Idiopathic symptomatic epidural lipomatosis of the lumbar spine

Acute neurologic decline in a patient with spinal stenosis: blame it on the epidural fat

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.

Lumbar Epidural Lipomatosis is Increased in Patients With Morbid Obesity and Subsequently Decreases After Bariatric Surgery

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.

Resolution of Idiopathic Epidural Lipomatosis after Bariatric Surgery: Case Report and Literature Review

Spinal epidural lipomatosis (SEL) is traditionally a rare disorder defined as an abnormal accumulation of unencapsulated epidural fat. SEL can be classified into idiopathic and secondary. We report a 46-year-old obese male with idiopathic epidural lipomatosis with a clinical picture of bilateral L5 and S1 radiculopathy, with an L5 and S1 distribution. Magnetic resonance imaging (MRI) showed epidural lipomatosis at L4, L5, and S1. After 2-year of sleeve gastrectomy, his bilateral sciatic radiculopathy disappeared, and updated MRI showed complete resolution of epidural lipomatosis. We present a case of an unusual epidural lipomatosis, resolved completely by bariatric surgery. This case report set out the effect of metabolic surgery on the local and systemic metabolic process.

[Nonneoplastic lesions of the spinal canal]

Numerous vascular, inflammatory, degenerative and tumorous lesions of the spinal canal can cause paraplegic symptoms. In addition to the neurological examination and the leading symptoms, the first topographical classification of the (suspected) disease is essential for further diagnostics. Hence, high-resolution magnet resonance imaging (MRI) is the gold standard for the majority of questions. To avoid diagnostic and therapeutic mistakes, differentiation of intraspinal tumors from tumor-like (nonneoplastic) lesions is indispensable, which is often only possible after follow-up imaging or surgical exploration.

Clinical and imaging characteristics in patients undergoing surgery for lumbar epidural lipomatosis

Background

Lumbar epidural lipomatosis (LEL) is characterized by abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. Such accumulation compresses the dural sac and nerve roots, and results in various neurological findings. However, the pathophysiology of LEL remains unclear. This study examined the associations between imaging and clinical findings in detail, and investigated the mechanisms underlying symptom onset by measuring intraoperative epidural pressures in LEL.

Methods

Sixteen patients (all men; mean age, 68.8 years) were enrolled between 2011 and 2015. Mean body mass index was 26.5 kg/m². Four cases were steroid-induced, and the remaining 12 cases were idiopathic. All patients presented with neurological deficits in the lower extremities. Cauda equina syndrome (CES) alone was seen in 8 patients, radiculopathy alone in 4, and both radiculopathy and CES (mixed CES) in 4. All patients subsequently underwent laminectomy with epidural lipomatosis resection and were followed-up for more than 1 year. We investigated the clinical course and imaging and measured epidural pressures during surgery.

Results

Subjective symptoms improved within 1 week after surgery. Mean Japanese Orthopaedic Association (JOA) score was 15.2 ± 2.8 before surgery, improving to 25.4 ± 2.5 at 1 year after surgery. On magnetic resonance imaging, all lipomatosis lesions included the L4–5 level. On preoperative computed tomography, saucerization of the laminae was not observed in radiculopathy cases, whereas saucerization of the posterior vertebral body was observed in all radiculopathy or mixed CES cases. Intraoperative epidural pressures were significantly higher than preoperative subarachnoid pressures. The results suggest that high epidural pressure resulting from the proliferation of adipose tissue leads to saucerization of the lumbar spine and subsequent symptoms.

Conclusions

Clinical courses were satisfactory after laminectomy. In LEL, epidural pressure increases and symptoms develop through the abnormal proliferation of adipose tissue. Higher epidural pressures induce saucerization of the laminae and/or posterior vertebral body. Furthermore, the direction of proliferative adipose tissue (i.e., site of saucerization) might be related to the types of neurological symptoms.

Tethered Cord as a Complication of Chronic Cerebral Spinal Fluid Diversion

Introduction

The etiology and treatment of tethered cord syndrome remains controversial, especially in adults. We present an unusual case of tethered cord syndrome with an associated epidural lipomatosis likely due to chronic over shunting of cerebrospinal fluid (CSF).

Methods

A 25-year-old woman had a history of Chiari malformation, hydrocephalus, and a ventriculoperitoneal shunt. She demonstrated progressively worsening gait, which led to a diagnosis of myelopathy and a posterior cervical decompression and fusion was performed. Imaging revealed engorgement of the epidural veins ventral to the spinal cord which was causing cord compression. Magnetic resonance (MR) imaging of the lumbar spine demonstrated a low-lying conus at the level of L2-L3 with an absence of CSF in the lumbar cistern. This was associated with this was a widening of the epidural space with secondary epidural lipomatosis. She underwent a laminectomy of L5 as well as decompression of the inferior aspect of the L4 and superior aspect of the S1 lamina. No free flow of CSF could ever be appreciated as was suggested by postoperative MR imaging. Postoperatively, the patient did well and was discharged in stable condition.

