Spinal cord compression by extradural fat after prolonged corticosteroid therapy

Thoracic spinal angiomyolipoma: case report from an Ethiopian neurosurgical teaching hospital. Illustrative case

BACKGROUND

Angiomyolipoma (AML) of the spine is a rare benign neoplasm (accounting for 0.14%-1.2% of all spine tumors) that is often described along with angiolipoma because of their similarities. They occur almost exclusively in the extradural space, with the thoracic spine being the commonest level.

OBSERVATIONS

The authors present the clinical presentation, diagnosis, and treatment of an extremely rare case of thoracic spine AML in a 47-year-old male patient. The patient underwent laminectomy and gross total resection of the tumor and had an excellent immediate postoperative neurological recovery and long-term functional neurological outcome.

LESSONS

It is always wise to consider rare benign spinal epidural neoplasms such as spinal AMLs in the differential diagnosis of spinal epidural mass, despite metastasis being the commonest epidural tumor with variable modes of treatment, because the management of benign spinal epidural masses such as spine AML is always surgical and associated with an excellent long-term outcome.

Thoracic Spinal Angiolipomas: A Systematic Review

BACKGROUND

 Spinal angiolipomas (SAs) are rare, benign tumors, representing 0.0004 to 1.2% of angiolipomas, usually located at the extradural and posterior thoracic level, with multimetameric extension.

METHODS

 A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The authors searched on PubMed and Scopus databases for published articles with the Mesh term "spinal angiolipoma" and pertinent associations. Language restriction to English papers was applied. The authors also reported three emblematic cases of patients who underwent surgical resection of spindle-shaped (type IA) and dumbbell-shaped (type II) SAs between 2014 and 2020.

RESULTS

 Of the 256 retrieved articles, 33 were included in the meta-analysis. These 33 studies, together with our 3 reported cases, included a total of 60 patients, 36 females (60%) and 24 males (40%), with a mean age of 53.12 ± 12.82 years (range: 12-77 years).T5 was the most represented level (22 patients). Usually, the localization of SA was extradural, with 53 patients suffering from spindle-shaped type IA SA (88.3%) and 7 patients from dumbbell-shaped type II SA (11.6%). Almost all patients underwent laminectomy (78.3%) and presented a full recovery of motor deficits (85%). Gross total removal (GTR) was performed in 93.3% of patients. The mean follow-up was of 22.71 ± 21.45 months (range: 2-80 months). There was no documented recurrence at follow-up magnetic resonance imaging in any of the patients.

CONCLUSIONS

 SAs are rare, benign tumors with a great vascular component that presents a favorable outcome. GTR is the gold standard treatment and usually an adjuvant therapy is not required. Even infiltrative lesions, which are more complex, can be treated successfully with a good prognosis. Dumbbell-shaped SAs must be differentiated from schwannomas and meningiomas, and require different surgical techniques, given the profuse bleeding associated with the attempt of debulking. En block resection is the key to treat these common benign tumors with acceptable blood loss.

Spinal Angiolipomas : Clinical Characteristics, Surgical Strategies and Prognosis

Objective

Angiolipomas are usually found in the subcutaneous tissue of the trunk and limbs. Spinal angiolipomas (SALs) are uncommon and have rarely been reported. We report a series of nine SALs patients who received surgical treatment in our department. To summarize the clinical characteristics of SALs, propose our surgical strategies, and evaluate the effects of the operation.

Methods

This was a retrospective review of nine SALs patients who received surgical treatment from August 2015 to March 2020. Total or subtotal resection was determined by the axial localization (dorsal or ventral) and the extent of intervertebral foramen involvement. The outcomes were assessed based on the modified Japanese Orthopaedic Association (mJOA) scoring system utilized before surgery and at various follow-up points.

Results

Among the nine patients, the mean mJOA score before surgery was 6.6±2.3, compared with 10.1±1.1 at the last follow-up time point (33.4±11.8 months). All patients achieved good outcomes, even in cases of subtotal resection.

Conclusion

Early surgical resection of SALs is recommended, and the specific procedures should be determined by the axial localization (dorsal or ventral) and the extent of intervertebral foramen involvement. Most of the patients had a good prognosis, even in cases of subtotal resection.

