Spinal epidural lipomatosis in korean

Could Spinal Epidural Lipomatosis Be the Hallmark of Metabolic Syndrome on the Spine? A Literature Review with Emphasis on Etiology

Spinal epidural lipomatosis is defined by an excessive amount of epidural fat in the spinal canal, usually in the lumbosacral tract: a well-known cause of lumbar pain and spinal stenosis with a possible wide range of neurological symptoms. Recent research data reveal that, nowadays, obesity has become the main cause of spinal epidural lipomatosis. Moreover, this condition was recently recognized as a previously unknown manifestation of metabolic syndrome. Radiological studies (CT and MRI) are the only tools that are able to diagnose the disease non-invasively. Indeed, radiologists play a key role in disease recognition, with subsequent possible implications on patients' systemic health assessments. Despite its clinical importance, the condition is still underreported and neglected. The current literature review summarizes all the main etiologies of spinal epidural lipomatosis, particularly regarding its linkage with metabolic syndrome. An overview of disease characteristics from diagnosis to treatment strategies is also provided.

Percutaneous full-endoscopic uniportal decompression for the treatment of symptomatic idiopathic lumbar spinal epidural lipomatosis: Technical note

Background

Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue within the spinal canal, compressing the dura sac and/or nerve roots. When conservative treatments fail and clinical symptoms progress quickly and seriously, surgical decompression should be considered. With the rapid development of endoscopic armamentaria and techniques, the pathological scope that can be treated by percutaneous endoscopic spine surgery is ever expanding.

Objective

In this paper, the authors describe a patient with lumbar spinal epidural lipomatosis who was treated with a percutaneous full-endoscopic uniportal decompression surgery successfully. This article aims to validate the feasibility of percutaneous full-endoscopic uniportal decompression for the treatment of symptomatic idiopathic spinal epidural lipomatosis via interlaminar approach.

Methods

We describe a case of a 69-year-old man with a 10-year history of low back pain, intermittent claudication, and bilateral leg neuropathic pain. He was diagnosed with lumbar epidural lipomatosis, which did not respond to conservative therapy. After a comprehensive evaluation, he underwent percutaneous endoscopic spine surgery to remove hyperplastic adipose tissue and decompress nerve roots and dura sac.

Results

The patient was treated with a percutaneous full-endoscopic uniportal decompression surgery successfully. After the procedure, his leg pain decreased and his walking capacity improved. There were no surgery-related complications, such as cerebrospinal fluid leakage, incision infection, etc.

Conclusions

The case with SEL was successfully treated with a percutaneous full-endoscopic uniportal surgery, which has the advantages of excellent presentation of anatomical structures, expanded field of vision, less surgical-related trauma, and bleeding. The key point of the procedure is to release and cut off the bands which divide the epidural space into small rooms filled with excess adipose tissue.

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.

MRI Features and Clinical Significance of Spinal Epidural Lipomatosis: All You Should Know

Spinal epidural lipomatosis (SEL) is defined as the abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. SEL can be asymptomatic or can cause a wide range of symptoms, the most common of which is neurogenic claudication. Several other neurological manifestations may also occur, above all myelopathy and radicular symptoms. The spinal level most frequently involved in patients with SEL is the lumbar one, followed by the thoracic one. Imaging plays a key role in disease assessment. MRI is considered the most effective and sensitive modality for diagnosing and staging SEL. Anyway, also CT scan can diagnose SEL. The diagnosis may be incidental (in mild-moderate disease) or may be taken into account in cases with neurological symptoms (in moderate-severe disease). There are some recognized risk factors for SEL, the most common of which are exogenous steroid use and obesity. Recent studies have found an association between SEL and obesity, hyperlipidemia and liver fat deposition. As a matter of fact, SEL can be considered the spinal hallmark of metabolic syndrome. Risk factors control represents the initial treatment strategy in patients with SEL (e.g. weight loss, steroid therapy suspension). Surgical decompression may be required when conservative treatment fails or when the patient develops acute/severe neurological symptoms.

Lumbar laminotomy and replantation for the treatment of lumbar spinal epidural lipomatosis: A case report

RATIONALE

Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by excessive overgrowth of extradural fat within the lumbar spinal canal. Surgical decompression is commonly performed to treat symptomatic SELs. Fenestration or laminectomy with epidural fat debulking was a routine surgical procedure according to the literature, that may be causing postoperative lumbar instability. In the present study, we presented a brief report of lumbar SEL and introduced another surgical approach.

PATIENT CONCERNS

A 55-year-old man complained of severe low back pain and right leg radicular pain for a year, accompanied by neurogenic intermittent claudication. He received a variety of conservative treatments, including non-steroidal anti-inflammatory drugs, acupuncture, and physical therapy. However, his pain did not diminish. Finally, a posterior epidural mass in the dorsal spine extending from the L3 to L5 level, which caused dural sac compression was found on lumbar magnetic resonance imaging. This mass was homogeneously hyperintense in both T1W1 and T2W1 images, suggestive of epidural fat accumulation.

DIAGNOSES

Lumbar SEL.

INTERVENTIONS

The patient underwent lumbar laminectomy, epidural fat debulking, and spinous process-vertebral plate in situ replantations.

OUTCOMES

The patient presented with complete recovery of radiculopathy and low back pain after surgery. Postoperative magnetic resonance imaging showed that the increased adipose tissue disappeared, and the dural sac compression was relieved. A computed tomography scan revealed the lumbar lamina in situ. He was able to walk normally and remained relatively asymptomatic for 12 months after the operation at the last follow-up visit.