Conclusion

Tethering of the spinal cord, associated with epidural lipomatosis, may be secondary to over-drainage of CSF. Symptoms of back pain and tethered cord phenomenon may warrant surgical intervention.

Patient-reported outcome of surgical treatment for lumbar spinal epidural lipomatosis

BACKGROUND CONTEXT

Spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of fat tissue in the spinal canal that can have a compressive effect, leading to clinical symptoms. This condition has a distinct pathology from spinal stenosis associated with degeneration of the intervertebral discs, ligaments, and facet joints. Several different conservative and surgical treatment strategies have been proposed for SEL, but its treatment remains controversial. There is a lack of evidence documenting the success of surgical decompression in SEL, and no previous studies have reported the postoperative outcome from the patient's perspective.

PURPOSE

The aim of the present study was to evaluate patient-rated outcome after surgical decompression in SEL.

STUDY DESIGN

A retrospective analysis of prospectively collected data was carried out.

PATIENT SAMPLE

A total of 22 patients (19 males; age: 68.2±9.9 years) who had undergone spine surgery for SEL were identified from our local Spine Surgery Outcomes Database, which includes a total of 10,028 spine surgeries recorded between 2005 and 2012. Inclusion criteria were epidural lipomatosis confirmed by preoperative magnetic resonance imaging (MRI) scans and subsequent decompression surgery without spinal fusion.

OUTCOME MEASURES

The Core Outcome Measures Index (COMI) was used to assess patient-rated outcome. The COMI includes the domains pain (separate 0-10 scales for back and leg pain), back-specific function, symptom-specific well-being, general quality of life (QOL), work disability, and social disability.

METHODS

The questionnaires were completed preoperatively and at 3, 12, and 24 months postoperatively. Surgical data were retrieved from the patient charts and from our local Spine Surgery Outcomes Database, which we operate in connection with the International Spine Tango Registry. Differences between pre- and postoperative scores were analyzed using paired t tests and repeated measures analysis of variance.

RESULTS

At 3-months follow-up, the COMI score and scores for leg pain and back pain had improved significantly compared with their preoperative values (p<.005). The mean decrease in COMI score after 3 months was 2.6±2.4 (range: -1.3 to 6.5) points: from 7.5±1.7 (range: 3.5-10) to 4.9±2.5 (range: 0.5-9.6). A total of 11 patients (50%) had an improvement of the COMI of more than the minimal clinically important change (MCIC) score of 2.2 points. The mean decrease in leg pain after 3 months was 2.4±3.5 (-5 to 10) points. Overall, 17 patients (77.3%) reported a reduced leg pain, 12 (54.6%) of whom by at least the MCIC score of 2 points. The significant reductions from baseline in COMI and leg and back pain scores were retained up to 2 years postoperatively (p<.02). The general QOL item of the COMI improved significantly after surgery (p<.0001). Over 80% of the cohort rated their preoperative QOL as bad (n=13) or very bad (n=5), whereas 3 months after surgery, only 7 patients rated their QOL as bad, and one as very bad (36%).

CONCLUSIONS

The present study is the first to demonstrate that surgical decompression is associated with a statistically significant improvement in patient-rated outcome scores in patients with symptomatic SEL, with a clinically relevant change occurring in approximately half of them. Surgical decompression hence represents a reasonable treatment option for SEL, although the reason behind the less good response in some patients needs further investigation.

[Spinal epidural lipomatosis as a rare side effect in steroid-dependent Jo-1 antibody syndrome]

Spinal epidural lipomatosis (SEL) of the thoracic and lumbar spine is a rare entity, which leads to compression of the spinal canal. The exact pathogenesis is still unknown. It most commonly occurs in patients with long-term exogenous or endogenous glucocorticoid excess or morbid obesity but there are also idiopathic forms. The symptoms depend on the severity of the SEL and can manifest as clinically asymptomatic, non-specific back pain, radiculopathy up to spinal cord compression. The diagnosis is usually achieved by magnetic resonance imaging (MRI) of the affected spinal segments. The treatment varies between discontinuation of glucocorticoids, weight reduction up to multisegmental decompressive laminectomy. The following case report presents the findings of SEL in a patient with steroid-dependent Jo-1 antibody syndrome and provides a current literature review on this rare disease.