Spinal angiolipoma: a report of two cases and review of the literature

Spinal angiolipomas (SALs) are extremely rare benign tumors composed of both mature fatty tissue and anomalous vascular channels. We present two cases of SALs and review the clinical presentation, radiological appearance, pathological aspects, and treatment of this distinct clinicopathological mass. The patients’ neurologic symptoms improved postoperatively and follow-up revealed no signs of tumor recurrence or neurological deficit. SAL should be considered as a differential diagnosis in patients with spinal cord compression. Magnetic resonance imaging is important for detecting and characterizing SALs. The gold standard treatment modality should be total resection.

Volumetric evaluation of lumbar epidural fat distribution in epidural lipomatosis and back pain in patients who are obese: introducing a novel technique (Fat Finder algorithm)

OBJECTIVE

Spinal epidural lipomatosis (EL) represents an excessive deposition of unencapsulated adipose tissue in the spinal canal that can result in chronic back pain in patients who are obese with and without diabetes. We aim to calculate the total volumetric epidural fat on lumbar spine MRI in a predominately obese population and correlate total epidural fat to lower back pain (LBP) and body mass index (BMI).

RESEARCH DESIGN AND METHODS

We developed a program (Fat Finder) to quantify volumetric distribution of epidural fat throughout the lumbar spine. Eleven patients with LBP were imaged using two MRI protocols: parallel axial slices and conventional clinical protocol. The distribution of epidural fat per level was analyzed and normalized to the spinal canal size.

RESULTS

Our sample had an average age of 59.9 years and BMI of 31.57 kg/m². EL subgroup consisted of seven patients. The L2-L5 total fat volume was 3477.6 mm³ (1431.1-5595.9) in the EL group versus 1783.8 mm³ (815.0-2717.5) in the age-similar non-EL group. A higher percentage of fat volume in the canal was associated with higher LBP scores. The fat percentage was 32.2% among patients with EL versus 15.4% for age-similar non-EL with LBP score of 6.1 and 4.0, respectively.

CONCLUSIONS

The Fat Finder is a novel volumetric method to quantify epidural lumbar spinal fat. The epidural fat favors the lower spinal segment with direct proportionality between the fat volume and LBP score, independent of BMI.

Epidural angiolipoma: A rare cause of spinal cord compression

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Spinal epidural angiolipoma is a rare cause of progressive spinal cord compression.

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Magnetic resonance imaging is necessary for diagnosis.

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Total resection is the treatment of choice.

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Necessary precautions before and during surgery have to be taken (embolisation, transfusion).

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Prognosis after surgical management is excellent even at the stage of complete paraplegia.

Introduction

Angiolipomas are benign, slow growing lesions, almost always located subcutaneously in the trunc or limbs. They are composed of mature lipocytes admixed with abnormal blood vessels. Spinal epidural angiolipoma are rare accounting for approximately 0.14–1.2% of all spinal axis tumors and 2–3% of epidural spinal tumors.

Presentation of case

We report the case of a 65 years-old-woman, presenting with complete paraplegia installed since 7 months. Magnetic resonance imaging (MRI) showed an epidural dorsal fatty mass. The patient recovered immediately after surgery. The pathological examination concluded to an angiolipoma.

Discussion

Angiolipoma patients most commonly have long-lasting pain and then develop progressive neurological symptoms secondary to spinal cord compression. The mean duration of symptom progression at diagnosis is 1 year. MRI is the most reliable examination for the diagnosis of spinal angiolipoma. Total resection is the treatment of choice. No adjuvant treatment is indicated.

Since SAL are very haemorrhagic lesions, preoperative embolization is recommended.

Conclusion

We think that spinal cord compression caused by angiolipoma have very good functional prognosis, even if tardily diagnosed

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.

