the surgery. Six months later the patient experienced progressively aggravated lumbar pain and sciatica. A follow-up MRI of the lumbar spine showed an increase in the amount of the epidural adipose tissue at this level and more pronounced fatty deposition of the involved lumbar vertebrae. Findings were consistent with progression of Paget disease and lumbar epidural lipomatosis and patient was treated with zoledronic acid. His neurologic function returned to normal within 3 weeks. He is free from symptoms on 5 months follow-up.

CONCLUSION

Paget disease of the spine may rarely be complicated by spinal epidural lipomatosis and may be considered in patients with paraparesis and symptoms of spinal stenosis.