Idiopathic Spinal Epidural Lipomatosis in the Lumbar Spine

Overgrowth of epidural fat, known as spinal epidural lipomatosis (SEL), can cause symptomatic compression of the spinal cord, conus medullaris, or cauda equina. Suggested predisposing factors such as obesity, steroid use, and diabetes mellitus have been based on a few reported cases, many of which were not surgically confirmed. There is a paucity of epidemiological data in surgically confirmed cases for this disorder. The purpose of this independently reviewed, retrospective, matched cohort analysis was to compare the demographics and incidence of comorbidities of patients who underwent lumbar decompression for SEL vs degenerative stenosis without SEL. Two surgeons' databases were reviewed to identify patients older than 18 years who underwent decompression surgery for magnetic resonance imaging-verified, symptomatic lumbar SEL. A matched control group comprised an equal number of patients with degenerative stenosis (n=14). Demographic data, body mass index, symptom type/duration, comorbidities, complications, treatment history, and associated pathology were collected from medical records. Previously suggested risk factors, such as obesity, endocrinopathy, and epidural steroid injections, were not significantly different between the SEL and control groups. Furthermore, there were no differences in operative times, complications, or blood loss. The only noted difference between the 2 groups was the preoperative duration of symptoms, on average double in patients with SEL. This series represents the largest of its kind reported to date. Because symptom duration was the only difference noted, it is postulated to be the result of lack of awareness of SEL. Future prospective study in a larger group of patients is warranted. [Orthopedics. 2016; 39(3):163-168.].

[Spinal epidural lipomatosis]

Spinal epidural lipomatosis (SEL) is a rare condition affecting the thoracic and lumbar spine, characterized by a hypertrophy and hyperplasia of the rich vascularized fat tissue inside the spinal canal. The etiology of SEL is unknown. A high number of cases are associated with obesity, corticosteroid intake and a dysbalance in adrenocorticotropic hormone (ACTH)-cortisone metabolism. It can be an incidental radiographic finding or present with symptoms, such as low back pain, weakness of the lower limbs, dysesthesia, radiculopathy, claudication or even cauda equina syndrome. The interdisciplinary treatment consists of weight reduction, weaning from corticosteroids and in persisting cases or neurologic alterations in surgical decompression of the spinal canal. The following article presents a current review and a case report of this rare entity.

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.

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.

Decompression of idiopathic symptomatic epidural lipomatosis of the lumbar spine

Epidural lipomatosis has been implicated as a cause or contributor of symptomatic lumbar spinal stenosis. Symptomatic spinal epidural lipomatosis (SEL) of the lumbar spine is a rare disease, often associated with steroid overload. Idiopathic lipomatosis is even much less frequent. Signs and symptoms depend upon the level and degree of nerve root compression. Diagnosis is best based on MRI. Weight reduction can be curative, however, after failure of medical treatment or in severe cases surgical decompression should be performed. A 70-year-old man with both lower limb severe paresthesia and radicular symptoms unrelieved with conservative treatments such as medications and physical therapy was treated by surgical decompression. Obesity, endocrinopathic disease, and chronic steroid therapy were excluded. Interlaminar fenestration, lateral recess decompression and fat debulking were applied at all levels through the L2-S1. After surgery there was a gradual improvement in symptoms. We report a rare case of idiopathic SEL which has shown entire evolvement of lumbar spine with specific increase of radiological and clinical severity from L2-3 to L5-S1 in a non-obese patient.

Thoracic spinal epidural lipomatosis associated with adolescent scoliosis

Although a variety of neural axis abnormalities in association with idiopathic scoliosis have been reported, there are no documented cases of spinal epidural lipomatosis (SEL) in a child with scoliosis. An otherwise healthy, neurologically intact 14-year-old girl presented with spinal deformity. Radiographs confirmed a left thoracic, right lumbar Lenke class 5CN scoliosis. Preoperative magnetic resonance imaging (MRI) demonstrated extensive SEL in the thoracic spine. She underwent posterior spinal fusion with segmental instrumentation using bony anchors that did not violate the spinal canal. Intraoperative spinal cord monitoring and postoperative clinical course were uneventful. SEL should be added to the list of potential abnormalities to be looked for in children with spinal deformities undergoing preoperative MRI of the neural axis.

Idiopathic spinal epidural lipomatosis

We report a rare case of paraparesis caused by thoracic spinal epidural lipomatosis in a female patient who did not have any recognized predisposing factor for this condition.

Decompression of idiopathic lumbar epidural lipomatosis: diagnostic magnetic resonance imaging evaluation and review of the literature

Object

Idiopathic symptomatic spinal epidural lipomatosis (SEL) is a rare condition, and few reports have discussed diagnostic imaging criteria. To evaluate factors relating to its clinical symptoms, correlations between clinical features and the presence of spinal epidural fat were investigated, and the literature concerning idiopathic SEL was reviewed.