Severity of presentation is associated with time to recovery in spinal epidural lipomatosis

We present a patient with prednisone-induced spinal epidural lipomatosis (SEL) and relatively acute neurologic deterioration followed by rapid recovery after surgical decompression. SEL is a rare disease characterized by hypertrophy of epidural fat, most commonly associated with exogenous steroid use. To our knowledge, an analysis of the dynamics of steroid dose related to time to onset has never been performed, or of patient presentation features with respect to patient outcome. We retrospectively reviewed the literature for English language series and case reports of SEL associated with prednisone use from 1975-2013. Data were compiled for 41 patients regarding the prescribed dose of prednisone and length of treatment, as well as the severity of symptoms on the Ranawat scale, time to onset, time to recovery, and degree of recovery of neurological symptoms. Fisher's exact test and analysis of variance were used for comparing proportions, and p values <0.05 were considered statistically significant. We found that the mean cumulative dose of prednisone trended towards an association with a lack of recovery (p=0.06) and may be related to rate of recovery. Prescribed prednisone dose varied inversely with the time before onset of neurological symptoms, but failed to reach statistical significance. Higher severity of presenting symptoms on the Ranawat scale were found to be associated with a higher likelihood of delayed recovery (p=0.035). Patients with symptoms lower on the Ranawat scale more frequently experienced complete neurologic recovery, though this did not reach significance. The acuity of neurological deterioration was not related to the time to recovery or ultimate degree of recovery. Severity of presentation on the Ranawat scale is associated with rate of recovery and may be related to degree of recovery in SEL patients. Cumulative dose of prednisone may be related to degree and rate of recovery. Prescribed dose of prednisone may be related to time to onset of neurological symptoms. Acuity of neurological deterioration is not related to rate or degree of recovery.

Spinal epidural lipomatosis in lumbar magnetic resonance imaging scans

The goal of this study was to quantify the frequency of advanced spinal epidural lipomatosis (SEL) detected on lumbar magnetic resonance imaging (MRI) scans performed at the authors' hospital and to compare the frequency, cause, and progression of SEL in these cases with that reported in the literature. The total number of MRI examinations of the lumbar spine performed at this hospital over 45 months was 1498 (705 men and 793 women; mean age, 60.3 years). After the MRI data were reduced (T1- and T2-weighted sagittal and axial images) on the basis of the exclusion criteria, the anterior and posterior diameters of the dural sac and spinal canal were measured, as well as the thickness of the epidural fat. On the basis of these parameters, the severity of SEL was classified as grade 0 to grade III. Five cases of grade III SEL were diagnosed. The frequency of grade III SEL noted in this study was 0.33% (5/1498). Obesity (body mass index greater than 27.5) was noted in 3 cases, and the use of exogenous corticosteroids was noted in 3 cases. Exogenous steroid usage associated with advanced SEL in this study was greater than that reported in the literature. Most symptoms of SEL progress slowly, and early diagnosis allows for a dose reduction of the prescribed steroids. Thus, lumbar MRI examinations should be conducted aggressively in patients with exogenous steroid use and presenting with low back pain or buttock pain.

Spinal angiolipoma: etiology, imaging findings, classification, treatment, and prognosis

PURPOSE

To summarise our experience treating patients with spinal angiolipomas (SAs) and to evaluate factors relating to its prognosis.

METHODS

We retrospectively reviewed the records of patients diagnosed with SAs who received surgical treatment from January 2001 to February 2013.

RESULTS

Twenty-one patients were described. We divide SAs into two types: "intraspinal" and "dumbbell-shaped". The former were further subclassified as "with lipomatosis" and "without lipomatosis". Overweight people are more likely to get the "with lipomatosis" type which needs different surgical strategy and/or a diet therapy to get better outcomes.

CONCLUSION

Diagnosis of SAs should be made with reference to clinical, radiological, and pathological findings. Application of different methods is needed to treat SAs.

A rare cause of neural foraminal widening

The differential diagnosis for lesions causing neural foraminal widening is vast. The majority are solitary benign peripheral nerve sheath tumours, such as neurofibromas or schwannomas. We present a case of a rare cause of neural foraminal expansion secondary to a posterior thoracic extradural angiolipoma. We describe the presence of chemical shift artefact on post gadolinium T1-weighted imaging as indirect evidence of a fatty component. This potentially important diagnostic sign may raise the suspicion of angiolipoma, especially in an isointense or hypointense dumbbell lesion on T1-weighted imaging, and has not been described previously in this context. Accurate radiological diagnosis of an angiolipoma is important to reduce unexpected haemorrhagic complications from biopsy or resection of the lesion.