LESSONS

Lumbar laminotomy and replantation provide an ideal option to treat lumbar SEL because it can achieve sufficient and effective decompression, simultaneously reconstruct the anatomy of the spinal canal, and reduce the risk of iatrogenic lumbar instability.

Lumbar cystic epidural lipomatosis with mass effect. Report of an unusual case

We present a rare case of symptomatic cystic lumbar spinal epidural lipomatosis that required surgical treatment via a minimally invasive tubular laminectomy. To our knowledge this is the first pathology confirmed report of compressive cystic lumbar spinal epidural lipomatosis available in literature.

Spinal Epidural Lipomatosis: A Review of Pathogenesis, Characteristics, Clinical Presentation, and Management

STUDY DESIGN

Narrative review of available literature.

OBJECTIVE

To summarize current trends in pathogenesis and management of spinal epidural lipomatosis (SEL) and suggest areas where more research would be of benefit.

METHODS

The available literature relevant to SEL was reviewed. PubMed, Medline, OVID, EMBASE, Cochrane, and Google Scholar were used to review the literature. Institutional review board approval is not applicable for this study.

RESULTS

This article clearly summarizes current trends in the pathogenesis and management of SEL.

CONCLUSIONS

Possible etiologies of SEL include exogenous steroid use, endogenous steroid hormonal disease, obesity, surgery induced, and idiopathic disease. Comorbidities such as acquired immunodeficiency syndrome and Scheuermann's disease have also been implicated in the pathogenesis of SEL. Steroid-induced SEL seems to have a proclivity for the thoracic region of the spine and has a higher incidence of paraplegia when compared with other forms. Several treatment modalities exist for SEL and are dictated by the underlying cause of the disorder. These include weight reduction, cessation of steroid medications, treatment of underlying endocrine abnormalities, and surgical decompression. Conservative treatments generally aim to decrease the thickness of adipose tissue in the epidural space, but the majority of patients tend to undergo surgical decompression to relieve neurologic symptoms. Surgical decompression provides a statistically significant reduction in symptoms, but postoperative mortality is high, influenced primarily by the patient's preoperative comorbidities. Physicians should consider the underlying cause of SEL in a given patient before pursuing specific treatment modalities, but alarm symptoms, such as the development of acute cauda equina syndrome, should likely be treated with urgent surgical decompression.

The Clinical Characteristics of Spinal Epidural Lipomatosis in the Lumbar Spine

Background

Spinal epidural lipomatosis (SEL) is a rare disease, defined as diffuse hypertrophy of unencapsulated adipose tissue causing spinal canal compression and progressive neurologic deficits. However, there are few studies on SEL in Korea.

Objectives

The purpose of this study was to describe the prevalence and clinical characteristics of SEL in Korea.

Methods

Of the 3702 symptomatic patients (1575 males and 2127 females) who underwent lumbar spine magnetic resonance imaging (MRI) at the age of 20 years or older from January 2014 to December 2016, 42 patients (27 males and 15 females) diagnosed with SEL were selected. Medical records and telephone counseling were used to document sex, age, height, weight, clinical symptoms, coexistent spinal disease, accompanying diseases, and alcoholism and smoking status. One radiologist classified the severity of epidural lipomatosis into three grades from I to III according to Borre et al. We obtained four linear measurements at the axial plane parallel based in the narrowest on MRI image.

Results

The incidence of SEL in the lumbar spine was 1.1%, which was 1.71% in men and 0.7% in women. The mean age was 69.4 ± 10.9 years and the mean body mass index (BMI) was 26.4 ± 3.5 kg/m². The most common clinical symptoms were lower back pain and radiating leg pain (26 patients, 61.9%). The level of affected SEL was found to be most prevalent at L5 - S1 (21 patients, 50%). Concomitant diseases were hypertension (26 patients, 61.9%) and diabetes (12 patients, 28.5%). The most common SEL grade was type III (21 patients, 50%), followed by types II (17 patients, 40.4%) and I (4 patients, 9.5%).

Conclusions

Lumbar spine MRI at one hospital showed that the incidence of symptomatic SEL was 1.1%; SEL is common at the L5-S1 level and in male patients, and severity grade is often severe.

Incidence of spinal epidural lipomatosis in patients with spinal stenosis

Inroduction

Spinal Epidural Lipomatosis (SEL) is believed to be a rare disorder. The incidence and prevalence of clinically symptomatic SEL in patients with spinal stenosis has never been reported in the literature. Our study aims to determine the prevalence, incidence, and associated risk factors of SEL in patients with the diagnosis of spinal stenosis.

Methods

This is a retrospective study. We reviewed the charts of 831 patients with the diagnosis of spinal stenosis over a 30 month period. All patients had spinal MRIs. Grading of SEL was performed using the Borré method.

Results

52 patients (21 female and 31 male) had symptomatic moderate and severe SEL. We found a prevalence of 6.26% and an annual incidence of 2.5%. SEL was most commonly seen at L5-S1 level. 27% had received corticosteroids. All SEL patients were overweight and 79% were obese.

Conclusions

SEL is not uncommon in patients with spinal stenosis. SEL should be considered as a possible diagnosis in those with symptoms of spinal stenosis especially in those with associated risk factors.

Scoliosis associated with idiopathic lumbosacral epidural lipomatosis

There are very few reports of spinal epidural lipomatosis (SEL) in association with scoliosis. A 49-year-old man presented with persistent back pain and right hip lump. The lumbar spine X-rays showed scoliosis (Lenke classification 5BN). Lumbar MRI demonstrated circumferential epidural fat deposit from L1 to lower S2 level. There was no obvious etiology of SEL except mild increased body mass index (BMI). The patient was managed with conservative treatment. After 6 months medication (limaprost and ginkgo), his symptoms were relieved.