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Thread: Spinal Epidural Lipomatosis

  1. #1

    Spinal Epidural Lipomatosis

    A member recently sent me a private message of an MRI that shows the presence of epidural fat at L5/S1 that "completely narrows the thecal sac". I thought that I would give my answer here so that other members can see and perhaps comment.

    Some epidural fat is normally present in the spinal canal, particularly in the sacral spinal canal where there is space, as suggested in the following diagram:

    MIDLINE SAGITTAL VIEW OF THE LUMBAR SPINE
    The posterior epidural space (shown in orange) is segmented by areas where the dura contacts bone. The posterior epidural space compartments have their greatest anteroposterior dimension at their superior end. The anterior dura is fused with the posterior longitudinal ligament and the annular ligament at the level of each intervertebral disc, which divide the anterior epidural space into vertical segments. The posterior longitudinal ligament separates from the anterior dura at the lumbosacral junction and the anterior epidural space becomes filled with fat more inferiorly.

    http://depts.washington.edu/anesth/r...aceframes.html

    Some epidural fat is normal. In fact, the epidural fat is typically soft and cushions the spinal cord in the canal. Epidural fat is typically absent from the cervical spine but may appear in the lower thoracic spine and usually is present in the lumbar and sacral spinal canal, usually in front of or in back of the spinal cord and in the sleeves of the spinal roots (Source). However, to have the spinal thecal sac enclosed by fat is abnormal. Lumbar stenosis (a narrowing of the spinal canal in the lumbosacral spine) is a common cause of back pain and neurological symptoms. Most of the time, it is due to narrowed bony canal and requires surgical decompression. However, in some cases, as in the one described above, epidural fat is the cause. It is interesting that in many cases of spinal stenosis, there is usually a loss of epidural fat (Source).

    Spinal epidural lipomatosis is sometimes associated with steroid long term steroid use or endocrinopathies such as Cushing's disease. There have been suggestions that it is associated with obesity. The attached is a paper from Hong Kong published in 2002, describing a 24-year old man who was diagnosed with spinal epidural lipomatosis around L4/5 level. He was put on a diet and lost 3 kg to 91.5 kg with no change in his symptoms. Although he had spondylosis of his spine at L4/5, injection of local anesthetics into the L4/5 joints did not reduce pain. The patient refused surgery and so was continued on a weight reduction program. The paper described a "Y-shaped sign" that is supposedly indicative of compression of the thecal sac.

    The choices of therapy are relatively straight forward. If the condition is associated with symptoms such as pain or neurological loss, particularly related to the position of the fat, the following course of action is reasonable. First, investigate for the possibility of endocrinopathy (such as Cushing's disease that can lead to accumulations of fat in various parts of the body), hypothyroidism (Source) or steroid use (which should be tapered). If obesity is present, efforts should be made to reduce weight. Second, if the above do not reduce symptoms, the only other option is surgery. The surgery is relatively simple. Epidural fat is relatively easy to remove and can even be done without unroofing the entire lumbosacral canal. Please remember that the spinal cord ends at just below the L1 vertebra and the thecal sac is filled with spinal roots at L5/S1 level.

    Wise.
    Attached Images Attached Images
    Last edited by Wise Young; 07-15-2009 at 07:12 PM.

  2. #2
    Thanks, Dr. Young. I just recently ran into my first referral for a patient with this as the cause of the SCI. His was at T6 though, and unfortunately the surgery for decompression only made his deficit worse.

    (KLD)

  3. #3
    I am happy I have found this site and even more so to find this thread. My husband has been recently diagnosed with SEL while receiving pain management from an auto accident while at work a few months ago. MRI and Myelogram revealed entire lumar area is involved to include 3 bulging discs. He has experienced intermit. loss of bladder & bowel. He is to have surery to correct the lipomatosis. The surgeon said his situation is severe. The limited info I am able to find about SEL indicates it is a relatively rare condition. Can you direct me to specific literature about SEL? After the Myelogram his legs went numb for about 15 minutes,.scared us pretty bad. His pain levels are pretty high with activity so he is taking it very easy. Frequently changes positions as no position is of comfort. I am worried. We are stunned and confused. Prior to the auto accident he has never experienced pain like this before. Thanks in advance for your reply.

  4. #4
    My husband has just been diagnosed with several spinal issues, large hemangioma, spondylolisthesis, epidural lipomatosis, etc. which reading your replies makes it seems like we have it easy in comparison to many in this community. Our family doctor gave us a list of several neurosurgeons. How does one go about finding/selecting a "good" neurosurgeon in the St Louis area?

  5. #5
    You can probably depend on the referral of your husband's primary care physician, but I would lean towards those neurosurgeons who also work at trauma hospitals in your area, and have university/teaching affiliations or appointments at the medical schools in your area.

    (KLD)

  6. #6
    Lower back MRI results: L3-L4 mild generalized disc bulge. ///////no central canal stenosis or foraminal narrowing is noted. There is prominent epidural fat posterior to L3 and L4 verteebral body causing some narrowing of the thecal sac. This is suggestive of epidural lipomatosis.
    L4-L5 there is generalized disc bulge and mild bilateral facet hypertrophey. there is mild central canal stenosis and mild bilateral foraminal narrowing. There is prominent epidural fat posetrior to the L5 vertebral body causing some narrowing of the thecal sac.
    L5-S1 there is generalized disc bulge, eccentric to the left. mild bilateral facet hypertrophy is note3d. Severe left and mild right foraminal narrowing is noted. There is mild central cananl stenosos. there is prominent epidural fat surrounding the thecal sac causing some narrowing. suggestive of epidural lipomatosis.

    CAN someone translate this to laymans terms

  7. #7
    I was researching epidural lipomatosis for my employer's auto accident client and found a link that states that a patient my become symptomatic after an accident, as the patient had no symptoms prior to the accident even though the lipomatosis existed. The link is:

    http://www.hkcr.org/publ/Journal/vol..._p.105-108.pdf

    If you google Reference No. 8, you can purchase that reference.

  8. #8
    Conservative therapy, including weaning of patients from steroids and weight loss, has been successful in a number of cases.Nevertheless, many patients receive steroid medications for other chronic illnesses and may not tolerate weaning from the therapy. Weight loss has been reported to be very successful in patients with SEL in whom obesity is thought to be the cause of the adipose hypertrophy.

  9. #9
    Greetings all!

    I wanted to put this out for opinions as I am wondering if I should be concerned or not? My MRI for the lumbar a week ago (just the area of concern)

    "L5-S1. Demonstrates early termination of thecal sac with prominence of epidural fat attenuating the thecal sac"
    Part of the Impression concerning this: "There is early termination of the thecal sac at L5-S1"
    Apparently it is suppose to extend through to S2-S3. Anyone? Thanks in advance!!

    Here is a link to the images:

    http://i783.photobucket.com/albums/y...x36440/SEL.jpg
    http://i783.photobucket.com/albums/y...36440/SELY.jpg

    This is new. Have had (still have) intermittent incontinence, constant mid and low back pain (hernias at L2/3 and L3/4), weakness in both legs, neuropathy both legs peripheral.

    Again, thanks in advance for any advice or words of wisdom. I see my Neurologist next Friday.

    Additionally: Not obese, no steroids, no cushings, no hyperthyroidism - idiopathic.

    Brenda

  10. #10
    I will ask Dr. Young to comment on this.
    CKF

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