Symptomatic spinal epidural lipomatosis with severe obesity at a young age

Symptomatic spinal epidural lipomatosis is a rare disorder characterized by overgrowth of fat in the extradural space. Most patients have an underlying endocrine disorder, such as Cushing's syndrome, or have taken exogenous steroids chronically. Although less common, obesity alone is thought to be a cause of spinal epidural lipomatosis, representing <25% of reported cases. Patients rarely become symptomatic before middle age without chronic exogenous steroid use. The usual clinical manifestations are similar to degenerative lumbar stenosis with neurogenic claudication, resulting in decreased walking and standing endurance with variable neurological deficits.This article describes 2 unique cases of spinal epidural lipomatosis, both in young patients with underlying morbid obesity who presented with acute progressive leg weakness and urinary retention. The patients had no underlying endocrinopathy, nor any history of exogenous steroid use. They underwent emergency laminectomy and removal of epidural fat, and histopathological examination confirmed the diagnosis of epidural lipomatosis. Postoperatively, the patients demonstrated significant improvement.We conducted a review of the available English literature and compared the age distribution in each group. Based on our review, our 2 patients are considerably younger than those in past reports, especially in the patient group to which the steroid was not administered. In addition, few cases exist of spinal epidural lipomatosis with acute sphincter dysfunction and paraparesis. Our cases suggest that morbid obesity can lead to juvenile spinal epidural lipomatosis with acute neurological changes.

Rapid progression of spinal epidural lipomatosis

Spinal epidural lipomatosis (SEL) is a rare but well-recognized condition. In general, the onset of its symptoms is insidious and the disease progresses slowly. We report two cases of rapid progression of SEL with no history of steroid intake in non-obese individuals after epidural steroid injection. These SEL patients developed neurologic symptoms after less than 5 months; these symptoms were confirmed to be due to SEL by serial MR images. After the debulking of the epidural fat, their symptoms improved.

Dorsal epidural spinal lipomatosis

The authors report a case of a thoracic epidural spinal lipomatosis causing severe neurological deficits along the review of pertinent literature. The patient is a 56-year-old woman who presented with acute onset of severe paraparesis; she was investigated with cervical and thoracic MRI and then surgically managed because of an intraspinal mass compressing the cord. The operation consisted in the excision of the mass confirmed to be a fibrolipoma by pathological analysis. The patient attained complete neurological recovery and at 18 months follow-up she reported a generalised well-being. Thoracic lipomas are rare lesions that presenting mostly with back pain; however, in rare instances they may cause progressive and/or abrupt neurological dysfunction. Appropriate imaging can help in the diagnosis and management of such cases.

Spinal extradural angiolipoma: report of two cases and review of the literature

Spinal angiolipomas are benign uncommon neoplasm composed of mature lipocytes admixed with abnormal blood vessels. They account for only 0.04-1.2% of all spinal tumors. We report two cases of lumbar extradural angiolipoma and review previously reported cases. We found 118 cases of spinal epidural angiolipoma (70 females and 48 males; age range 1.5-85 years, mean 44.03) spanning from 1890 to 2006. Prior to diagnosis 40.6% of the patients had weakness of the lower limbs. The interval between the initial symptoms and tumor diagnosis ranged from 1 day to 17 years (mean 20.2 months). Except for four cases diagnosed at autopsy, 109 patients underwent surgery and gross-total resection was performed in 79 cases (72.4%). Spinal angiolipomas are tumors containing angiomatous and lipomatous tissue, predominantly located in the mid-thoracic region. All angiolipomas show iso- or hyperintensity on T1-weighted images and hyperintensity on T2-weighted images and most lesions enhance with gadolinium administration. The treatment for spinal extradural angiolipomas is total surgical resection and no adjuvant therapy should be administered.

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.

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.

Reducción de las masas periodontoideas tras artrodesis posterior: revisión a propósito de 2 casos no vinculados a artritis reumatoide

Inflamatory periodontoid pannus is quite common in patients with rheumatoid arthritis. However, the occurrence of a pannus-like periodontoid mass that is unassociated with rheumatic inflammation is less frequent. Transoral surgery associated with a posterior stabilization has long been considered one of the most efficient methods to resolve the problem of instability in patients presenting neurological deficits secondary to the pannus. We present two cases of non rheumatic etiology, in which an occipito-cervical arthrodesis was used to resolve the proliferative lesion around the odontoid apophysis. Two women (67 and 60 years old respectively) presented symptoms of pain and neurological deterioration with an antecedent of possible past odontoid fracture in one case, and a previous large anterior cervical arthrodesis to correct spondylarthrosis in the other case. Both patient's neurological condition improved after placement of an arthrodesis through a posterior approach.

