Spinal epidural lipomatosis.
ABSTRACT Epidural lipomatosis is an uncommon disorder defined as a pathologic overgrowth of normal epidural fat. It is most often associated with administration of exogenous steroids of variable duration and dose. However, it can occur in the absence of exposure to steroids. We report two cases of spinal epidural lipomatosis following more than 20 years of steroid use due to asthma. Pathologic compression fracture due to osteoporosis and acute cord compression syndrome were found in these 2 cases. After emergent decompressive laminectomy and fusion surgery, neurological function recovered. From a review of literature, most patients received decompressive laminectomy surgery. But in our additional cases, we performed decompressive laminectomy and fusion surgery which might prevent further spinal deformity and improve the spinal stability, then patients' symptoms subsided completely. Therefore, decompression surgery and fusion surgery may be necessary in patients with symptomatic spinal epidural lipomatosis with compression fracture.
- SourceAvailable from: Arash YavariClinical Radiology Extra 01/2005; 60(2):23-26.
ceiv ing chronic ste roid treat ment for a va ri ety of med i -
cal prob lems and can pres ent as non spe cific back pain,
radiculopathy or frank spi nal cord com pres sion. Di ag -
no sis is gen er ally made us ing com puted to mog ra phy
and MRI find ings.1-3 Treat ment in cludes muti- level
decompressive laminectomy and weight loss ther apy.,5
We re port two cases of spi nal epidural lipomatosis. The
lit er a ture was re viewed re gard ing pre sen ta tion, eval u a -
tion and treat ment of this con di tion.
pi nal epidural lipomatosis (SEL) is an un com mon
dis or der. It is most fre quently seen in pa tients re -
Case Re ports
A 54-year-old male was sent to our emer gency
unit due to pro gres sive weak ness of the lower legs for
4 days. He had asthma since he was a child which was
reg u larly con trolled by ste roid in ha la tion and
bronchodilator. Phys i cal ex am i na tion re vealed cen -
tral obe sity and buffle hump. The bi lat eral lower legs
mus cle power was about grade 2-3 and DTR was in -
creased. There was paresthesia be low T6 level. Plain
x-ray re vealed T5/T6 com pres sion frac ture and os teo -
po ro sis. (Fig. 1) MRI re vealed T5 com pres sion frac -
ture with a long-shaped epidural le sion from T5 to T9
with cord com pres sion, which showed high sig nal on
T1WI (Fig. 2). Epidural lipomatosis with cord com -
pres sion was di ag nosed. Then, emer gent decom -
pressive laminectomy from T3 to T8 and in ter nal fix a -
tion with fu sion were per formed from T3 to T8. Af ter
the op er a tion, mus cle power re cov ered and the pa tient
could walk. He was dis charged with out any neu ro log -
i cal def i cits.
Chi nese Med i cal Jour nal (Tai pei) 2002;65:86-89
Case Re port
Spi nal Epidural Lipomatosis
De part ment of Neu ro sur gery, China
Med i cal Col lege Hos pi tal, Taichung,
Tai wan, R.O.C.
fu sion sur gery;
spi nal epidural lipomatosis;
Epidural lipomatosis is an un com mon dis or der de fined as a patho logic
over growth of nor mal epidural fat. It is most of ten as so ci ated with ad min -
is tra tion of ex og e nous ste roids of vari able du ra tion and dose. How ever, it
can oc cur in the ab sence of ex po sure to ste roids. We re port two cases of
spi nal epidural lipomatosis fol low ing more than 20 years of ste roid use
due to asthma. Patho logic com pres sion frac ture due to os teo po ro sis and
acute cord com pres sion syn drome were found in these 2 cases. Af ter
emer gent decompressive laminectomy and fu sion sur gery, neu ro log i cal
func tion re cov ered. From a re view of lit er a ture, most pa tients re ceived
decompressive laminectomy sur gery. But in our ad di tional cases, we per -
formed decompressive laminectomy and fu sion sur gery which might pre -
vent fur ther spi nal de for mity and im prove the spi nal sta bil ity, then pa -
tients’ symp toms sub sided com pletely. There fore, de com pres sion sur gery
and fu sion sur gery may be nec es sary in pa tients with symp tom atic spi nal
epidural lipomatosis with com pres sion frac ture.
[Chin Med J (Tai pei) 2002;65:86-89]
Re ceived: January 5, 2001. Ac cepted: October 30, 2001.
Cor re spon dence to: Chun-Chung Chen, MD, De part ment of Neu ro sur gery, China Med i cal Col lege Hos pi tal, 2, Yuh-Der Road,
Taichung 407, Tai wan. Fax: +886-4-202-9083; E-mail: email@example.com
A 69-year-old male pa tient was sent to our emer -
gency unit due to pro gres sive weak ness of lower legs
for one week on July 19, 2000. He had a past his tory
of asthma which was reg u larly con trolled by ste roids
and bronchodilator. Be fore ad mis sion, he had suf fered
from chronic lower back pain and claudication for 2
years. The phys i cal ex am i na tion re vealed cen tral obe -
sity. Mus cle power of bi lat eral legs was about grade 3.
DTR was in creased. Plain x-ray re vealed com pres sion
frac ture over L1 and T9. There was sen sory im pair -
ment be low T10 level. Emer gent MRI re vealed an
epidural le sion from T6-T8 with cord com pres sion.
The le sion showed high sig nal on T1WI (Fig. 3).
Epidural lipomatosis was di ag nosed and emer gent
decompressive laminectomy from T5 to T8 and in ter -
nal fix a tion with fu sion were per formed from T6 to
T11. Af ter the op er a tion, mus cle power re cov ered and
there were no more neu ro logic def i cits.
