The Clinical Characteristics of Spinal Epidural Lipomatosis in the Lumbar Spine

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

INTRODUCTION

Spinal Epidural Lipomatosis (SEL) is a rare disorder of pathological overgrowth of the spinal epidural fat in the extradural space. The pathogenesis of SEL usually involves exogenous steroid use or endogenous steroids overproduction. However, idiopathic cases have been reported. Magnetic resonance imaging (MRI) is the gold standard for diagnosis. Both conservative and surgical approaches are employed in management of these patients.

CASE PRESENTATION

A 17-year-old male presented to our hospital complaining of progressive lower limb weakness, loss of sensation with urinary incontinence which ended up with paraplegia. He underwent extensive investigations and received multiple inaccurate diagnoses. MRI of the thoracic spine showed spinal epidural lipomatosis with dorsal kyphosis. Hemi-laminectomy for spinal cord decompression and trans-pedicular fixation for correction of kyphosis were performed showing excellent outcomes.

CLINICAL DISCUSSION

Diagnosing SEL can be challenging due to its symptom overlap with other neurological conditions. Thus, higher levels of clinical suspicions and utilization of numerous diagnostic modalities including MRI are required. Treatment is largely determined by the clinical presentation and the severity of symptoms. Given the severity of neurological symptoms in our case, surgical intervention was performed resulting in fully regained functionality of previously paralyzed muscles.

CONCLUSION

This case highlights the rare presentation and the diagnostic challenges of spinal epidural lipomatosis SEL in a young patient who was misdiagnosed for 9 consecutive months before receiving the correct diagnosis, emphasizing the importance of considering SEL in the differential diagnosis for progressive neurological deficits and the importance of MRI, especially in atypical cases.

Role of epidural fat in the local milieu: what we know and what we don't

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.

Outcome of posterior decompression for spinal epidural lipomatosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Clinical research progress of spinal epidural lipomatosis]

Objective

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

Methods

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

Results

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

Conclusion

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

Postpartum Spinal Epidural Lipomatosis With Epidural Venous Engorgement

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

A Rare Cause of Low Back Pain

This is the case of a 60-year-old man with no known medical history who presented with progressively worsening lumbar pain and was found to have idiopathic dorsal epidural lipomatosis. The patient's condition improved significantly with pain management. Therefore, no surgical intervention was warranted at the time, but the patient was advised to keep close follow-up as an outpatient. Being familiar with this potential cause of lumbar pain is vital, as it can lead to severe morbidity if left unrecognized.

Clinical and radiological characteristics of spinal epidural lipomatosis: A retrospective review of 90 consecutive patients

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.

Acute Spinal Cord Injury Due to Epidural Lipomatosis Without Osseous Injury

Spinal epidural lipomatosis (SEL) is a common pathology of the lumbar spine. While the natural history is not well understood, there is a strong association with metabolic syndrome and endocrine dysfunction. Clinical presentation typically involves slow, progressive onset of radicular and myelopathic symptoms. Treatment primarily consists of weight loss, while surgery is reserved for refractory cases or acute cauda equina syndrome. We present a case of acute spinal cord injury (SCI) after trauma with underlying SEL in the cervicothoracic spine. Additionally, a literature review using a MEDLINE search of the English literature through April 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed to identify all documented cases of acute spinal cord injury with underlying SEL. A 72-year-old obese male with insulin-dependent diabetes mellitus presented with subacute bilateral lower extremity weakness after a fall with a flank injury three days prior to evaluation. Within hours of admission, the patient acutely progressed to paraplegia and sensory loss below the T6 level consistent with an ASIA (American Spinal Injury Association) A spinal cord injury. No fracture or dislocation was identified on CT imaging. MRI of the thoracic spine revealed spinal cord compression secondary to extensive posterior epidural lipomatosis with resultant anterior displacement of the thecal sac. The patient underwent emergent T2-T9 laminectomy for decompression. Post-operatively, the patient regained sensation below the level of injury. A review of the literature reviewed no published articles on cases of complete spinal cord injury secondary to underlying SEL without associated fracture. Finally, we present the first report of an acute spinal cord injury in the setting of SEL without fracture. Our case demonstrates that SEL outside the lumbar spine confers increased risk for SCI following trauma. Patients with cervicothoracic SEL may require close neurological observation and timely surgical decompression.

Spinal Epidural Lipomatosis: A Comprehensive Review

Purpose of review

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

Recent Findings

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

Summary

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

Idiopathic Spinal Epidural Lipomatosis: Unusual Presentation and Difficult Management

Epidural lipomatosis (EL) is a pathology characterized by abnormal accumulation of unencapsulated fat in the epidural space. Although rare, it is a possible cause of lumbosciatica or narrow lumbar canal in adults. It is often associated with favorable factors such as prolonged corticosteroid therapy or obesity. We report an observation of an 18-month-old child who presented with walking delay without other abnormalities, and the radiological exploration confirmed the lumbar epidural lipomatosis. The management was mainly symptomatic, based on motor physiotherapy with additional management in neurosurgery. Various etiologies can cause this disease, remain rare in pediatrics, and the idiopathic form is predominant in children.

Epidural lipomatosis in elderly patient: A rare cause of cauda equina compression

Background:

The most common cause of cauda equina compression in the elderly is lumbar spinal stenosis. Epidural lipomatosis is an additional known but rare cause of cauda equina compression readily diagnosed on MR studies. Notably, spinal canal decompression and direct excision of the epidural fat effectively manage this combined pathology.

Case Description:

A 70-year-old male presented with progressive truncal obesity associated with refractory lumbar neurogenic claudication. The lumbar magnetic resonance imaging (MRI) showed excessive epidural fat extending from L4 to S2 resulting in thecal sac compression; this was confirmed on the MRI myelogram study. Following a decompressive laminectomy, the patient’s cauda equina syndrome resolved.

Conclusion:

Recent weight gain with increased neurogenic claudication and the onset of a cauda equina syndrome may herald the presence of significant lumbar epidural lipomatosis. Here, laminectomy for excision of the excessive epidural fat resolved the patient’s symptomatic spinal stenosis.