Atlantoaxial Instability and Retroodontoid Mass-Two Case Reports-

Two relatively elderly male patients (61 and 78 years) suffered moderately severe trauma to the head 1 and 3 years, respectively, prior to presentation with progressive quadriparesis and neck pain. Investigations revealed retroodontoid ligamentous hypertrophy and subtle mobile atlantoaxial dislocation. Following atlantoaxial fixation, both patients showed remarkable and sustained neurological improvement. These cases provide further evidence that retroodontoid ligamentous hypertrophic mass lesion could be secondary to instability of the atlantoaxial region.

Bilateral lower limb hypoesthesia after radical prostatectomy in the hyperlordotic position under general anesthesia

PURPOSE

To report a case of postoperative bilateral lower limb hypoesthesia occurring after surgery under general anesthesia in the hyperlordotic position for radical prostatectomy. The possible pathophysiologic mechanisms are discussed.

CLINICAL FEATURES

This 52-yr-old patient was slightly overweight and was on fenofibrate for hypercholesterolemia. He had no history of cardiovascular disease. Arterial blood pressure was overall well maintained except for a very transient hypotension at surgical incision. Blood loss was moderate and did not require transfusion. Soon after recovery, the patient complained of paresthesia in both legs and neurological examination revealed bilateral lower limb hypoesthesia, compatible with an incomplete medullar syndrome at the level of T12-L1. On postoperative day one, a plain magnetic resonance imaging scan demonstrated a hyperintense signal in the spinal cord from T8 to T9 on T2-weighted images consistent with ischemia of the spinal cord whereas the heterogeneous aspect of the spinal cord was due to an unusually high fat content of the epidural space. Neurological signs improved progressively and one week later the patient had recovered normal sensory functions of both lower limbs.

CONCLUSION

Although arterial ischemia is the most common cause of postoperative spinal cord injury, other mechanisms may be invoked. We raise the possibility that a combination of intraoperative risk factors (hypotension, excessive postural changes) with anatomic predispositions (increased epidural venous pressure or fat content, previous bone disease) can produce arterial and/or venous ischemia of the spinal cord.

Cauda equina syndrome

Single or double-level compression of the lumbosacral nerve roots located in the dural sac results in a polyradicular symptomatology clinically diagnosed as cauda equina syndrome. The cauda equina nerve roots provide the sensory and motor innervation of most of the lower extremities, the pelvic floor and the sphincters. Therefore, in a fully developed cauda equina syndrome, multiple signs of sensory disorders may appear. These disorders include low-back pain, saddle anesthesia, bilateral sciatica, then motor weakness of the lower extremities or chronic paraplegia and, bladder dysfunction. Multiple etiologies can cause the cauda equina syndrome. Among them, non-neoplastic compressive etiologies such as herniated lumbosacral discs and spinal stenosis and spinal neoplasms play a significant role in the development of the cauda equina syndrome. Non-compressive etiologies of the cauda equina syndrome include ischemic insults, inflammatory conditions, spinal arachnoiditis and other infectious etiologies. The use of canine, porcine and rat models mimicking the cauda equina syndrome enabled discovery of the effects of the compression on nerve root neural and vascular anatomy, the impairment of impulse propagation and the changes of the neurotransmitters in the spinal cord after compression of cauda equina. The involvement of intrinsic spinal cord neurons in the compression-induced cauda equina syndrome includes anterograde, retrograde and transneuronal degeneration in the lumbosacral segments. Prominent changes of NADPH diaphorase exhibiting, Fos-like immunoreactive and heat shock protein HSP72 were detected in the lumbosacral segments in a short-and long-lasting compression of the cauda equina in the dog. Developments in the diagnosis and treatment of patients with back pain, sciatica and with a herniated lumbar disc are mentioned, including many treatment options available.