Methods

Morphological gradings of epidural fat were evaluated in seven patients with idiopathic SEL by using magnetic resonance (MR) imaging. In addition, body mass index (BMI), the number of involved vertebral levels, grade, and preoperative Japanese Orthopaedic Association (JOA) score were analyzed. Surgery resulted in symptomatic relief, with a mean JOA score recovery rate of 67.4%. Grading of epidural fat tended to display a slight negative correlation with preoperative JOA score, whereas a strong significant positive correlation was found between the number of involved vertebral levels and BMI.

Conclusions

The number of involved vertebral levels and obesity are strongly correlated, whereas severity of dural compression is not always significantly associated with neurological complications. These results indicate that epidural fat of the lumbar spine contributes to neurological deficits. In addition, weight-reduction therapy appears to decrease the number of vertebral levels involved. Magnetic resonance imaging–based grading is helpful for the diagnosis and evaluation of idiopathic lumbar SEL. Moreover, symptoms and neurological findings are important for determining the surgical approach.

Spinal epidural lipomatosis following haploidentical allogeneic bone marrow transplantation for non-Hodgkin lymphoma

OBJECTIVES

Spinal epidural lipomatosis, is a very rare condition, usually seen as an uncommon complication of Cushing's syndrome secondary to chronic steroid therapy leading to increased fat deposits in the epidural space.

CASE REPORT

We report the first documented case of acute symptomatic spinal epidural lipomatosis in a patient with relapsed non-Hodgkin lymphoma. The patient underwent an allogeneic bone marrow transplantation (BMT) and a month of steroid treatment for acute graft vs. host disease (GvHD). He presented with a mild to moderate Cushing's syndrome and minimal obesity. He progressed rapidly to paraparesis, sensory deficit, urinary incontinence and finally respiratory arrest complicated with staphylococcal sepsis.

CONCLUSION

Epidural lipomatosis, with subacute thecal sac compression, is a possible life-threatening complication of relatively short-term systemic glucocorticoid therapy for GvHD in BMT setting.

Spinal epidural lipomatosis: case reports, literature review and meta-analysis

BACKGROUND CONTEXT

Symptomatic spinal epidural lipomatosis (SEL), a rare cause of spinal cord compression, has most often been associated with exogenous steroid use.

PURPOSE

Identify four associations with SEL, correlate the associated groups with level of disease and compare treatment with outcome data in these groups.

STUDY DESIGN/SETTING

Case reports of three patients and analysis of 104 cases from the literature.

PATIENT SAMPLE

Three patients from the senior author's practice.

OUTCOME MEASURES

Not applicable.

METHODS

The authors report three new cases of SEL not associated with steroid use. They review all available English literature and present a table of all 104 reported cases.

RESULTS

The clinical course of three new patients is reported.

CONCLUSIONS

Associated conditions are exogenous steroid use, obesity, endogenous steroid excess, and some remain idiopathic. Although SEL is a rare condition, our review of the literature reveals many more reported cases than previously thought. With increased awareness of this condition and improved imaging techniques, further studies of this disease should be undertaken.

Epidural Steroid Injections in the Treatment of Symptomatic Lumbar Spinal Stenosis Associated with Epidural Lipomatosis

Epidural lipomatosis has been implicated as a cause or contributor of symptomatic lumbar spinal stenosis. Although epidural steroid injections have been very successful for symptomatic treatment of spinal stenosis; their role in treatment of symptomatic stenosis secondary to epidural lipomatosis is unclear. A review literature (MEDLINE, PubMed) found no reports justifying the use of steroids. We present two patients with lumbar epidural lipomatosis causing or contributing to symptomatic spinal stenosis. Both patients presented with unilateral lower limb radicular symptoms unrelieved with conservative measures such as medications and physical therapy. They were treated with a single transforaminal epidural steroid injection at the symptomatic level. Both had 80-85% pain relief. These reports suggest a beneficial role of epidural steroid injections for patients with symptomatic lumbar spinal stenosis caused by or contributing to epidural lipomatosis.

Spinal epidural lipomatosis: a review of its causes and recommendations for treatment

Spinal epidural lipomatosis is most commonly observed in patients receiving long-term exogenous steroid therapy, but can also be seen in patients with endogenous steroid overproduction, obesity, or idiopathic disease. With this condition, there is hypertrophy of the epidural adipose tissue, causing a narrowing of the spinal canal and compression of neural structures. A majority of patients will present with progressive myelopathy, but radicular symptoms are also common. Conservative treatment—weaning from steroids or weight loss—can reverse the hypertrophy of the adipose tissue and relieve the neural compression. If conservative management fails, surgery with decompressive laminectomy is also very successful at improving the patient's neurological symptoms.