Dis cus sion
The de po si tion of fat is a com mon fea ture of en -
dog e nous or ex og e nous hypercorticosteroidism and is
part of Cush ing’s syn drome.2 While truncal obe sity is
fre quent, epidural fat de po si tion with symp tom atic
spi nal cord com pres sion is rare; it has been de scribed
in pa tients treated with corticosteroids and in mark -
edly obese pa tients.
The epidural fat seems to re late with ste roids, as
does the fat of the head, neck and trunk in Cush ing’s
syn drome, but its oc cur rence is un pre dict able and is
not cor re spon dent with the dos age or du ra tion of ste -
roid use. From a re view of the lit er a ture, male gen der
Feb ru ary 2002
Spi nal Epidural Lipomatosis 87
Fig. 1. Plain x-ray of tho racic spine re vealed on T5-T6
com pres sion frac ture.
Fig. 2. MR im age of T1WI (A) and T2W2 (B) re vealed epidural lipomatosis from T5 to T9.
and obe sity seem to pre dis pose to epidural lipoma -
tosis3,6. The ma jor ity of pa tients re ceived ei ther high
daily doses of more than 30 mg, or lower doses over a
long time (more than 4 years). So, the oc cur rence of
epidural lipomatosis is multifactorial.
Back pain and weak ness are the most fre quent
pre sent ing com plaint in 64 to 88% of pa tients,whereas
weak ness is the most fre quent find ing on neu ro log i cal
ex am i na tions in 60% of pa tients, fol lowed by de -
creased sen sa tion and al tered re flexes in 52% of pa -
tients.1 Spi nal MRI is the di ag nos tic test of choice. On
con ven tional spin echo MRI, fat dem on strates in -
creased sig nal in ten sity on noncontrast T1-weighted
scans and an in ter me di ate sig nal in ten sity on
T2-weighted scans. Rob ert son in di cated that T6-T8
and L4-L5 were the most com monly in volved lev els
in the tho racic and lum bar spines.1
The most com mon treat ment for epidural
lipomatosis with corticosteroid-use pa tients con sists
of sur gi cal de com pres sion.4,5 Rich ard et al. rec om -
mend that decompressive laminectomy is in di cated if
pa tients pres ent with signs of spi nal cord com pres -
sion. If pa tients pres ent with radiculopathy or back
pain but no signs of cord com pres sion, lim ited
laminectomies (one to two lev els) is in di cated. And if
pa tients have no ev i dence of cord com pres sion or
radiculopathy, de creased ste roid dos age and weight
re duc tion ther apy is in di cated.2 But Roberson rec om -
mends that lim ited laminectomies (one to two lev els)
with fat debulking at the site of the great est ste no sis
88 Chun-Chung Chen, et al.
Chi nese Med i cal Jour nal (Tai pei) Vol. 65 No. 2
Fig. 3. MR im ages of T1W1 re vealed epidural lipomatosis on T6-T8.
can be suc cess ful to re lieve the symp toms de spite
other lev els be ing in volved.1 Sur gi cal decompressive
sur gery is suc cess ful in approxiately 80% of pa tients
for symp tom re lief.1 But there is a high risk of post op -
er a tive mor tal ity, about 22%, due to immuno -
compromised sta tus in duced by ste roid use.2 So, in
cases with mi nor neu ro logic def i cits and with out cord
com pres sion or radiculopathy, med i cal treat ment in -
clud ing corticosteroid with drawal or weight re duc tion
will be in di cated. But, re peated im ages and close fol -
low-up are nec es sary.1,5
In pa tients with long-time corticosteroid use, os -
teo po ro sis is com mon and the spi nal ver te brae be -
come rel a tively un sta ble due to com pres sion frac ture.
There fore, op ti mal fu sion sur gery may be nec es sary in
ad di tion to decompressive laminectomy in symp tom -
atic SEL pa tients with com pres sion frac ture. Fu sion
sur gery can help to gain spi nal sta bil ity, de crease back
pain and im prove neu ro log i cal func tion. In our cases,
com pres sion frac ture was found, so we per formed fu -
sion sur gery with in ter nal fix a tion and decompressive
laminectomy. Af ter the op er a tion, the pa tients’ neu ro -
log i cal func tion com pletely re cov ered and back pain
In con clu sion, spi nal epidural lipomatosis is a rare
com pli ca tion of ste roid use. In these pa tients, os teo po -
ro sis with com pres sion frac ture is com mon. For treat -
ment of spi nal epidural lipomatosis with com pres sion
frac ture, op ti mal fu sion sur gery to gain sta bil ity of
spine may be nec es sary in ad di tion to decompressive
Ref er ences
1. Rob ert son SC, Traynelis VC, Follett KA. Id io pathic spi nal
epidural lipomatosis. Neu ro sur gery 1997;41:68-74.
2. Fessler RG, John son DL, Brown FD. Epidural lipomatosis in
ste roid-treated pa tients. Spine 1992;17:183-8.
3. Hierolzer J, Benndorf G. Epidural lipomatosis: case re port
and lit er a ture re view. Di ag nos tic Neuroradiology 1996;38:
4. Souheil FH, Pat rick W. Id io pathic and glucocortico-induced
spi nal epidural lipomatosis. J Neurosurg 1991;74:38-42.
5. Roy-Camille R, Chmazei M, Husson JL. Symp tom atic spi nal
epidural lipomatosis in duced by a long-time ste roid treat -
ment. Spine 1991;16:1365-71.
6. Drew A, Bednar K. Symp tom atic lum bar epidural lipoma -
tosis in a nor mal male. Spine 1990;15:52-3
Feb ru ary 2002
Spi nal Epidural Lipomatosis 89