Thoracic epidural lipomatosis with associated syrinx: case report

A 54-year-old black male with a 15-year history progressive lower extremity weakness was evaluated with a thoracic MRI that revealed epidural lipomatosis extending from T1-T10 with an associated syrinx at T1-3. He was neither overweight nor taking steroids. A multilevel thoracic laminectomy with resection of lipoma was performed without directly addressing the syrinx. Postoperatively, his symptoms improved and an MRI obtained 1 year after surgery demonstrated resolution of the syrinx. This is the only case of epidural lipomatosis with an associated syrinx that we have seen reported in the world literature.

Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections: case report

OBJECTIVE AND IMPORTANCE

Spinal epidural lipomatosis, which causes symptomatic compression of neural elements, is a well known but uncommon complication of Cushing's syndrome. Spinal epidural lipomatosis has been reported frequently in association with chronic systemic corticosteroid therapy, but thus far only one case has been attributed to local epidural corticosteroid injections.

CLINICAL PRESENTATION

We report another case of symptomatic spinal epidural lipomatosis after epidural corticosteroid injections. This is the first such case documented by magnetic resonance imaging and confirmed with surgical exploration.

INTERVENTION

The patient's symptoms of neurogenic claudication resolved after lumbar laminectomy in the region of previous corticosteroid injections and the removal of epidural fat, which was compressing the thecal sac.

CONCLUSION

This case should alert clinicians that epidural lipomatosis, which causes symptomatic thecal sac compression, is a possible complication, not only of systemic glucocorticoid therapy, but also of local epidural corticosteroid injections.

Ninety-degree rotation of the thoracic spinal thecal sac. Case report

This 44-year-old man presented with a 4-year history of progressive spastic weakness of his legs. He was found to have epidural lipomatosis behind the thoracic spinal cord, and the nerve roots exited from the posterior and anterior midline planes of the dura, indicating a 90 degree rotation of the thoracic cord. Magnetic resonance images clearly demonstrated the segmental thoracic nerve roots exiting from the dorsal midline of the dura, a finding confirmed at surgery. The authors found only one previously published case of rotation of the spinal cord. Directed mechanical stress caused by deformation of the rotated spinal cord, rather than compression from adipose tissue, is proposed as the mechanism of the myelopathy. The extent, location, and thickness of the associated extradural adipose tissue is suggestive of epidural lipomatosis. The lipomatous tissue might have been an epiphenomenon and cord rotation an isolated congenital anomaly. Alternatively, asymmetrical growth of epidural fat may have exerted torque, rotating the thecal sac.

Idiopathic spinal epidural lipomatosis

OBJECTIVE

Spinal epidural lipomatosis (SEDL) is a rare disorder often associated with the administration of exogenous steroids or the elevation of endogenous steroids. Spinal epidural lipomatosis develops in some patients in the absence of elevated steroid levels. The limited information known about idiopathic SEDL comes predominantly from isolated case reports. We proposed to study our experience with idiopathic SEDL and to review the literature.

METHODS

We identified eight symptomatic patients with idiopathic SEDL treated at our institution, which is the largest series reported. All patients were male and obese by body mass index (> 27.5 kg/m2). The mean age of the patients was 35.4 years. Idiopathic SEDL was equally distributed between the thoracic and lumbar spine. Six patients underwent laminectomy and fat debulking with good postoperative results; two patients were treated with a weight loss diet, which resulted in the relief of symptoms after losing > 15 kg each.

RESULTS AND CONCLUSION

A review of our patients in conjunction with other reported cases reveals the following: 1) idiopathic SEDL occurs almost exclusively in the obese population; 2) idiopathic SEDL seems to occur with equal frequency between the thoracic and lumber spine; 3) a strong male predominance exists; 4) thoracic SEDL presents at an earlier age compared with lumbar SEDL; 5) surgical decompression remains the treatment of choice for the immediate relief of symptoms. Our experience suggests that idiopathic epidural lipomatosis may be a pathological entity that has been underdiagnosed.

[Epidural lipomatosis: complication of long-term corticotherapy. Apropos of 2 cases]

Spinal epidural lipomatosis (SEL) is defined as the deposition of loose fat tissue in the epidural space. Two cases are reported which illustrate the main features of this uncommon disease. Most frequently SEL is revealed by neurologic manifestations such as an acute chronic spinal cord compression. Corticosteroid therapy and obesity are the main factors able to induce the disease. The common location of the SEL at the thoracic spine is explained by the physiologic abundance of fat and by the relative narrowness of the spinal canal at this level. An osteoporotic vertebral crush fracture which reduces the diameter of the canal frequently reveals the SEL. MRI confirms the diagnosis of SEL and shows the extent in the spinal canal. The treatment of SEL is difficult. The decrease or the stop of corticosteroid therapy has allowed the recovery in a few cases with chronic neurologic symptoms. The risks of a surgical procedure are important in these patients and the medical or surgical treatment should be discussed taking into account the clinical symptoms of SEL, its location and extent, and the risks of recurrence if corticosteroid therapy must go on.

Epidural lipomatosis: case report and literature review

We report a case of symptomatic epidural lipomatosis in a 36-year-old man following a heart lung transplant and 3.5 years of steroid medication. A review of the pertinent literature emphasises the importance of including this diagnosis in the differential diagnosis of patients receiving steroid medication or markedly obese patients with back pain or symptoms suggesting spinal cord or cauda equina compression.

Sudden infant death syndrome and lipoma: the presence of fat tissue in the spinal canal

An epidural lipoma in the spinal canal in a case of Sudden Infant Death Syndrome (SIDS) is described. Histologic sections from ten SIDS cases were compared with five controls. It is concluded that there are no indications that an increased amount of fat in the spinal canal plays a role in the pathogenesis of SIDS.

Idiopathic spinal extradural lipomatosis in a non-obese otherwise healthy man

Spinal extradural lipomatosis is rare and is usually associated with long-term steroid administration or obesity. It is most commonly thoracic in situation. We present a unique case of spinal extradural lipomatosis in a 20-year-old non-obese, clinically normal man. The role of MRI in investigation and the management options are discussed.

Idiopathic and glucocorticoid-induced spinal epidural lipomatosis

Pathological overgrowth of the epidural fat in the spine has been described and reported nearly exclusively in patients either with Cushing's syndrome or on chronic intake of glucocorticoids for a variety of clinical disorders. The authors report four patients with documented spinal lipomatosis (three pathologically and one radiologically). Only one of these patients received corticosteroids, and none had an underlying endocrinological abnormality. All four patients were adult males with a mean age at onset of symptoms of 43 years (range from 18 to 60 years). The symptoms ranged from simple neurogenic claudication and radicular pain to frank myelopathy. Myelography followed by computerized tomography were instrumental in the diagnosis of the first three patients; the fourth was diagnosed by magnetic resonance imaging. The thoracic spine was involved in two cases and the lumbosacral area in the other two. The different treatment modalities were tailored according to the symptomatology of the patients. These included weight reduction of an overweight patient with minimal neurological findings in one case and decompressive laminectomy and fat debulking to achieve adequate cord decompression in the remaining three cases. Two patients improved significantly, the condition of one stabilized, and the fourth required a second decompression at other spinal levels. The various modalities of treatment and their potential complications are discussed.

Pseudotumor of the craniocervical junction during long-term hemodialysis

A systematic study of the upper cervical spine was performed using magnetic resonance imaging in 25 patients (15 men and 10 women) who had been undergoing hemodialysis for more than 10 years. Seven pseudotumors of the periodontoid soft tissue were disclosed, which were similar to the pannus recently described in rheumatoid arthritis. Bone cystic radiolucencies were observed in association with these pseudotumors in 5 patients. The radiolucencies were located in the atlas (1 in the lateral mass and 1 in the anterior branch) and in the axis (3 in the odontoid process and 1 in the vertebral body). No horizontal or vertical atlantoaxial subluxation was demonstrated. These features were observed only in patients who had amyloid arthropathy. They could be a frequent, yet thus far little-recognized, feature of beta 2-microglobulin amyloidosis.

Surgical treatment of lumbar stenosis: long-term results

Lumbar stenosis is a disease of the elderly which is due, in the majority of cases, to degenerative changes. This disease causes considerable disability which cannot be ameliorated well by conservative treatment. Surgery is usually the treatment of choice, although long-term results have been reported in only a few publications. We attempted a reevaluation of our patients one to seven years after intervention. Overall results indicate that about 80% of our patients benefited from surgery in varying degrees. Only 10% showed post-operative deterioration. One third of operated cases achieved complete working or functional capacity, while in the remaining cases disability persisted. Since long-term results are similar in patients over and under 65 years of age, intervention is recommended even in the older patient if his general condition is good enough to allow surgery.

Symptomatic spinal epidural lipomatosis without exogenous steroid intake. Report of a case with magnetic resonance imaging

Epidural lipomatosis may be unassociated with steroid use and should be considered in the differential diagnosis of lumbar radiculopathy. This may cause widening of the spinal canal on plain film and complete block on myelography. CT or MRI is diagnostic.

Epidural hibernoma as a complication of corticosteroid treatment. Case report

Centripetal fat deposition is a well-recognized consequence of excessive use of corticosteroids, either endogenous or exogenous. Recently, several patients receiving large doses of corticosteroids have suffered compressive myelopathies due to excessive epidural fat collections, labeled "epidural lipomatosis." Two of these have been children, and a third child is reported here. This child was receiving chronic steroids for juvenile rheumatoid arthritis when he presented with such a myelopathy, which was confirmed by metrizamide computerized tomography myelography as well as by surgical exploration. Histological examination revealed that the epidural tissue was a brown-fat tumor or "hibernoma." An epidural hibernoma has not been described previously. The histological and endocrine features of fat in Cushing's syndrome are discussed, and the literature concerning hibernoma and epidural lipomatosis is reviewed.

Spinal cord compression by epidural lipomatosis in juvenile rheumatoid arthritis

Two cases of spinal cord compression secondary to steroid-induced epidural lipomatosis in systemic juvenile rheumatoid arthritis (JRA) patients are reported. This complication of prolonged corticosteroid therapy has not been described previously in children with JRA. Epidural lipomatosis should be considered in the differential diagnosis of JRA patients receiving high-dose and/or prolonged corticosteroid therapy who present with neurologic signs and symptoms referable to the spinal cord.

Epidural lipomatosis and renal transplantation

A 34-year-old man presented with progressive myelopathy 4 months after cadaveric renal transplant for endstage renal disease. Radiographic evaluation gave findings consistent with epidural lipomatosis and compression of the thoracic thecal sac. Decompressive laminectomy resulted in dramatic improvement of his neurologic deficit. This case is unusual in the brevity of steroid treatment prior to onset of the myelopathy, as well as the relatively small dose. The 10 previous cases of epidural lipomatosis are also reviewed.

Symptomatic spinal epidural lipomatosis as a complication of steroid immunosuppression in cardiac transplant patients. Report of two cases

Patients with Cushing's syndrome may develop spinal epidural lipomatosis, an abnormal accumulation of fat in the spinal epidural space. This accumulation of fat may cause compression of the spinal cord or cauda equina with resulting neurological deficit. Two cases of symptomatic spinal lipomatosis are reported in cardiac transplant patients receiving chronic corticosteroid treatment. The literature is reviewed, and diagnostic and therapeutic considerations are discussed.

Spinal epidural lipomatosis: report of a case secondary to hypothyroidism and review of literature

Epidural lipomatosis usually occurs as a complication of steroid therapy. This report includes the first description of a case secondary to hypothyroidism. Adults in all age groups can be affected and present with progressive signs and symptoms of spinal cord or cauda equina compression. The dorsal aspect of the thoracic spine is most commonly involved, usually in its total extent. Spine radiographs are normal and myelography poorly delineates the nature and extent of abnormality. While computed tomography can provide information about the nature of the spinal mass, magnetic resonance imaging is the investigation of choice. Extensive decompressive laminectomy is useful but the results are variable. Correction of underlying endocrine abnormality can reverse the process. The need for early diagnosis of this disorder is therefore emphasized.

Extradural spinal angiolipoma

Two cases of extradural spinal angiolipomas are reported. The literature is reviewed and the entity of extradural spinal angiolipoma proposed. A tumor of adulthood, unassociated with bony changes, it occurs mainly in the mid-dorsal spine. Paraparesis progresses over a period of 1-2 years and may wax and wane with pregnancy or body weight changes. Characteristically, the tumor lies over the dorsal aspect of the dura, from which it may be peeled off easily. Its port-wine color contrasts strikingly with the contiguous epidural fat. A benign condition, it responds favorably to surgical excision.